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Self-care Management and Support

Jaye Dela Cruz

Purdue University Global

NU501: Advanced Nursing Roles

Dr. Brian Kennedy

May 28, 2024

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Self-care Management Advanced Practice Intervention Self-care Management

Activity Role Principle
From Agency for healthcare Principles from the Joint
research quality, 2020 Commission (Battersby et al.,
2010)

1. Gather clinical data

before a visit.
Nurse Practitioner For providers  Clinical assessments
For providers – collecting Role  Sending pre-visit are brief and targeted –
data prior to patient visit is questionnaires. clinicians can focus on
crucial for enhancing Clinical Nurse Reviewing the main concerns in
personalized care delivery Specialist electronic health patients’ health
and thorough care. record from problems.
Advanced Practice previous visit
For patients- be an active Case Manager information, recent  Health behavior
member of your health care lab results for assessments are brief
team by asking questions trend, reports form and targeted – patient
and making sure you specialists the concerns and problems
understand the answers to patient has seen, can be fully addressed.
ensure better outcomes. ensuring medication
list is up to date.  Patients work on SMS
With pre visit planning, For patients with several members
patients and providers are  Bring all medicines of the health care
prepared to make you take to your team; the commitment
meaningful use of their time visit. Write down to SMS is practice-wide
during each visit questions you have – office staff receiving
(Gholamzadeh, M., Abtahi, for the provider, and triaging patients
H., & Ghazisaeeidi, M., know your current will help in identifying
2021). medical condition. goal for the visit as
Answer pre-visit soon as the patient
questionnaires to arrives.
identify goals for
the visit.
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2. Set agendas for

patient visits.  Identify problems  Clinicians maintain a
Nurse Practitioner from patient’s non-judgmental
Agenda setting is a Role perspective by approach to patients –
communication strategy asking open ended clinicians support
providers use at the Clinical Nurse questions and patients by asking open
beginning of clinical visits Specialist facilitate reflective ended questions and
to elicit, propose, and listening to patient uses reflective listening
organize a complete list of Advanced Practice responses. to mirror patient
topics to be covered (Gobat Case Manager responses.
et al., 2015)
 The focus is self-
Agenda setting is believed efficacy—clinicians
to enhance patient strive to enhance
outcomes and experiences, patient’s self-efficacy
improve providers through empowering
comprehension of patients them to take an active
concerns, and aid in role in their health.
provider organization and
time management. This  SMS interventions are
approach reduces the delivered in a variety of
number of unaddressed formats (in person, by
issues and minimizes phone, online, via print
unexpected topics that materials) – clinicians
patient might introduce provide resources to
later in the visit. patients that will
ensure positive
outcomes may it be in
person talk, by phone,
online health portals
and print materials.
3. Help patients set
health goals. Nurse Practitioner  Collaborative goal  Collaborative priority
setting, action- and goals setting – to
Goals are mental Clinical Nurse planning, and have greater alignment
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representation of desired Specialist identify barriers in between health care

outcomes, and goal setting achieving set goals interventions and
is the process by which one Advanced Practice and provide self- patient goals.
identifies specific goals and Case Manager management  Collaborative problem
determines how they will be education. solving – to enhance
achieved (Mann, de Riddler,  Facilitate using patient engagement,
& Fujita, 2013) SMART criteria for satisfaction and builds
goal setting relationship with
(Specific, patient.
Measurable,  Evidenced-based
Achievable, information is used to
Realistic and Timed) guide patient clinician
(Bovend’Eerdt, discussions and shared
Botell, & Wade, decisions – promotes
2009) skill development

4. Develop action  Evidence-based

plans for achieving Nurse Practitioner  Provide tailored information is used to
goals. education and skills guide shared decision
Clinical Nurse training materials making – provides a
Care plan is based on Specialist appropriate for clear roadmap for
patients’ needs and patient culture and achieving goals,
preferences (Boeykens et Advanced Practice health literacy level fostering
al., 2022). There is a Case Manager (Glasgow et al., accountability,
consensus that the care 2003) when collaboration, and
plan should reflect the Certified Nurse developing action success.
question: “What matters to Educator plan with patients  Focus is self-efficacy –
you?”. Hence, it is ideal to for achieving goals. changes in behavior
involve patients’ informal and health status might
caregivers and family in the be attributed to
care plan development patients feeling they
process. have better command
over their symptoms.
 SMS by diverse
providers – involve
nurses, case managers,
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pharmacist, dietitians,
and family members in
delivering SMS
interventions.

5. Track health
outcomes. Nurse Practitioner  Implement  Active follow up –
standardized ongoing follow up,
To truly understand a Clinical Nurse questionnaires or supported by feedback
patient’s progress in Specialist surveys that assess and reminders to both
treatment, programs need patients’ clinicians and patients.
to monitor change overtime Advanced Practice perceptions of their
and adapt treatment and Case Manager health, symptoms,  Multifaceted
support. Measurement and quality of life. Interventions – SMS is
based care involves utilizing Leverage wearable delivered using
standardized assessments devices, mobile multifaceted
to evaluate progress, applications, and interventions than a
pinpoint issues and utilize telehealth platforms single component
data to modify individual to remotely monitor intervention.
clinical interventions adherence to  SMS by diverse
promptly and effectively treatment plans. providers – different
(AHRQ, n.d.)  Engage in provider roles follow
interdisciplinary up with patient
collaboration and compliance, provide
care coordination reminders and
efforts to ensure communicates to team
seamless members about patient
communication and outcomes.
continuity of care.  SMS interventions are
delivered in a variety of
formats – in person
patient visits,
telephone or video
appointments or mailed
print materials
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provided to patients to
ensure adherence to
interventions.

6. Refer patients to
community  Refers patients to  Guideline based case
programs. Nurse Practitioners community management – can
programs that improve self-
Clinicians can support Clinical Nurse offers various management and
patient self-management by Specialist supportive services. patient outcomes if it is
providing information about  Referral to case goal directed and
community resources such Advanced Practice management for guideline based.
as the local health Case Manager various resources  Linkages to Evidence-
department, chamber of about the based community
commerce, YMCA and local Certified Nurse community that can programs – connect
chapters of societies aligned Educator help support self- patients with valuable
with patient conditions management. resources outside of
(Coleman & Newton, 2005). clinical setting, thereby
Numerous community enhancing their overall
organizations provide care and support
opportunities such as network by promoting
exercise programs, support patient peers.
groups, educational  SMS delivered and
workshops, and self-care reinforced in numerous
initiatives. Providers can multifaceted
play a pivotal role by interventions.
guiding patients to these  SMS interventions are
resources and potentially delivered in a variety of
offering space for formats – patients are
community groups. given opportunities to
meet people with the
same health problems
and facilitates
relationship building to
enhance motivation
and patient
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engagement.
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References

Agency for Healthcare Research Quality. (2020). Self-management support. https://www.ahrq.gov/ncepcr/tools/self-

mgmt/self.html

Agency for Healthcare Research and Quality. (n.d.). Tracking patient outcomes. In Opioid Use Disorder Playbook.

Retrieved from https://integrationacademy.ahrq.gov/products/playbooks/opioid-use-disorder/monitor-patient-

and-program-progress/tracking-patient-outcomes

Battersby, M., Von Korff, M., Schaefer, J., Davis, C., Ludman, E., Greene, S. M., Parkerton, M., & Wagner, E. H.

(2010). Twelve evidence-based principles for implementing self-management support in primary care. The

Joint Commission Journal on Quality and Patient Safety, 36(12), 561-570. https://doi.org/10.1016/S1553-

7250(10)36084-3.

Boeykens, D., Boeckxstaens, P., De Sutter, A., Lahousse, L., Pype, P., De Vriendt, P., Van de Velde, D., & Primary

Care Academy (2022). Goal-oriented care for patients with chronic conditions or multimorbidity in primary

care: A scoping review and concept analysis. PloS one, 17(2), e0262843.

https://doi.org/10.1371/journal.pone.0262843

Bovend'Eerdt, T. J., Botell, R. E., & Wade, D. T. (2009). Writing SMART rehabilitation goals and achieving goal

attainment scaling: A practical guide. Clinical Rehabilitation, 23(4), 352-361.

Coleman, M. T., & Newton, K. S. (2005). Supporting self-management in patients with chronic illness. American

family physician, 72(8), 1503–1510.

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Gholamzadeh, M., Abtahi, H., & Ghazisaeeidi, M. (2021). Applied techniques for putting pre-visit planning in

clinical practice to empower patient-centered care in the pandemic era: a systematic review and framework

suggestion. BMC health services research, 21(1), 458. https://doi.org/10.1186/s12913-021-06456-7

Glasgow, R. E., David, C. L., Funnell, M. M., et al. (2003). Implementing practical interventions to support chronic

illness self-management. Joint Commission Journal on Quality and Safety, 29(11), 563-574.

Gobat, N., Kinnersley, P., Gregory, J. W., & Robling, M. (2015). What is agenda setting in the clinical encounter?

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829. https://doi.org/10.1016/j.pec.2015.03.024

Mann, T., de Ridder, D., & Fujita, K. (2013). Self-regulation of health behavior: Social psychological approaches to

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