Table 4.

Priority Alignment Around Self-Management Support (SMS) Transformation

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.