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The specific skills that are really important to use for self management support, I think the biggest one is the open-ended question. Really just getting the patient's story. And letting them know that you want to know them. You want to hear their story. Building that relationship so that that builds trust so that then it's easier to contemplate making a behavior change if you have a relationship with somebody.

Mostly what I do I feel like is listen. And then reflective listening, which is a really important self management skill. So it sounds like instead of making your back worse maybe it's helping you. It might be helping me…

Once you get it, it makes it so much easier. Because we're just mirroring to the patient what they're telling us so that they can better understand and also so we can. Bringing the patient more into the conversation and instead of talking about them, talking to them.

Those are things we do naturally and now we have names for them and now we can think about how to implement them more systematically specifically to improve care. I think I can say with complete confidence right now that everybody loves this system of working with patients on self management for chronic problems.

What we've tried to do here is integrate collaborative goal setting into the clinical visit. And the way that we do that is we have the nurse, the triage nurse, start the goal- setting process with the patients when they come in to have their blood pressure taken. So she helps them to identify health care goals. She starts the action plan with them.

And then when they're ready to see me they bring that paper with them to me and I'm able to go over their goal with them, go over their action plan with them. Clarify things, sometimes make some changes, encourage them, reinforce that and that has been the way that we have integrated the goal setting into the context of the medical visit.

The way I look at it the team has got to work together. I like to empower them. Either the nurse practitioner or the respiratory therapist comes in and takes their inhaler and their aerochamber and says show me how you use it. They might spend 20 minutes doing that whereas I'm seeing another patient. So from my personal point of view that makes it much more efficient.

So you go about five days a week to the gym?

We work together. We really are a team working for my health. I feel that not only am I working hard for me but that each and every one of my team is.

We bring the family in sometimes extended family members. And then in every clinic visit we go over the areas that have become challenging for them or that they're confused about. We know how important the team is and so we make it our business to work closely together and figure it out.

There wasn't a particular day that I came in and everything changed. But there definitely was a moment when I realized this is so much better. And … being in a place where I felt like I could continue to make improvement.

When I see a patient it's finding the key that opens that door that will make them want to take care of themselves. It's also the follow up that helps. If I am keeping track of what she's doing and we are keeping track of that and giving her the support at every step of the way.

When we have a patient who's been designated with a chronic illness, first thing is the provider-patient encounter. The providers then include our health coaches. So some of it is a little bit of a hand off to the health coach because the health coach is going to be the person who is going to follow along with the patient. This means follow-up phone calls, could be group visits, individual visits. Many of the health coaches are very independent in taking patients into a room and following up with them on their self management support. What we did was we shifted the basic education from the exam room so that the providers were able to maximize their time with patients dealing with the more difficult complexities of the disease process. And a lot of the chronic illness basic education was left for the health coaches and medical assistants to have with patients.

Since the beginning of this epidemic Harlem Hospital has been in the business of treating and providing care. And they learned early on that peer interaction is positive. So that if a person can see another person's success they would buy into the therapy. When I meet somebody I say, I was where you were in that seat…

We face a lot of challenges with patients who don't buy into self management. At that point, that's where a peer is valuable. And the more they learn about their illness, the more successful they become. And they start to get excited. And they start to find, I want to find out more, I want to do more. I want to be more. I have a mission. I have a goal. I have an objective, and it's wellness.

We're really asking them to change their behaviors and to do that it's so important for us to recognize that we have to change our own behaviors first. A lot of medical providers didn't come into this job asking patients what they want, what feels right to them. They're used to telling. So it's really about us looking at our own behaviors and how we can be more patient-centered and then supporting each other in making those behavior changes.

As far as giving advice to someone who's thinking about embracing self management, I'd say give it a go, give it a try.

You can make a big difference by doing some simple things.

The open ended question.

Reflective listening.

Staff engagement.

Relationship building.

Basic education.

Collaborative goal setting.

People meeting their goals and then wanting to set new goals.

That is so fabulous!