Using the patient activation continuum to improve care

There are lots of different definitions for patient engagement, said Christine Bechtel, vice president of the National Partnership for Women & Families. That disparity was the impetus for an article published in the February issue of Health Affairs, which reviews numerous studies on patient activation and how healthcare organizations can better utilize patients to improve outcomes and lower costs.

“We found that the most common definitions focus on engagement in care, involving behavior change or compliance and convincing and compelling patients to do something,” Bechtel said in a webinar hosted by the Patient-Centered Primary Care Collaborative. “Activation is a much more patient centered and modern term.”

There is a need for both a shared definition of patient engagement that is more multifaceted and reflects the evolution in the patient-clinician relationship, she said, as well as the evolution seen in the consumer world outside of healthcare.

There is a continuum of engagement at the direct care level, Bechtel said. The most basic is at the organizational level. For example, a medical practice might conduct a patient experience survey. More advanced practices would involve patients, families and perhaps an advisor in more areas of their work to determine methods to improve the patient experience. “At the highest level, patients and families are co-leaders of such initiatives.”

Patient activation represents a “big paradigm shift for providers,” Bechtel said. “It’s not part of their training and it’s a different way of thinking about their role.”

The authors spent a lot of time defining patient activation which resulted in an activated patient being “someone who has knowledge, skill and confidence to take on the role of managing their health and healthcare,” said Judith Hibbard, DrPH, senior researcher at the University of Oregon.

Activated patients understand their role and have the ability to take it on, she said. More activated people make more informed choices, can be a partner in their care and engage in preventive and self-management activities.

The authors’ research found that activation varies with age, income and education levels and “actually varies quite a bit within those groups,” she said. “Unfortunately, when people can’t do everything, they tend to do nothing.”

Many studies indicate that people who measure higher on the patient activation measure (PAM) scale are much more likely to engage in preventive and healthy behaviors, Hibbard said. While PAM score does predict behavior, as behaviors require more sustained action and maybe even require people to be assertive, fewer people in all levels actually do them. “The insight we got is that many of the things we’re asking people to do are only done by the most activated patients. Maybe we are setting people up for failure by asking them to do the most difficult things.” A better plan is starting people with small goals they can easily achieve and set them up for success.

Providers cannot overwhelm low-activated patients with too much to do and too much information, Hibbard said. The Health Affairs paper reviewed over 100 studies and found that lower-activated patients are more likely to be hospitalized and visit the emergency department. Higher-activated patients report better care experiences.

After controlling for demographics and severity, less activated patients have 8 percent higher costs in the base year and 21 percent higher costs in the following year than more activated patients.

Innovative healthcare delivery systems are using PAM scores as a vital sign, Hibbard said. Some patient-centered medical homes are allocating resources differently based on disease burden and PAM score, thereby providing more help to those patients less able to self manage.