Chapter 5. Self-Management Training for Montgomery County PCC Clinics

A key objective of learning networks is to find innovative ways to spread a successful intervention. Due to an extension of the contract with Delmarva Foundation for 9 months, the availability of contract funds, and the timing for system-wide implementation of an EMR for the 10 Montgomery County PCC clinics, a unique opportunity for spread became available. The Center for Health Improvement of the PCC wanted to continue the emphasis on patient self-management and goal setting, spread the intervention to its other clinics, and use goal setting for additional chronic diseases. AHRQ approved the following plan for spread activities.

• The PCC incorporated goal-setting data elements into its new EMR to facilitate the documentation of patients’ goals and the monitoring and tracking of goals by clinic team members.
• Delmarva and the PCC designed a patient self-management training session for teams from the 10 clinics.
• Delmarva’s medical director met with the clinic medical directors to make the case for patient self-management and the goal-setting intervention.
• The PCC encouraged medical directors to send teams to the training session.
• Delmarva sent three brief emails to all participants registered for the training within the 2 weeks prior to the session that provided evidence and, hopefully, motivation for goal setting.
• The training session was held at AHRQ on September 21, 2007. Forty team members attended the session. Clinic teams developed action plans for implementing the goal-setting intervention within their clinics.
• The PCC Center for Health Improvement presented a 1-hour training at the end of the session to a smaller group of participants on using the new EMR to document goals of patients.
• Twenty-five participants evaluated the patient self-management training, and 96 percent agreed or strongly agreed that the program objectives were achieved.

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