Section 2 - Monitoring Self-Management Support Activities

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Section 2: Monitoring Self-Management Support Activities

Ongoing monitoring is needed to ensure that your organization’s staff or care teams continue to meet clients’ needs and provide the necessary follow-up to help clients achieve and maintain health. Collecting and assessing feedback from persons with behavioral health and substance abuse conditions as well as their natural supports improves the quality and responsiveness of care. New roles for staff will include organizing and using information and data from clients and their natural supports for monitoring and program improvement. Data systems can simplify the process for ongoing monitoring, but organizations can start with low-tech activities to assess whether self-management support and recovery activities are occurring for the majority of their clients. Leaders may need to assign responsibility and enable staff to function in these roles.

2.1 Is a formal feedback mechanism available for clients and their natural supports to comment on their care and help make improvements in your organization?
Feedback from clients and their natural supports should address the quality, appropriateness, and experience of the care they receive. Ideally, feedback is requested in a timely manner and includes the use of focus groups, interviews, surveys or other means to capture client input. Let clients know that feedback about changes in care delivery processes is valued, and describe how it is used to make substantive changes.


  • Gather client feedback through client experience surveys or comment cards.
  • Conduct client walkabouts, documenting client feedback as they experience an in-person visit, home visit, or other encounter with staff at your organization.
  • Involve clients and their natural supports in developing surveys and other feedback mechanisms.

2.2 Is input on program and staff activities sought from the client and their natural supports?
Client and natural support input can be sought at all levels of program operation, including policy and program design, monitoring and evaluation, and performance improvement initiatives.


  • Include clients and their natural supports on governing or advisory bodies, quality improvement teams, agency committees, and work groups.
  • Involve them in developing information resources and tools, such as new client orientation guides.
  • Document preferences and suggestions in the client’s chart or electronic record

2.3 Are reports and feedback on care and self-management support activities available to providers in a timely manner for ongoing quality improvement purposes?
Care teams require ongoing information about their clients to assess the consistency and effectiveness of their actions. This information is also needed to compare their performance with peers to support the sharing of best practices.


  • Review ten care plans over the prior three months and report to care teams. Review documentation to confirm client involvement in care planning or follow-up on short-term objectives.
  • Track how often care plans are made and the follow progress of clients toward meeting their goals.

2.4 Are provider-level or care team data reports generated and tied to guidelines or care plans to support self-management and care?
Ideally, providers and care teams should be able to quickly assess which clients need follow-up and reminders. Provider-level reports are critical tools to allow providers to effectively manage groups of clients. They can be generated from existing electronic systems to assist providers in directing their efforts to those clients who need it most. If data reports are not easily accessible through existing electronic systems, organizations may use a report generation module for developing client-level reports.


  • Use an electronic registry or database to sort clients by their care team and to identify which clients have outstanding follow-up steps. These modules can be built into external registry systems or through databases or tracking systems.

2.5 Does the organization have a team that leads QI activities focused on self-management support?
A dedicated QI team ensures appropriate projects are being initiated, metrics are being monitored and shared with providers, and projects and their metrics are discussed across the organization. Leadership must provide organizational support and dedicated time for team members to focus on these activities.


  • Create a QI team with provider, clinical support, program manager, and IT staff when available. Ideally the team should include clients and their natural supports.
  • Support clients and natural supports by involving multiple clients in QI activities, so that their level of representation is comparable to that of staff.

2.6 Does the organization provide opportunities for staff training in QI?
Build QI expertise by offering trainings or participating in collaborative QI projects that focus on measurement and use of data to drive clinical and operational changes.


  • Use resources from organizations that offer tools for health care professionals, such as the Institute for Healthcare Improvement.
  • Hire QI consultants to help coach teams to build the necessary skills for developing metrics and for effectively using data to drive improvements.
  • Support clients and natural supports by providing orientation to concepts and QI terms to ensure understanding and reporting of their input. Even if a recommendation is rejected or delayed, let them know the response to their input.

2.7 Does the organization have a formal means for sharing the results from QI initiatives?
Share data at the care team level and with clients and their natural supports to ensure continual improvement and sharing of best practices. Regular data sharing across teams can help motivate interest in improving care and facilitate the sharing of promising practices.


  • Discuss data at regular meetings and consider linking results to performance reviews and incentives for the organization.
  • Post paper graphs or dashboards on the clinic walls so that providers, clients, and natural supports can view the performance and goals of the organization.