WA has three different approaches as part of our learning about ways to work with this population:Seattle and is based in a Area Agency on AgingSW WA and is based in a mental health facilityIncludes clients receiving in-home personal care services
Washington is the first state to use the PAM with Medicaid clients.We are just beginning to see some effects of CCM on client activation- details on later slide
Coaching for Activation is on the Insignia Health website and can be used by clients as a tutorial or by clinicians for concrete steps in goal setting – related to specific disease condition and level of readinessSeattle area program received intensive training with Susan Butterworth of OHSU and Centers for Health Care Strategies on MI.Training included recorded conversations with feedback from trainers and lots of practice
Care managers feel MI has been a “breakthrough” technique for working with chronic care management clients.
Note there are similarities between the two systems for the first levels.
These next two levels are also essentially the same
Stages of change has two additional levels:Termination which acknowledges a stage when a person is comfortable with the changes madeRecyle/Relapse - recognizing movement between levels
N= 78 clientsPAM is administered every 4-6 months.The graph hints that something in the time interval moved about 5% more people into the highest readiness category.
Specific action steps included trigger identification, problem solving related to the relationship with her daughter, and meeting with the nurse in a safe, neutral setting outside her home.Able to resolve or manage her symptoms with coaching
Total number of responses = 1381Level 1 is lowest activation-Level 1: May not yet believe that the patient role is important Level 2: Lacks confidence and knowledge to take action Distribution for these chronic care Medicaid clients is heavy in Levels 1 and 2. This is the opposite of what Insignia has seen in the commercially insured population. The Medicaid population reported here are complex clients with more than one chronic condition.
Action Plan: increase his physical activity, manage his pain, lose weightWith coaching at his activation level, he gained enough confidence to accomplish a lot!
Increasing self management of chronic conditions through the use of PAM and MI
Increasing self management of chronic conditions through the use of PAM and MI<br />MaryAnne Lindeblad, BSN, MPH<br />Medicaid Purchasing Administration <br />State of Washington<br />October 6, 2010<br />MaryAnne Lindeblad<br />1<br />
High risk, high cost aged, blind and disabled adults with co-occurring disorders<br />The most complex of the complex<br />Payment is through a per member per month method with actuarially certified rates<br />Program is classified as an Prepaid Ambulatory Health Program with CMS<br />Currently using a 1937A Benchmark Benefit Authority<br />MaryAnne Lindeblad<br />2<br />Chronic Care Management in Washington State<br />
<ul><li>Patient Activation Measure (PAM) is part of the assessment
Stages of Change measured through modified Stanford Self-Efficacy tool http://patienteducation.stanford.edu/research/download.html</li></ul>MaryAnne Lindeblad<br />3<br />Client Readiness is Key to Change<br />
<ul><li>Developed by Dr. Judith Hibbard at Oregon Health Sciences University
Insignia Health designed “Coaching for Activation” for use by clients or clinicians in conjunction with PAM<br />Motivational Interviewing is used after Stages of Change are assessed<br />Both rely on client readiness for change and confidence in achieving goals<br />MaryAnne Lindeblad<br />5<br />Intervention Techniques<br />
<ul><li>First described by William H. Miller in 1983 as a technique to treat problem drinkers
Focused, directive counseling intended to elicit behavioral change that comes from client’s desire and confidence
Techniques - open questions, reflective listening, affirming and summarizing</li></ul>MaryAnne Lindeblad<br />6<br />Motivational Interviews (MI)<br />
MaryAnne Lindeblad<br />7<br />Comparison of Readiness Levels<br />
MaryAnne Lindeblad<br />8<br />Comparison of PAM Levels and Stages of Change, cont.<br />
Comparison of PAM Levels and Stages of Change, cont<br />MaryAnne Lindeblad<br />9<br />
MaryAnne Lindeblad<br />10<br />Impact of Intervention on Activation Level<br />
<ul><li>45-year-old female with depression, fibromyalgia, GERD, severe and persistent nausea and vomiting plus pain identified as stress related to her daughter.
Action plan included specific action steps for stress management.
Activation scores moved from Level 2 to Level 3 as she felt more confident in her ability to manage her own health care.</li></ul>MaryAnne Lindeblad<br />11<br />Case Study 1Increased Activation with Coaching<br />
MaryAnne Lindeblad<br />12<br />Distribution of PAM ResponsesWashington Medicaid<br />
<ul><li>55 year old male with morbid obesity, COPD and bilateral osteoarthritis of the knees with PAM Activation Level 1.
Agreed to participate in CCM in order to get gastric bypass and total knee replacement surgeries.
Client developed action plans related to goal for the knee and bypass surgery .
Lost 100 pounds, did not need gastric surgery and doing water aerobics.</li></ul>MaryAnne Lindeblad<br />13<br />Case Study 2PAM Level 1 Client Success<br />
<ul><li>Expect movement back and forth between stages and levels. Motivation and Activation are dynamic states.
Significant life events such as housing change, hospitalization of self or family/friends, new diagnosis, financial stress can stall or change a person’s ability to self manage.</li></ul>MaryAnne Lindeblad<br />14<br />Washington Experiences<br />
<ul><li>Hierarchy of needs impact motivation. Threat of losing housing, not receiving check in time or not having enough food can take precedence over health action plan.