What is Self-Management Support (SMS)?

Self-management support is the assistance care team members provide to patients with chronic conditions (although applicable for all patients) to encourage daily decisions that improve health-related behaviors and clinical outcomes.

Why is SMS Important?

Many patients do not understand what clinicians have said to them and do not participate in decisions about their care, leaving them ill-prepared to take daily actions that lead to a healthy lifestyle. Helping patients make good choices and maintain healthy behaviors requires a collaborative relationship between the care team, the individual, and their families.

This partnership increases patient empowerment and involvement in their care, helps them understand and adhere to recommendations, and contributes to better health outcomes and higher patient and provider satisfaction.

SMS Approaches

Practices can take many different approaches in their delivery of self-management support:

• Individual clinic visits
• Group visits
• Co-consults
• Peer support
• Community-based classes
• Technology-based support

Steps to Implementing SMS

1. Define the target patient population.

Options include patients who are high risk, have a specific diagnosis, request assistance, whose conditions are poorly controlled, and/or based on outcomes of a comprehensive health assessment.

2. Determine what self-management support(s) are most appropriate to offer based on the needs of the population.
3. Identify which SMS tools/referrals the practice will use.

SMS includes a variety of techniques and tools that help patients choose and maintain healthy behaviors. Care team staff can ease into an SMS program by learning how to use tools such as action plans, goal-setting worksheets, and problem-solving techniques to support and motivate patients.

4. Determine the roles and responsibilities of the practice care team. Assign the following roles and responsibilities on the care team to ensure close coordination of effective SMS:

• Gather clinical data before the visit
• Introduce SMS and patient role
• Set visit agenda
• Collaboratively setting goals
• Create an Action Plan
• Provide information, training, and community resources to patients
• Proactive follow-up

5. Identify what type of training the care team members will need. Consider training care team members skills that will strengthen the patient relationship, such as motivational interviewing, reflective listening, and coaching.
6. Determine the follow up and data collection and reporting plan.

• How will the impact of SMS be measured?
• Who will report the outcomes?
• How frequently will measures be tracked and reported?

Options include provider satisfaction, patient satisfaction, progress on goal attainment, and/or quality measures.