Comprehensive patient self-management: The practice partners model

Based on the literature and our experience in quality improvement, we designed a comprehensive patient self-management (PSM) model—Practice Partners (PP). It is designed to implement best practice approaches to improve the care of chronic medical conditions. PP addresses office practice and behavior change and linkages to community services.

The practice partner establishes and trains the PCP practice team in skill development with patients (goal setting and action planning); evidence based disease learning materials, linking patients to community resources, and techniques to increase medication adherence. The PP works with patients on skill development such as: improving knowledge and communication skills with providers, increasing confidence regarding care management, and improving medication adherence. This involves individual and group visits and follow-up based on patient needs.

Third, the PP works to integrate Community resources thereby offering support such as: linking patients and services, promoting resource utilization, and identifying gaps in available resources.

This model addresses current deficiencies such as: (1) rushed practitioners not following established practice guidelines; (2) lack of care coordination; (3) lack of patient follow-up; (4) inadequate patient education essential for management and (5) lack of patient involvement in treatment planning. The model uses newly created assessment tools to measure practice gaps in providing state-of-the-art PSM services; a training module for providers and evaluation measures of patient health improvement.