Self-Management Support Before, During, & After Visit

• Prepare for self-management support by gathering clinical and patient experience data

• Ask patients to bring questions and concerns and health monitoring information.

• Be intentional about incorporating this information meaningfully with care team members.

• Collaboratively develop a visit agenda with the patient and family, ideally no more than 2-3 topics, and plan return visits as appropriate.

• Engage the entire practice team in supporting patients, use warm handoff introductions, and explain team member roles to patients. Consider how the entire team can support this work. For example, the front desk staff can provide the SMS tool while the MA assists with agenda setting.

• Ask about patient goals to improve their health and help them make action plans that build confidence in their ability to reach these goals. Goals should always be S-M-A-R-T (Specific, Measurable, Attainable, Realistic, Timely).

• Use “Ask-Tell-Ask” to provide just the right information at just the right time and close the loop to ensure patients know how to use the information.

• Prepare a care plan or visit summary (in writing or via the patient portal) that includes goals and action plans to ensure patients and families know what to do when they leave the visit.

• Consider a referral to group medical appointments, peer-led support groups, or patient education classes that provide opportunities for patients to share experiences and support

• Organize follow-up support to help patients sustain healthy behaviors in-between visits.

• Extend care into the community by linking patients to community programs.

Help patients understand their central role in managing their conditions and that the care team is there to help. 

Care for the patient is no longer the provider’s sole responsibility – it is a care team effort with the patient involved in directing their own care.

Designate and train a care team member to be the SMS champion by supporting ongoing skill development.

Assign responsibility for SMS tasks to all care team members, extending the work out from the physician.

Use daily team huddles to review the schedule of patient’s charts, anticipate care needs, enhance the flow of care, and inform staff of previously set SMS goals for follow up