Implementing Networks Self-management Tools Through Engaging Patients and Practices

Specific Aim 1: Implement the Agency for Healthcare Research and Quality SMS Resources and Tools (SMS Library/Toolkit) across four participating networks and 16 practices using Boot Camp Translation in a stepped-wedge design.

Specific Aim 2: Assess the impact of implementation on practice staff and patients engaged in chronic care management.

Specific Aim 3: Identify the factors related to successful implementation.

Background and Significance:

With almost one-half of Americans projected to have at least one chronic condition before 2020 it will be paramount that the health care system reduce the burden to primary care for disease management by facilitating the development of activated, informed individuals who are proficient in self-management skills. This represents a significant cultural shift in health management, and clinicians and staff may lack confidence introducing and promoting self-management support (SMS). In fact, SMS is the area of disease management least often implemented and most challenging to integrate into usual care. This difficulty occurs at the patient and clinician level. Using the Patient Activation Measure (PAM), Hibbard and colleagues found that 60% of patients feel passive about managing their own health and a third of patients had barriers in knowledge and confidence in caring for themselves.