Milestone 4: Practice can demonstrate that it encourages patients and families to collaborate in goal setting, decision making, and self-management.
Goal: Practice can demonstrate that patients and families are collaborating in goal setting, decision making and self-management (e.g. shared care plans, documentation of self- management goals, compacts, etc.).
sTRATEGIES
Train staff in motivational interviewing approaches
Create a shared care plan for every patient
Use evidence-based decision aids to provide information about risks and benefits of care options in preference-sensitive conditions
Routinely share test results, along with appropriate education about the implications of those results, with patients
Engage patients, family and caregivers in developing a plan of care and prioritizing their goals for action, documented in the Electronic Health Record (EHR)
Incorporate evidence-based techniques to promote self- management into usual care, using techniques such as goal setting with structured follow-up, Teach Back, action planning or motivational interviewing
Use tools to assist patients in assessing their need for support for self-management (e.g., the Patient Activation Measure or How’s My Health)
Provide a pre-visit development of a shared visit agenda with the patient
Provide coaching between visits with follow-up on care plan and goals
Provide peer-led support for self-management
Provide group visits for common chronic conditions (e.g., diabetes)
Provide condition-specific chronic disease self-management support programs or coaching or link patients to those programs in the community
Train staff in self-management goal setting
Standardized action planning and plan follow-up process so entire team can participate Educate patients and families on health care transformation so they can be active, informed change agents. Use appropriate language, simple language, and pictures
Ensure patient leaves office with plan of care in hand
What our enrolled practices are doing:
Created a monthly discussion group for patients and their families to share and discuss specific conditions,