Article Figures & Data
Figures
- Figure 1.
Framework for self-management support (SMS) practice improvement. Adapted from: Solberg LI. Improving medical practice: a conceptual framework. Ann Fam Med 2007;5:251–256.
- Figure 2.
Facilitators and barriers for self-management support (SMS) implementation.
Tables
- Table 1.
Baseline Practice Characteristics from 36 Primary Care Practices in Colorado and Northern California; Data Collected from 12/2013 to 9/2015
Variables Mean (SD) or % Minimum, Maximum Number of clinicians 6.86 (3.95) 2, 16 Specialty (% FM alone) 63.9% — Type of practice organization (CHC vs other) 75.0% — Number of patients with type 2 diabetes 508 (369) 60, 1542 Percentage of diabetic patients with HgA1c >9 26.7 (8.8) 4.3, 46.0 Percentage Medicaid 38.3 (20.2) 0, 70.0 Percentage uninsured 27.0 (8.8) 0.9, 56.0 Percentage rural location 27.8 — Percentage care manager present 27.8 — Ongoing Quality improvement team meets regularly, with or without outside assistance 89.9% — NCQA PCMH recognition 66.7% — FM, family medicine; CHC, Community Health Center; NCQA, National Committee for Quality Assurance; PCMH, Patient-Centered Medical Home; SD, standard deviation.
- Table 2.
Baseline Practice Member Surveys from 36 Primary Care Practices in Colorado and Northern California; Data Collected from 12/2013 to 9/2015
Name of Survey Measure Items Mean (SD) Practice Monitor Patient SMS (overall score) 65.7 (20.9) SMS individual items (0 to 5 range) System implemented for identifying patient needs for assistance with psychosocial issues, health behavior change, and managing chronic illness 3.45 (1.19) System implemented for assisting patients with developing shared care plans with specific goals and action plans for health behavior change and management of chronic illness 3.25 (1.25) Shared care plans are developed collaboratively with patients and families 3.14 (1.30) Care plans and action plans are regularly reviewed to monitor patient progress in accomplishing goals 3.11 (1.30) Patients and families are actively linked with community resources to assist with their self-management goals 3.20 (1.25) Patients and families are provided with tools and resources to help them engage in the management of their health between office visits 3.40 (1.21) There is a care manager or other staff members in the practice trained to assist patients and families in health behavior change and chronic disease management 3.43 (1.45) Practice Culture Assessment Change Culture 64.0 (18.9) Practice Culture Assessment Work Culture 63.8 (18.4) Practice Culture Assessment Chaos 43.5 (18.5) N = 716 staff and clinicians. SD, standard deviation; SMS, self-management support.
- Table 3.
Baseline Practice and Practice Member Variables Associated with Greater Self-Management Support Activities, from 36 Primary Care Practices in Colorado and Northern California; Data Collected from 12/2013 to 9/2015
Variable Unadjusted Bivariate Associations Coef (P value) Bivariate Associations, Adjusted for Clustering Coef (SE) Multivariable Model 1* Coef (SE) Multivariable Model 2* Coef (SE) Multivariable Model 3* Coef (SE) Intercept — — 50.47 (2.78) 30.67 (5.59) 51.28 (5.61) Specialty (FM vs multispecialty/other) 0.0799 (.0330) 3.45 (2.54) — — — Rural location 0.1197 (.0014) 6.23 (2.54)† — — — Number of diabetic patients 0.0732 (.0508) 0.0043 (0.0034) — — — Care manager 0.1615 (<.0001) 6.42 (2.33)‡ 5.22 (1.68)‡ 5.24 (1.99)‡ 5.63 (1.89)‡ Percent Medicaid 0.1014 (.0068) 0.1234 (0.0599)† — — — Percent uninsured 0.1262 (.0007) 0.1479 (0.0640)† — — — Level of PCMH 0.1925 (<.0001) 3.73 (0.89)‡ 2.46 (0.81)‡ 3.20 (0.90)‡ 2.74 (0.87)‡ Underserved designation 0.1665 (<.0001) 9.50 (3.01)‡ 5.81 (2.62)† 6.66 (2.90)† 5.97 (2.81)† PCA change 0.3426 (<.0001) 0.4305 (0.0385) — 0.3500 (0.0455)‡ — PCA chaos −0.2858 (<.0001) −0.3420 (0.0401)‡ — −0.1440 (0.0459)‡ −0.2632 (0.0471)‡ PCA work 0.2264 (<.0001) 0.2943 (0.0318) — — 0.1429 (0.0480)‡ Coef, Coefficient; FM, family medicine; PCMH, Patient-Centered Medical Home; PCA, Practice Culture Assessment; SE, standard error.
↵* Model 1 includes basic practice characteristics, model 2 added one combination of PCA scale (Change culture and chaos), and model 3 tested the other combination of PCA scales (Work culture and chaos). Change culture and work culture were tested in separate models to reduce multicollinearity; SE, standard error.
↵† P < .05.
↵‡ P < .01.
Propelling factors pushing for SMS transformation Conceptual alignment: positive emotional response to the principles of SMS; good fit with other quality programs and initiatives. “I have a group of patients in my practice who are pretty controlled but they once in a while will get out of control. Having some type of self-management support that would help them to figure out, ‘What am I doing wrong so I can get back on track,’ would be helpful.” Functional priority alignment: at least partial fit with improving existing team-based care process priorities, such as group visits, care management, and patient health educators. “The clinicians who are now doing all of the SMS said that it usually gets pushed into the last 2 minutes of an appointment, when it gets covered at all. They did seem to think that CTH tools will help structure and streamline SMS, however.” Motivation for change and improvement: most clinician leaders expressed desire to improve their SMS delivery, especially in terms of more consistency. “Given our population, given the type of constraints but I'm really excited to be able to track whether it's making a difference because we've had diabetes clinic for quite some time. I've always been curious to know well how have those patients who have had those three professions intervention have they done? We have seen some changes, but I've not been able to gather that information and kind of present it in a way that it shows it's made a difference.” Visible champions: in about half of the practices, there was at least one individual (clinician, staff, or administrator) who showed interest in committing effort to SMS changes. “My impression is that they can absolutely do something with CTH because the PA wants to try. She stayed after the training to ask questions about the time commitment and other things.” Repelling factors pushing against SMS transformation No shared vision for how SMS aligns with practice priorities: The vision for how SMS aligns conceptually or functionally was rarely a vision shared or discussed among all staff, clinicians, or administrators. There were early concerns about full buy-in across staff and providers, especially that the processes, staff roles, time, and resources would be insufficient. Reluctance, hesitance, or passive interest in SMS was especially visible among staff in meetings we observed. “A [practice] manager [said] that this practice is ‘not a strong team’ prior to the training session. They ‘just get things done’ and historically have operated in ‘survivorship’ mode…. Both providers were present and one of them… came armed with a lot of implementation questions… she was engaged. A comment from [another provider] today signaled impatience as she wanted a quick decision, ‘Can we just make a decision and stop talking about it.’” Varying definitions of SMS: How staff and clinicians described SMS often included some components (e.g., goal-setting, action plans, collaborative decisions), but rarely were these complete or shared across staff and clinicians. In several cases, there were perceptions that SMS was already done by someone else in the practice. “[SMS means] That they take care of their own selves with managing their own diabetes or whatever it is; to manage their own care and to know what goal they had for the next month. Just to take care of their own self. “[SMS] means, starting with the patient and asking what they need and giving recommendations or maybe more importantly, collaborating with the patient on strategies to address what they think they need. Telling them what to do, based on what the PCP thinks they need. No visible champion for SMS changes: In about half of the practices there were no staff or clinicians who were visible champions for SMS changes or improvements. “She [care coordinator] doesn't identify a strong SMS champion or “driver” at the clinic at this time. She doesn't think there is a shared approach or structure re SMS that is used across all providers/ care teams.” Priority on avoiding adding more work and more duties: In most practices, there were concerns about already being busy with current work. Clinicians were concerned about extra time needed with patients or for documentation; staff, especially health educators, expressed concerns about adding extra duties, or duplicated work, or extending beyond their job descriptions. “The clinician who was most actively engaged during the presentation talked with me afterward, saying that she thinks the staff is passive and it may therefore be challenging to get SMS up and running practice-wide… based on the staff's very limited response to the presentation, it appears likely that they would be willing to do SMS work as assigned by leadership, but probably would not volunteer for expanded roles with patients or be assertive with recommendations for SMS implementation” CTH, Connection to Health.
Propelling factors pushing for change process capabilities Supporting infrastructure: Most practices at baseline had at least some resources, workflows, visits, and roles already deployed that aligned with delivering more robust patient SMS, such as, patient health educators/care coordinator, group visits, or existing workflows. ““I found this team attentive and engaged in the topic…. I was struck by the empowered role of the MAs here. They do so much more than room patients take vital signs and follow the clinician's directions…. . I see the benefits as two-fold: the MAs seem happy and engaged and the clinicians don't appear stressed. Their workflow is working for them.” [FN 110].” Functional Care Teams or QI Teams: At least moderately functional teams (QI or care teams) were observed in some practices where clinicians, staff, and administrators were present and at least minimally engaged in some decision making around SMS changes; or they appeared to have systems in place to communicate across care team roles or QI teams about changes planned. “The team already has many of the attitudes and skills (follow up calls to check on action plan progress, etc.) that will help them be successful in expanding SMS with their patients.” [MF 202] Staff and clinician stability: There were several practices that described staff and clinicians who had been with the practice and for multiple years, and had good knowledge of how the clinic operates and experience with practice change or quality improvement. “After 24 years in this small clinic, she [practice manager] is well aware of every aspect of the practice. It is a very pleasant practice. She understands practice redesign. [MF 116” [MF 202] Repelling factors pushing against change process capabilities Siloed infrastructure: Especially, in larger practices, clinical roles were siloed with integration across roles beyond an initial referrals or hand-offs. Most practices appeared to have ad hoc approaches to quality improvement work. Among those in systems, there was no specific mention of how the systems would directly support the QI processes at the practice level. “I don't cross paths with the PHEs.” [BHP 110] “I don't know exactly what the providers do about SMS.” [PHE 110] “Does not feel diabetes care is collaborative. The lack of collaboration is a “company issue” because it “takes time and providers slow down”. [FN clinic 110] Communication issues: Communication across roles or from systems leaders to practices was incomplete. This extended to how decisions were made, with staff and clinicians in several clinics feeling that the decision to participate was “made for us” by someone else in their system. “She noted that the team is “not quite as knit as it should be” because the provider and their MA “circle” but the rest of the team may not know due to “limited communication.” [MF clinic 110] Time and resource constraints: The capacity to take on additional work, was acknowledged widely among the clinical leadership as a potential threat to fully implementing SMS. There were numerous concerns raised about capacity of clinicians—and especially staff—to take on new work or different work, change workflows, and adopt new tools. “She noted that the team is “not quite as knit as it should be” because the provider and their MA “circle” but the rest of the team may not know due to “limited communication.” [MF clinic 110] Potential turnover/arrival of key people: Even at baseline, eight practices described the recent arrival or anticipated departure of key clinicians, including medical directors, SMS champions, diabetes clinic directors, or behavioral health providers. “A new development was that our previous contact, a PA, is leaving [the practice]. This person was also the lead clinician for the Shared Medical Appointments that [practice] is putting stock into to help manage the diabetes populations for each clinician.” [FN clinic 101] Competing programs: Just a few practices made notable mentions, at baseline, of the potential for competing programs to affect implementation of CTH/SMS. “They seem to have a lot going on. A new QI tracking program that is discussed in the PA interview, a mandated state Wise Women's Program and now this project.” [FN, 104] CTH, Connection to Health.
