Patient Engagement
and Self-Management
Jeanie Knox Houtsinger
University of Pittsburgh School of Medicine
Department of Psychiatry
Robert Wood Johnson Foundation
Depression in Primary Care National Program
Presentation Overview
Key concepts related to patient
engagement and self-management
Why are they critical components of good
chronic illness care?
Strategies for engaging patients,
developing wellness toolkits and working
through symptom relapse
Engagement – employing strategies to
motivate patients to access and use
services and tools to manage their illness.
Self Management - process patients can
use to look at their health behaviors and
then make choices to improve their health
based on their knowledge, skills and
Barriers to Patient Engagement
System Barriers
Patient Barriers
System Strategies for Addressing
Barriers to Patient Engagement
National thought leadership
Curriculum reform
Professional standards
Patient expectations for care
Personal health information
Performance information
Patient safety improvements
Process based payment
Outcomes based payment
Patient financial responsibility
Engagement Interventions
Focus on 2 phases of treatment
Initial attendance
Ongoing retention
Can be implemented in all areas of
Chronic Care Model
Engagement Interventions and the
Chronic Care Model
Delivery system
Redesign system to assure effective and efficient clinical care and promote
Create culture, organization and mechanisms that promote effective
interaction, workflow improvement, and self-management.
Clinical information systems
Use patient registry to track assessment scores, appointment attendance,
patient action plan.
Decision support
Promote self-management strategies consistent with scientific evidence and
patient preferences
Telephone engagement and use of patient action plan
Use evidence-based guidelines to help patient address barriers to achieving
self-management goals
Community services
Information and linkages with community services (e.g. childcare,
transportation, activities) to reduce no-shows and help patients achieve selfmanagement goals
Empowering the Patient
Effective Self-Management Tools:
Don’t require an “expert”
Rely on “natural supports” (friends, family,
neighbors, etc.) rather than “programs”
Can be applied across a range of
conditions (not just a single disorder)
Meet people “where they are” through the
course of their illness and recovery
Can fit on a refrigerator door
Self–Management Supports:
What to Avoid
Gender bias
Cultural bias
Literacy assumptions – including
“computer literacy”
Excessive focus on medication
Overuse of the word ”Compliance”
Examples of
Action Plans
Wellness Action Recovery Plan (WRAP)
Wellness Toolbox: Used to develop WRAP Plan
List of activities that patients have done in the past - or could do
in the future - to help them stay well
List of activities that patients can do to help them feel better
when they are not doing well
Elements of written WRAP plan
Daily Maintenance List
Early Warning Signs
Things are Breaking Down
Crisis Planning
Developed by Mary Ellen Copeland, MA
Wellness Toolbox:
Examples of Wellness Tools
Talk to a friend
Talk to a health care professional
Peer counseling or exchange listening
Focusing exercises
Relaxation and stress reduction exercises
Guided imagery
Journaling (writing in a notebook)
Creative affirming activities
Diet considerations
Elements of WRAP Plan
Daily Maintenance List
Describe how you feel when you are feeling well.
List the things you need to do for yourself every day to stay well.
List reminders that you might need to do based on how you are
List those things that, if they happen, might cause an increase in
your symptoms or things that may have triggered your symptoms
in the past.
Write an action plan that you can use if triggers come up.
Elements of WRAP Plan
When Things Are Breaking Down
List early warning signs that you have noticed in the past when your
condition worsened.
Write an action plan to use if early warning signs come up.
Crisis Planning
Develop crisis plan slowly when you are feeling well.
Use crisis plan to instruct others about how to help you when you are
not feeling well and need help.
Crisis plan keeps you in control even when it seems like things are
out of control.
Insures your needs are met because others will know what to do
Saves time and frustration
Where Can I Learn More?
Self-Management Tools on the Web
New Health Partnerships (
Designed to facilitate collaborative self-management engaging patients,
family members, and health care providers who want to work together as
partners in care.
Institute for Healthcare Improvement
Features links to websites and publications focusing on self-management
and patient-centered care.
Massachusetts Consortium on Depression in Primary Care
Includes consumer information in English and Spanish on medications used
to treat depression and suggestions for managing their illness.
MacArthur Foundation Initiative on Depression (
Provides downloadable self-management tools in English and Spanish.
Hope to Healing (
Forum for patients to share personal stories about challenges they face, how
they sought help and ongoing efforts to manage their disease.
Suggested Reading: Engagement
Wang et al. (2008) Disruption of Existing Mental Health Treatments
and Failure to Initiate new Treatment after Hurricane Katrina, The
American Journal of Psychiatry, 165(1):34-42.
Cavaleri et al. (2007) The Sustainability of a Learning Collaborative
to Improve Mental Health Service Use among Low-Income Urban
Youth and Families, Best Practices in Mental Health, 3(2):52-61.
McKay et al. Integrating Evidence-Based Engagement Interventions
into “Real World” Child Mental health Settings (2004) Brief
Treatment and Crisis Intervention, 4:177-186.
Wagner et al. (1998) Chronic Disease Management: What Will It
Take to Improve Care for Chronic Illness? Effective Clinical Practice,
Suggested Reading: Self-Management
Brownson et al. (2007) A Quality Improvement Tool to Assess SelfManagement Support in Primary Care. The Joint Commission Journal on
Quality and Patient Safety, 33(7):408-416.
Bachman et al. (2006) Patient self-management in the primary care
treatment of depression. Administration Policy and Mental Health,
Pincus HA et al. (2005) Depression in primary care: Bringing behavioral
health safely into the main stream. Health Affairs, 24:271-276.
Battersby MW. (2004) Community models of mental care warrant more
governmental support. British Medical Journal, 329:1140-1141.
Bodenheimer et al. (2002). Patient self-management of chronic disease in
primary care. Journal of the American Medical Association, 288:24692475.
Wagner et al. (2001). Improving chronic illness care: Translating evidence
into action. Health Affairs, 20, 64-78.
Copeland ME. (2001). The Depression Workbook: A Guide to Living With
Depression and Manic Depression. Oakland, CA: New Harbinger

Patient Engagement and Self-Management