Chronic Care: Self Management The following guideline provides recommendations for self management by members and/or families of members with chronic conditions in order to improve health outcomes. For the purpose of this guideline, chronic illness is defined as a medical condition of more than 3 months and/or persistent functional limitations and/or the extended use of healthcare services beyond usual primary care services Self Management is the ongoing process by which members with a chronic condition and/or the family of a member with a chronic condition engages in activities which manage symptoms and promote health as well as manage the impact of the condition on function, interpersonal relationships and life roles. The objective of self management is to optimize health status and quality of life. Eligible Key Components Recommendation Frequency Population Member and/or Assessment Obtain a diagnosis and medication history. Assess activities of daily living, assistive devices, With each well child check and with family of member medical equipment, diet, mental health status, life planning. Evaluate visual, hearing, cultural, and any transitions in care/significant with a chronic linguistic needs as well as preferences and limitations. Determine knowledge of disease process health care changes condition ages birth and treatment plan. Evaluate caregiver resources. Evaluate current benefits to 12 years of age Interventions to promote Self • Advise: Counsel regarding health risks and benefits of change At time family elects to work on Self Management require that the • Agree: Agreement on goals that are collaboratively set based on member’s/family’s level Management Goals family/member have an active of importance and confidence in their ability to change the behavior and central role in their care • Assist: Help to problem solve/identify barriers, identify strategies and supports, and build With changes in Self Management self management skills Goals i.e. Goals met, new goals, • Arrange: Determine and arrange for a specific follow-up plan, referrals and next contact. changed goals. Self management interactions and re-assessments need to occur on a regular, structured basis

Collaboration Identify and assess other agencies/case managers available to member for collaboration. At time family elects to work on Self Management Goals and with any Possible sources: changes in providers, insurance, or • The member’s primary care provider office CMS clinics which may lead to • The Health Department of the county where the member resides additional resources. • The specialist medically managing the member’s chronic condition • Children’s Multidisciplinary Specialty (CMS) Clinics • The member’s pharmacy

Ages 12 years old All of the above plus integrating the Develop self-management activities which increase member’s active participation. When child reaches 12 years of age and above with a child into an active role in their care and with changes in Self chronic condition (if appropriate) Possible self management support goals: Management Goals i.e. Goals met, • Preparing and taking medications independently new goals, changed goals. Note: withdrawal of parental • Demonstrating good preparation and judgment by making arrangements for meds to be taken support/supervision is a gradual when away from home and individualized process; • Setting up appointments however, parental support in • Keeping written records of meds and care plan and symptoms chronic care is associated with • Anticipating possible side effects that may be bothersome improved outcomes. • Identifying obstacles up front and plans to address

Source: Chronic Care: Self-Management Guideline Team, Cincinnati Children’s Hospital Medical Center: Evidence-based care guideline for Chronic Care: Self- Management. www/cincinnatichildren’sorg/svc/alpha/h/health-policy/ev-based/chronic-care.htm, Guideline 30, pages 1-32, March 9, 2007. Approved by the UPHP CAC 6/12/13; 9/9/15; 9/13/17, 9/11/19 Page 1 of 1