Patient Activation Measure - e-Patient perspective

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

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

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

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

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

23. © 2008 University of Oregon 23 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.

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

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.

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)

37. © 2008 University of Oregon 37 37 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

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

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

Patient Activation Measure - e-Patient perspective

Patient Activation Measure - e-Patient perspective

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