Chronic Conditions - Key Activity 16


Support Patient Self-Care


This key activity involves all seven elements of person-centered population-based care: proactive patient outreach and engagement; care coordination; behavioral health integration.


The term “self-care” refers to patients’ engagement in the activities and decisions that improve their health and well-being. Supporting self-care involves activities that enhance the capacity of individuals to engage in their care.

To address the healthcare needs of communities, patients and families must have skills and knowledge to make healthy lifestyle choices. This is a daunting task, but primary care practices can help by taking opportunities to enhance patients’ ability to self-manage through provision of resources tailored to patient needs and of coaching in self-care practices.

Evidence suggests that supporting self-care can improve patient outcomes and quality of life.[1] In addition, a focus on the capacity of individuals in underserved segments of the population to engage in their care is foundational to ensuring equitable care delivery.

Underserved populations experience lower rates of health literacy and less access to resources and training for self-care. Health centers can help bridge these inequities by empowering patients through training and coaching support on self-care. Those patients who are more self-activated are better able to navigate their healthcare and social needs.

Relevant health information technology (HIT) capabilities to support this activity include care guidelines, registries, clinical decision support, care dashboards and reports, quality reports, outreach and engagement, and care management/care coordination.

(See Appendix E: Guidance on Technological Interventions.)

Given the challenges with equitable access to technology, a multimodal approach to supporting patients is important. The range of opportunities to provide patient support and education include face-to-face sessions, telephone sessions, asynchronous communication tools (e.g., patient portals and texting modalities) as well as telehealth visits.

Action steps and roles

1. Improve information resources to patients.

Suggested team member(s) responsible: clinic staff; if a patient and family advisory council is in place, ask them to develop and/or refine patient information materials.

  • Update patient information materials and have them available in the languages most prevalent in the community. Gaining input from patients is also valuable during this process.
  • Support patient use of a patient portal that allows for easy access to the electronic health information.
  • Utilize health literacy universal precautions when creating widely circulating resources. The use of universal precautions is an approach to providing health information and services, which assumes that all patients may have difficulty comprehending health information or accessing services.[2] On an individual patient level, being aware of a patient’s level of health literacy helps staff members convey information effectively.
  • Discuss a patient’s interest in information about health topics during clinic visits. Rather than assuming that a patient needs and wants certain information, use tips from the field on motivational interviewing to ask open-ended questions.

Tip: Consider holding “onboarding” group visits for new patients, which orient the patients to the clinic, its workflows and resources, and opportunities for self-care support.


2. Identify opportunities to enhance patient knowledge and confidence.

Suggested team member(s) responsible: clinic staff, including social workers, diabetes educators, nurses and clinicians.

Provide patients with tools, such as mobile apps or wearable devices, to monitor their vital signs, physical activity and medication adherence. Regular monitoring enhances self-awareness and accountability.

Offer workshops and classes on nutrition, physical activity, stress management and/or sleep hygiene. Encourage patients to adopt healthier lifestyles through practical tips and motivational support.


3. Implement shared care plans with patients.

Suggested team member(s) responsible: care team; patients; and family members, if appropriate.

Implementing shared care plans (see AHRQ's Develop a Shared Care Plan) involves decisions of:

  • How the patient-clinician discussion will fit into the clinic visit workflow.
  • Training in facilitating collaborative conversations with patients.
  • How the shared care plan will be shared with the patient (e.g., paper, patient portal).
  • How the shared care plan will be documented.


4. Address health-related social needs that impact self-care.

Suggested team member(s) responsible: care team.

Implement universal social needs screening and use the results to identify health-related social needs of patients. See Key Activity 17: Use Social Needs Screening to Inform Patient Treatment Plans for more information.

Update a directory of community-based resources (see Key Activity 20: Strengthen Community Partnerships) and routinely refer patients to appropriate resources through the care coordination process already in place. Follow up with patients who have been referred to community-based resources to learn if the referral was helpful.


5. Implement self-management support.

Suggested team member(s) responsible: care team.

Self-Management Support is a technique that enables patients to play an active role in their healthcare. Self-Management Support uses the ask-tell-ask approach, patient-directed goal setting and follow-up to support individuals in making decisions that benefit their health and well-being. Training for staff and clinicians will be necessary to implement Self-Management Support.

Implementation tips

Begin self-care coaching in the exam room. Consider opportunities to leverage the extended members of the care team who often are representative of the populations you are serving. The self-management coaching can be before a patient is seen by a clinician (while waiting for the clinician) and after the patient has seen the clinician. The key is to ensure the self-management coaching is well coordinated by the integrated care team.

Self-care coaching can begin with new patients. Consider holding onboarding group visits for new patients, which orients the patients to the clinic, its workflows and resources, and opportunities for self-care support.


  1. Hibbard JH, Greene J. What the evidence shows about patient activation: better health outcomes and care experiences; fewer data on costs. Health Aff (Millwood). 2013 Feb;32(2):207-14. doi: 10.1377/hlthaff.2012.1061. PMID: 23381511.  
  2. AHRQ Health Literacy Universal Precautions Toolkit [Internet]. 2020 [cited 2024 Jan 12]. Available from: