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Integrating Self Management in Primary Care: Organizational Supports

Characteristics of organizational support for self management include:

Continuity of Care

Continuity of care is supported by systems that ensure: assignment of patients to a provider; scheduling of planned visits; tracking and follow up of patient visits and lab tests. Team members work together to meet patient care guidelines.photo

Coordination of Referrals

Coordination of referrals is accomplished by having systems in place to track referrals and follow-up with patients and/ or specialists to complete referral as needed. The patient care team works together to document and monitor referrals and coordinate with specialists to adjust the patient’s care plan as needed. 

Ongoing Quality Improvement

Ongoing quality improvement happens when the team uses data to identify trends and initiate actions to make improvement. Systems that support quality improvement generally use a registry or electronic medical record to routinely track key performance indicators. They also have structured and standardized processes for quality improvement, accountability for improvements, and management support.

System for Documentation of Self Management Support Services

Documentation includes charting patient care plans
and self management goals so that all team members and providers can access the information to guide care planning. In systems committed to comprehensive diabetes care, self management goals are an integral part of the patient’s medical record, easily accessible to all team members and organized to show progression.

Patient Input

Patient input can be achieved in a variety of ways including focus groups, surveys, membership on advisory councils, etc. In patient-centered systems, patients are made aware of mechanisms for input and encouraged to participate in decisions regarding patient care practices and service delivery. Their input is considered essential to decision-making processes, and there is evidence that the information provided is used to improve care practices.

Integration of Self Management Support into Primary Care

Care for all those with chronic conditions will improve when self management support becomes routine throughout the practice setting. Evidence of integration includes attention to self management in the primary care practice ’s strategic plan, routine monitoring for quality improvement and leadership support. 

Patient Care Team

The team at each site may vary according to available resources and may be comprised of providers, clinical and non-clinical support staff.  In well functioning teams, roles and responsibilities are clearly defined and communicated, team members have complementary skills and are cross-trained. Every member’s role in providing self management support is clear and mutually reinforcing. The concept of a patient care team is embraced, supported and rewarded by senior leadership and is part of the system culture.

Education and Training of the Care Team in Self Management

Self management support depends on a team that has been trained in self management using accepted approaches and is consistent in their approach to patient self management. Commitment to excellence is evidenced by a system that supports continuing education, includes self management skills in job descriptions, and assesses and monitors performance.

Assessing and Evaluating the System of Care

The Diabetes Initiative developed an instrument that helps primary health care settings assess their current levels of organizational and patient care supports for self management and identify areas for quality improvement. This tool, the Assessment of Primary Care Resources and Supports for Chronic Disease Self-Management (PCRS), is designed for use in a variety of primary care settings and across different chronic illnesses.

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The Diabetes Initiative was a national program of the Robert Wood Johnson Foundation from 2002 to 2009.
Archived in 2009, this site is a repository for information and resources gathered over the course of the Initiative.