Protocols for Patient Self-Management

To support patient self-management, the health care team will need to:
 

Establish Self Management

• Assess patient readiness 
• Assess patient/staff cultures 
• Assist patients to define their role in self- management and build knowledge and skills needed to undertake self-management tasks.
• Define staff role in patient self-management process.
• Train staff to educate and train patients in self-management techniques.

Share Information

• Ensure that patients understand the implications of the diagnosis and related symptoms, treatment, medications, outcomes and outcomes measurements.
• Provide patient education on applicable clinical practice guidelines.
• Staff trains patient in self-management techniques.
• Health care workers share communicate and share complete and unbiased information with patients and their family in ways that are affirming and useful.
• Patients and families receive timely, complete and accurate information in order to participate in care and Decision making.

Develop Mutual Goals

• Overview on Developing Mutual Goals 
• Mutual goal setting in the facility is a change process involving patients, staff and other stakeholders.
• Mutual goal setting with patients.

Develop a Care Plan

• Care plan development in a change process involving patients, staff and other stakeholders. 

Evaluation

• Use problem-solving techniques to identify barriers and areas for improvement
• Collaborative Care Model Implementation 
• Reinforce self-management goals and tasks through the evaluation of progress and evidenced-based outcomes
• Outcomes Evaluation Strategy 
• See also Mutual goal setting with patients for ongoing goal evaluation strategies.