Patient Education and Skill Building

Patients and families need clear information to understand the signs and symptoms of the disease(s) and treatments, and training to build the skills to monitor clinical indicators such as glycemic control or peak flow volume. This clinical content distinguishes self-management education from self-management support, which helps people make behavior changes and sustain them over time. Physicians, nurses, or other clinicians with appropriate training can provide self-management education. Primary care teams may have difficulty finding time and appropriate staff to provide patient education sessions in the course of an office visit, but providing just the right information in response to patient needs or questions is a very effective way to incrementally increase their understanding and skills. For in-depth education, programs offered by public health entities or hospitals are an underused referral resource. Psychosocial and emotional stressors as well as physical symptoms should be considered in these programs.

Goal Setting, Action Planning, and Problem Solving

Helping patients know what to do to stay healthy is important, but the goal of self-management support is to help them adopt the behaviors that will keep them healthy over time. Motivating and coaching healthy behaviors is one method of supporting self-management that can be done very effectively by non-clinicians. By developing skills through training and practice, tasks required to support patients and familiessuch as making a specific plan of action, anticipating barriers, and connecting them with community resourcescan be the responsibility of members of the care team other than the physician, often with equivalent results.

For patients with chronic conditions, setting health goals with the help of a physician is an important step, but few patients achieve goals without more specific planning. Additional behavior change coachingspecifying action planning steps and anticipating barriersis needed to develop patient confidence in reaching goals. Medical assistants, nurses, nutritionists, behavioral health professionals, health educators or trained lay people, if trained in action planning and problem solving strategies, can effectively work with patients to define their action plans.

• Assist the patient in completing an Action Plan form and give them a copy to take home.

Setting Healthy Goals

Studies show that patients rely on physician advice in determining health goals. Collaboratively setting health improvement goals with patients is an important step in motivating healthy behaviors. Physicians or other providers set treatment priorities and make recommendations about changes that would enhance health. To be effective in engaging the patients and families toward healthy behaviors, physicians will also ask about patient concerns and priorities, and then they will collaboratively arrive at a plan for self-management.

Using agenda-setting tools such as the Bubble Diagram can introduce the collaborative process of establishing healthy goals. It is important that patients’ priorities in goal setting lead the decision about which goals are established. Keep in mind that achieving small successes toward a goal that is important to patients will enhance their confidence and sense of control in managing their illness, and this will pave the way to achieving goals in other areas.

• Use a variety of tools such as the Bubble Diagram or Dinner Plate Menus to engage the patient in setting a health goal.