To help patients self-manage their care, incorporate culturally and linguistically tailored evidence-based techniques for promoting self-management into usual care, and provide patients with tools and resources for self-management. Examples of evidence-based techniques to use in usual care include: goal setting with structured follow-up, Teach-back methods, action planning, assessment of need for self-management (for example, the Patient Activation Measure), and motivational interviewing. Examples of tools and resources to provide patients directly or through community organizations include: peer-led support for self-management, condition-specific chronic disease or substance use disorder self-management programs, and self-management materials.
Improve health outcomes by helping patients improve self-management.
Documented use of culturally and linguistically tailored evidence-based techniques to promote self-management into usual care. Include both of the following elements:
1) Patient literacy and language capture – Documentation of patient literacy level and/or language preference captured in the medical record (e.g., screenshot, electronic health record [EHR] report); AND
2) Provision of appropriate self-management care techniques – Documented use of evidence-based techniques to promote self-management into usual care (e.g., eligible clinicians' completed office visit checklist, electronic health record report of completed checklist, copies of goal-setting tools or techniques, motivational interviewing script/questions, action planning tool with patient feedback, record of condition-specific self-management coaching). Materials must be provided in a format appropriate for the patient's literacy and/or language preference.
Examples of Additional Activities that Qualify for Attestation
A primary care practice identifies cultural and educational variability, and associated variability in health literacy, in its patient population. To meet the needs of their patient population, the eligible practice clinicians review all self-management materials used by the practice and make changes to ensure all are written at the 6th-grade level or lower and are available in all languages needed for the patient population. If materials are not in all languages needed for patient population, the practice connects with an organization to translate the materials into languages not previously covered. Materials provided to the patient are referenced specifically in the EHR.
- Context, recommendations, and resources on Health Literacy: https://www.aafp.org/afp/2005/0801/p463.html
- Overview and resources: https://www.ahrq.gov/ncepcr/tools/self-mgmt/self.html
- Center for Disease Control and Prevention’s chronic disease self-management program: https://www.cdc.gov/arthritis/interventions/programs/cdsmp.htm; https://www.cdc.gov/arthritis/marketing-support/1-2-3-approach/docs/pdf/provider_fact_sheet_cdsmp.pdf
- Approaches for language assistance services to patients with limited English proficiency: https://www.cms.gov/About-CMS/Agency-Information/OMH/Downloads/Lessons-from-the-Field.pdf
- Guide to ensure meaningful access to programs: https://www.cms.gov/About-CMS/Agency-Information/OMH/Downloads/Language-Access-Plan.pdf
- Catalog of diabetes prevention resources tailored to various audiences: https://www.cms.gov/files/document/culturally-and-linguistically-tailored-type-2-diabetes-prevention-resource.pdf
- Medicare benefits for diabetes self-management training, with links to multi-language resources: https://www.medicare.gov/coverage/diabetes-self-management-training
- Find Administration for Community Living funded resources for self-management in your area: https://acl.gov/programs/aging-and-disability-networks