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Self-Management & Self-Management Support

Self-management is an important part of daily life for people living with chronic kidney disease.

It relates to steps a person can take to live well with one or more chronic conditions. It includes steps to gain confidence managing:

  • their medical conditions
  • roles they have in their medical care and daily life
  • emotional challenges

To advance collaborative patient goal-setting as a provincial renal network, a provincial strategy and a worksheet were developed:

Self-management support refers to the systematic provision of education and support by health care staff to increase a patient's skills and confidence in managing their health challenges. This can include:

  • regular assessment of progress and challenges
  • patient goal-setting
  • support for problem-solving

Provincial frameworks for self-management and self-management support include:


Goal-setting is a pivotal element of self-management. It is defined as the process of acquiring information for and setting of specific, collaborative goals between health professionals and the patient in managing chronic conditions. The focus is on what matters to the patient. The process involves a series of conversations:

  • to understand what matters to the patient
  • to set an overarching medical and/or non-medical goal
  • to break it down into shorter-term goals over time that have realistic and concrete action plans
  • to follow up and provide support if needed

This is relevant to patients at all stages of the kidney journey, enabling optimal person- and family-centred care and ultimately leading to better patient experiences and outcomes.

Over the past decade, BC Renal repeatedly administered a patient experience survey called the Patient Assessment of Chronic Illness Care (PACIC). Goal-setting was consistently identified as a process that should be developed across all modalities of kidney care and all renal programs.

To better understand patient goal-setting from various perspectives and identify common areas for improvement across modalities, BC Renal and the renal programs conducted a series of focus groups and a provincial workshop with kidney health professionals and patients and family members living with kidney disease across BC.

Patient Experience Survey Reports

Patient Goal-Setting in Kidney Care: Report on Focus Groups

SOURCE: Self-Management & Self-Management Support ( )
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