Stepped Care Model for Self Management Support

CCMI has developed a number of informational and interactive materials to foster shared understandings and approaches on specific relationship based care models. Please explore our site and blog to learn more about our programs, resources, and tools.

The Stepped Care Model for Self Management Support is a way to think about care in levels or “steps”. Different patients need different levels of care. If patients aren’t meeting their health goals, or lack confidence to self-manage, we step up our support. We can determine how much support people need by checking in with them (assessment). Clinicians might be familiar with stepped care for high blood pressure, diabetes or depression. The steps include:

Expert Methods

This step is for people who need very specialized care. Examples of people who have these skills are psychologists and addictions specialists.

Advanced Approaches

This step is for people who need more than the core techniques. Some examples include Group Visits, which provide the opportunity for group interactions and strong peer modelling, and Motivational Interviewing (MI), which helps to address ambivalence (feeling two ways about something).

Motivational Interviewing: This is a collaborative style to strengthen a person’s own motivation and commitment to change.

Behaviour Change Support – Action Planning

This step helps people to achieve their goals by making action plans, problem solving, and following up or checking in on how plans are going. It leads to increased patient confidence and learning. Brief Action Planning (BAP) is one example of an effective tool to help people set goals.

Brief Action Planning: This is a tool for people that want to help others make plans to improve their health or well-being. Making a Brief Action Plan with someone involves helping them to become focused, specific, committed, and confident in their plans. It is one way to partner with patients around their goals.

Culture – Health Literacy – Engagement

This step is the foundation for all health care interactions. Below are examples of things that need to be in place to ensure patients are receiving care that is matched to their needs.

Engagement: Engagement means encouraging people to be active in making a difference in their health through their daily actions.

Health Literacy: This refers to the ability to hep people get information that is useful, clear and important to their situation.

Diversity: This means having a health system that can respond to the different needs in a community (e.g. age, language, cultural background).

Informed Decision Making: Encouraging people to get all the information they want to help make a decision about their health. 

Download the printable handout: Stepped Care for Self-Management Support Handout