Quality improvement instrument improves multidisciplinary approach to self management in West Virginia clinics

Objective: To improve self management supports in the clinic through use of a quality improvement tool and planning processes that engage the patient care team. Methods: Marshall University Center for Rural Health (Marshall) has partnered with the West Virginia Diabetes Prevention and Control Program since 1999 to improve diabetes outcomes within a network of primary care centers. Collaborating with the Robert Wood Johnson Foundation's Diabetes Initiative, Marshall assisted a primary care center partner to implement the Assessment of Primary Care Resources and Support for Chronic Disease Self Management (PCRS) developed by the Diabetes Initiative. The PCRS defines elements of self management support (SMS), provides a mechanism to assess current capacity and identify gaps in SMS, and promotes teamwork designed to lead to integration of self management into routine care. A baseline self assessment was conducted by multi-disciplinary teams; the findings were analyzed to build consensus for systems change; and the teams formulated quality improvement strategies. A follow-up assessment and EMR reports gave clinics data to improve self management integration. Results: 1) The PCRS informed teams of performance standards and optimal system of care for self management support; 2) Clinics gained understanding of gaps in existing system, and agreed on quality improvement strategies; 3) Patient and staff competence in self management processes was improved; and 4) Behavioral and clinical outcomes improved.

Conclusion: The PCRS is a user-friendly self assessment tool that primary care teams can use to assess their current capacity and plan improvements that support consistent patient-centered self management.