Self-management Support for Community Health Centers

1. Self-management Support for Community Health Centers West Central Cluster Connie Sixta, MSN, MBA Consultant for TACHC

2. Background: • In 1999, Community Health Centers began implementing the Care Model (BPHC Health Disparity Collaboratives). • Patient self-management is a key component of the Care Model, and the key to chronic disease management. • The average percentage of patients with self-management goals has been low (30% through mid 2004).

3. WCC Plan for Supporting Self-management at CHCs STEP 1. Identified problems related to self-management implementation at CHCs (Staff, Provider, Management Questionnaires).

4. Problems with implementing Self-management • Self-management process has not been taught at Phase II Learning Sessions. • Phase II teams (staff and providers) have not had self-management training-----Providers and staff want it. • Diabetic patient education is done almost exclusively on a 1:1 basis and in over 50% of the cases by a provider.

5. Problems (con’t) • Hospital-based diabetic education programs are accessible for many CHC patients but are cost-prohibitive. • All CHCs are trying to set behavioral goals with patients, but are not discussing barriers or assisting patients with problem solving. • Goal follow-up is done every three to four months.

6. Problems (con’t) • Documentation of patient self-management is inconsistent. • Many patient self-management tools do not meet the patients’ needs. • Most CHCs do not have a infrastructure to support self-management (Promotora, Case-management, Health Educator, CDE)--- Providers and staff want it.

7. Problems (con’t) • Professional staff for support of a self-management program are in short supply.

8. WCC Plan STEP 2. Convened a group of CHC self-management experts to design change packages for self-management (Providers and Staff).

9. WCC Plan STEP 3: Developed the change package and tools. • Videos (Provider and Staff) • Self-management Manual • Provider-specific Tools

10. Next Steps • Survey WCC CHCs to determine interest in testing/building a self-management infrastructures (Promotora, Case-management, etc.)