As patient engagement (aka consumer engagement) earns attention, the question increasingly arises: “Where do we start? What can we do?” More specifically, “What do we mean when we say ‘patient engagement’?” The Patient Activation Measure is a powerful tool for understanding where someone's at and how to interact with them differently.

1. © 2008 University of Oregon
Increasing Patient Activation to
Improve Health and Reduce
Costs
Judith H. Hibbard, DrPH
Institute for Policy Research and Innovation
University of Oregon

2. © 2008 University of Oregon 2
The Agenda
• What is patient engagement/activation?
• What do we know about those who are more
and less activated/engaged?
• Major insights– the big AH HA’s
• How does activation/engagement relate to
costs and outcomes?
• How do we segment? change activation?
• The future– ACO’s, PCMH, Care Transitions
and changing care to activate patients

3. © 2008 University of Oregon 3
The Need to Do Better with Less
 Patients and consumers are an important
resource in health care.
 Their participation is essential. We won’t reach
quality goals and improved outcomes without
patient engagement

4. © 2008 University of Oregon 4
There is great variation in patient activation/
engagement in any population group
If we don’t measure we won’t know if we are
making progress… measurement allows us:
 To know who needs more support
 To target the types of support and information patients
and consumers need
 To evaluate efforts to increase activation

5. © 2008 University of Oregon 5
Measurement Has Produced New
and Important Insights
• Hundreds of researchers all over the world
using PAM– we are learning from those efforts
• Having rigorous measurement is allowing the
development of the evidence base in this area

6. © 2008 University of Oregon 6
What Does it Mean to Be Activated ?

7. © 2008 University of Oregon 7
Patient Activation Measurement (PAM)
Difficulty Structure of 13 Items
Unidimensional
Interval Level
Guttman-like
Measurement Properties
•Uni-dimensional
•Interval Level
•Guttman-Like Scale

8. © 2008 University of Oregon
PAM 13 Question
* Related instruments: PAM 10, PAM 2, Clinician PAM
8

9. © 2008 University of Oregon 9
Activation is developmental
Source: J.Hibbard, University of Oregon

10. © 2008 University of Oregon 10
New Insights--Emotion plays a profound role in
patient activation

11. © 2008 University of Oregon 11
11
In their own words, Diabetes patients demonstrate
the differences between activation levels
“I don’t remember (medications). My
memory isn’t so good. I have a home health
care provider help me”
“I don’t understand the cause. I just know
I was told I have diabetes”
“I’m under a lot of stress because my
husband has cancer, but I try to do the
things I’m supposed to do. I have to be here
to take care of my husband”
“They say I should test my sugar every
day. I don’t do this because I can’t stand
to prick myself”
“I try to stay away from sweets …
sometimes I win, sometimes I lose”
“I know I’m supposed to (tell a doctor
concerns) but sometimes I don’t. I try to
cut down on my time at the doctor”
“I write down my concerns. I also have goals for
myself – like losing weight. I write down how I’m
doing with my goals. I’ve lost 20 pounds!”
“In the beginning I didn’t want to help myself.
For the first four years, I was in denial … and
really depressed. Then I bought the book
“Diabetes For Dummies,” and I got over my
depression and decided to start helping myself.
I’m doing a lot better now”
“I have to be my own advocate when
it comes to my health”
“My doctor can only do so much. I
have to manage my health”
“I feel it has to be a team effort between
the doctor and the patient and the
patient needs to be proactive in it”

12. © 2008 University of Oregon 12
Activation Level is Predictive of Behaviors
Research consistently finds that those who are more
activated are:
– Engaged in more preventive behaviors
– Engaged in more healthy behaviors
– Engaged in more disease specific self-
management behaviors
– Engaged in more health information seeking
behaviors

13. © 2008 University of Oregon 13
Level of activation is linked with each behavior
Source: US National sample 2004

14. © 2008 University of Oregon 14
14
Behaviors by Level of Activation Among Diabetes Patients
RWJ PeaceHealth Study 2006
© Insignia Health 2009

15. © 2008 University of Oregon 15
Behaviors in Medical Encounter by Activation
Level

16. © 2008 University of Oregon 16
New Insights
 Use activation level to determine what are realistic
“next steps” for individuals to take
 Many of the behaviors we are asking of people are only
done by those in highest level of activation
 When we focus on the more complex and difficult
behaviors– we discourage the least activated
 Start with behaviors more feasible for patients to take
on, increases individual’s opportunity to experience
success

17. © 2008 University of Oregon 17
Activation level insights guide support toward what is
realistic and achievable for a given level
17

18. © 2008 University of Oregon 18
New Insight---When activation changes several behaviors
change. Implications for how to start this process
Baseline 6 Weeks 6 Months
Wave
60
65
70
75
80
85
90
Estimated
Marginal
Means
72.0
79.9
87.4
62.1
64.4
61.7
Activation Growth Class
Estimated Marginal Means of Activation by
Wave by Activation Growth Class
Increased Growth Class
Stable Growth Class
11 of 18 behaviors show
significant improvement
within the Increased
Growth Class compared to
the Stable Growth Class

19. © 2008 University of Oregon 19
New Insight– When we offer new
patient programs and services,
who shows up?
 Stanford CDSMP
 Patient Portal use (higher activated twice as
likely to use portal than lower activated)
 PHR/ patient Portals
 When we don’t measure, we never know who we
are are reaching
 Because low activated are passive, they are
unlikely to respond to one-size fits all approaches

20. © 2008 University of Oregon 20
Insight--Activation is important in
any situation where the patient has
a significant role to play
 If people don’t understand their role, they
aren’t going to take action, they aren’t going
to look for or take in new information
 If people don’t feel confident, they are less
likely to be pro-active
 This appears to be true regardless of condition

21. © 2008 University of Oregon 21
21
National Study 2004
Medication Adherence by Level of Activation
for Different Conditions

22. © 2008 University of Oregon 22
Low activation signals problems (and opportunities)
22

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Engagement/Activation related to
Outcomes and Costs?
 Studies that examine how well activation
predicts future outcomes
 Studies that examine the relationship
between activation and clinical indicators
 Studies that examine activation and patient
costs
 Studies aimed at changing activation– impact
on outcomes and costs

24. © 2008 University of Oregon 24
Multivariate analysis which controlled for age group, gender,
race, comorbidities and number of diabetes-related prescriptions.
Carol Remmers. The Relationship Between the Patient Activation Measure, Future Health
Outcomes, and Health Care Utilization Among Patients with Diabetes. Kaiser Care
Management Institute, PhD Dissertation.
Activation can predict utilization and health
outcomes two years into the future for diabetics
% change for a 1
point change in
PAM Score
10 Point Gain in
PAM Score 54 (L2)
vs. 64(L3)
P
Hospitalization 1.7% decline 17% decreased
likelihood of
hospitalization
.03
Good A1c control
(HgA1c < 8%)
1.8% gain 18% greater
likelihood of good
glycemic control
.01
A1c testing
3.4% gain
34% greater
likelihood of testing
.01
LDL-c testing

25. © 2008 University of Oregon 25
Study Implications
• Findings highlight the importance of the
patient role in outcomes and cost
• As provider payments become more closely
linked with patient outcomes, understanding
how to increase patient activation will become
a priority for payers and providers.

26. © 2008 University of Oregon 26
Increases in Activation are
Possible
• If we want patients to take ownership we have
to make them part of the process.
• Listen, problem-solve, and collaborate
• Help them gain the skills and confidence they need
• This represents a major paradigm shift
– Moving away from simply “telling patients what to
do.” Different than “compliance”--
– There is a focus on developing confidence and
skills, and not just the transfer of information.

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Patients who get more support for self-management
from their Doctors are more activated.

28. © 2008 University of Oregon 28
Patient Experience and Patient
Satisfaction
• Findings from multiple studies, and with
different populations in different settings,
indicate that more activated patients get
better care, have better experiences with their
care, and are more satisfied with their care.
– Findings from hospital settings and from
ambulatory settings. Higher activated report
fewer care coordination problems, and better
communication with providers

29. © 2008 University of Oregon 29
 Tailored coaching
 Including brief coaching in the clinical setting– with follow-up
 Segmentation approaches and differential allocation
of resources
 Care transitions and reducing hospital re-admissions
 Wellness, disease management
Increasing Activation

30. © 2008 University of Oregon 30
Use PAM in Coaching in 4 Ways
►Assess activation level
►Tailor coaching to activation level
►Visual scan to open a productive discussion
►Track progress

31. © 2008 University of Oregon 31
TAILORING : Levels 1 and 2
Characteristics Approach to Patient Support
•Overwhelmed
•Weighted down by negative
emotions
•Lack confidence
•Poor problem solving skills
•Lack basic health/condition
knowledge
•Poor self-awareness
•Few self-management skills
developed
•Passive. Self-management is
following Dr. orders
• May not grasp importance of their
role
Lower
Activated
• one focus at a time. Avoid a long
list of goals/actions
•Focus on what is important to the
patient
•Reinforce the importance of their
participation
•Small steps with encouragement
•Experiencing success builds
confidence
•Loop back on behavioral goals
• Show empathy – “You have a lot
going on”, “feeling overwhelmed is
understandable”
• Build on strengths
•Focus on positive emotions
•Develop problem solving skills–
jointly problem solve

32. © 2008 University of Oregon 32
TAILORING : Level 3
Characteristics Approach to Patient Support
•Takes some positive actions
around health
•Feels more ready to take on
challenges
•Still needs to build confidence and
fill knowledge gaps
•Use small step approach, but focus
on ‘larger’ single step
•Focus on what Individual wants to
focus on
•Build on strengths
•Provide encouragement
•Loop back on behavioral goals
•Jointly problem solve around
specific behaviors

33. © 2008 University of Oregon 33
TAILORING: Level 4
Characteristics Approach to Patient Support
•Goal Oriented
•More self-aware
•Self-management skills developed
•Pro-active
•Good problem solving skills
Higher
activated
• Focus on what is important to the
patient
• Focus on maintaining behaviors
and any lagging behaviors
• Still use small steps approach
•Experiencing success builds
confidence
•Stretch goals
•Problem solving around relapse
issues
• Build on strengths

34. © 2008 University of Oregon 34
Tailored Coaching Study
▶ Intervention group coached based on level of activation.
Control group was “usual care” coaching (DM company)
▶ Examined changes in claims data, clinical indicators, and
activation levels
▶ 6 month Intervention period.

35. © 2008 University of Oregon 35
Coaches allocated more talk time to lower activation
participants when they had access to PAM scores

36. © 2008 University of Oregon 36
PAM tailored coaching resulted in a statistically
significant greater gains in activation
N.=245 in intervention group; N=112 in control group. Only those with 3 PAM scores are included.
Repeated measures shows that the gains in activation are significant in the intervention group and
not significant for the control group (P<.001)

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Tailored coaching can improve adherence and reduce
costly utilization
Hibbard, J, Green, J, Tusler, M. Improving the Outcomes of Disease
Management by Tailoring Care to the Patient’s Level of Activation. The
American Journal of Managed Care, V.15, 6. June 2009
Clinical Indicators*
Medications: intervention group
increased adherence
to recommended immunizations and
drug regimens to a
greater degree than the control
group. This included getting influenza
vaccine.
Blood Pressure: Intervention group
had a significantly greater drop in
diastolic as compared to control
group.
LDL: Intervention group had a
significantly greater reduction in LDL,
as compared to the control group.
A1c: Both intervention and control
showed improvements in A1c.
*Using repeated measures, and controlling for
baseline measures

38. © 2008 University of Oregon 38
Tailoring had a positive impact on all patient
outcomes
• Findings consistent across all outcome measures
• Results are compared to usual coaching
• Valuable Implementation lessons learned along
the way

39. © 2008 University of Oregon 39
PCMH are using a team-based
approach to supporting activation
• Tailoring to PAM levels is being patient
centered
• PAM levels shared with all team members.
• Strategies and approaches to supporting self-management
can be consistent and reinforced by all team members
• Allocate resources based on both patient clinical
profile and PAM score– providing more help to those
patients less able to self-manage
• More efficient use of resources: target those who
need more help

40. © 2008 University of Oregon
# of Patient Visits to ED or Urgent Care
PeaceHealth Medical Home Program

41. © 2008 University of Oregon 41
Accountable Care Organizations
• ACOs are being evaluated on the triple aims:
– Improved population health
– Improved quality
– Cost control
As patients play a significant role in all of these
outcomes, ACO aspirants are looking closely at
ways to activate patients.
4 of the “pioneering” ACO groups are using the PAM
model

42. © 2008 University of Oregon 42
42
James
Peters VA
Center
Adoption of PAM and PAM based coaching is supporting care
transitions, the medical home, and accountable care programs

43. © 2008 University of Oregon 43
Chronic Illness Patients Need both
Clinical and Behavioral
Interventions
 Activation is more likely to occur if the patient
is getting consistent and appropriate
messages and support
 Communications based on activation level
(tailoring)
 Type and amount of support based on activation
level (segmenting)

44. © 2008 University of Oregon 44
Measuring Activation Can:
• Improve efficiencies– more targeted use of
resources through segmentation
• Meet the needs of your members, Tailored:
coaching, communications, plan design, &
customer service
• Improve the quality of the medical encounter:
provide feedback to clinical teams;
• Evaluate the impact of web strategies

45. © 2008 University of Oregon 45
Engagement Means…
• Start where the patient is
• Encourage realistic steps– creating
opportunities to experience success
• Build on strengths
• Attention to emotions
• Use measurement to assess and to track
progress