Impact Studies in Health Literacy and Patient Activation - PART 3

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Slide 1

But what about people with low activation? What we know might sound familiar:   People with low activation are more likely to delay care and less likely to seek and obtain preventive health services.   People with low activation are less likely to comply with recommended treatment and less likely to engage in self-management of health conditions.   People with low activation are less likely to report that they set goals or were taught how to self-monitor their condition and people with low activation also appear to get less support in managing their health.   And people with low activation are less likely to ask questions and seek out additional information about their condition or treatment.

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People can have low health literacy and low activation. That puts them in the highest risk category: at risk for making medication errors, not adhering to treatment, missing appointments, missing prevention screenings and services, etc.   We can reduce these risks by raising health literacy skills (we do this by providing health information that easy to obtain, process and understand) and by increasing activation. Doing both can move patients into the lowest risk category.

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One finding of Dr. Hibbard’s research that fascinates me is that activation may actually compensate for lower literacy skills.

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Dr. Judith Hibbard, form the University of Oregon, developed the concept of patient activation and the Patient Activation Measure (PAM).

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I want to take a couple minutes to talk about a national study using the Patient Activation Measure to access the level of activation in the U.S. adult population. Just as we have national data for literacy and health literacy, this study conducted by the Center for Studying Health System Change provides a snapshot of patient activation.

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Some of the key findings:   Levels of activation vary considerably   And activation is lowest in populations with low incomes, less education, those who self-report poor health, and Medicare/Medicaid enrollees. These are the same populations at greter risk for low literacy and low health literacy.

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The study found that less than half of all adults are in the highest level of activation. Even at this level, most people still struggle to maintain healthy behaviors. Activation also fluctuates, and can change overtime.

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A patient can move both forward and backward on the patient activation spectrum. Overall literacy often remains the same over time: can decline with age, can improve if patient with low literacy skills seeks assistance from a resource such as their local literacy council. Health literacy and patient activation fluctuate over time, impacted by a number of factors, and is often independent of a person’s overall literacy skills. In other words, a person with high literacy skills can have low health literacy or low activation or both. Likewise a person with low literacy skills can be activated, and higher activation can compensate for lower literacy skills.

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Common beliefs and statements of patients at various levels of activation.   Notice the difference at Level 1: “My doctor takes care of me” vs. Level 4: “My doctor can only do so much. I have to manage my health.”

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Part of the patient activation measure survey (short form is 13 questions).   Patient activation begins with an awareness that I am responsible for managing my health.

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The Patient Activation Measure (both the long and short form) is validated, reliable, and predictive.

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Increased levels of activation correlate with increased self-management behaviors.

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Using chronic disease as a summary/comparison of low health literacy and low patient activation.   Patients with low literacy as well as patients with low activation (and a patient can have both) are less likely to engage in self-care management and less likely to comply and follow through on lifestyle changes and treatment recommendations.

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A research example:   Project IDEAL looked at health knowledge acquisition and retention and compared it to adherence over a 12 month time period. Participants in the research were enrolled in the program through community health clinics. Strategies to improve health literacy skills were included in the design of the education program.   Participants were tested and surveyed regarding their knowledge of several self-management behaviors to manage diabetes.

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Participants scored very high in knowledge of medications to manage diabetes, as well as how to take the medications, what they do, and why they are important. Participants also tested high in knowledge of how to test blood sugar and why it is important. Participants also scored high in knowledge about healthy eating.   After a month, only 78% of participants were adherent in taking their medications, and after a year adherence dropped to 51%.   While knowledge was high about how to test blood sugar levels and why this is important, after one month 66% of participants were testing their blood sugar as directed, and after a year adherence dropped to below 60%.   Healthy eating seems to be a behavior many patients struggle with. While nearly 90% of participants scored high in knowledge of healthy eating strategies, after one month, only half were adhering to the recommendations; and after a year, adherence dropped to under 20%.

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What do these findings tell us?   Knowledge is not enough Self-management skills must be included, and patients need to be activated or motivated to adhere to recommendations Education and support needs to be continuous Health literacy and patient activation should be considered as strategies to improving patient-centered care   Evaluate and meet patients where they are

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Meeting patients “where they are” is an important element of patient activation. Using the Patient Activation Measure as baseline, and then measuring at set intervals does a couple of things:   First, it helps the provider, care management nurse, case manager, care giver evaluate activation levels and to tailor education and action steps accordingly. Second, it provides an opportunity to check for progress over time.   Research using the Patient Activation measure in this way revealed the benefits of a step approach, and that patients can be moved to higher levels of activation by building off of small successes that increase confidence and self-efficacy.   Also, more complex, complicated behaviors require higher levels of activation. For example, focusing on exercise and counting carbs requires level 3 and 4 activation skills and confidence, and would not be an effective strategy for patients in the lowest levels of activation. Starting there most likely would cause high levels of anxiety and increase the likelihood of failure, and it’s hard to recover from failure. It leads to “I tried that and it didn’t work” syndrome. But taking small steps and building on success is an effective strategy for increasing activation. And increased activation, the research shows, leads to improved self-care management.

Slide 1

Patient Activation Patients with Lower Activation: are more likely to delay care have lower levels of preventive health behaviors and preventive care are less likely to comply with recommended treatment are less likely to engage in self-management of health conditions are less likely to report that they set goals or were taught how to self-monitor their condition appear to get less support in managing their health are less likely to ask questions

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Low Health Literacy or Low Patient Activation?

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Patient Activation Research suggests activation may help compensate for lower literacy skill, increasing comprehension among those with lower literacy. (Judith Hibbard et al.)

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Patient Activation Patient Activation Measure (PAM) developed by Judith Hibbard (University of Oregon)

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How Engaged Are Consumers in Their Health and Health Care, and Why Does It Matter? Center for Studying Health System Change (HSC) National study, released in October 2008 The study analyses data from HSC’s 2007 Health Tracking Household Survey The first large representative survey of 13,500 adults using the Patient Activation Measure (PAM) to assess the level of activation in the U.S. population Hibbard JH, Cunningham PJ. How engaged are consumers in their health and health care, and why does it matter? Res Briefs. 2008 Oct;(8):1-9 . http://www.hschange.org/CONTENT/1019/1019.pdf

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How Engaged Are Consumers in Their Health and Health Care, and Why Does It Matter? Key findings: The level of patient activation (a person’s ability to manage their health and health care) varies considerably in the U.S. population. Activation levels are low for people with low incomes, less education, Medicaid enrollees, and people with poor self-reported health. Hibbard JH, Cunningham PJ. How engaged are consumers in their health and health care, and why does it matter? Res Briefs. 2008 Oct;(8):1-9 . http://www.hschange.org/CONTENT/1019/1019.pdf

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Patient Activation "Less than half of all adults in the United States (41.4%) are in the highest level of activation. Even at this level, people still struggle to maintain healthy behaviors but tend to have the skills and confidence to manage their health in a more proactive way." Hibbard JH, Cunningham PJ. How engaged are consumers in their health and health care, and why does it matter? Res Briefs. 2008 Oct;(8):1-9 . http://www.hschange.org/CONTENT/1019/1019.pdf

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“Patient Activation Measure; Copyright 2003-2005, University of Oregon. All Rights reserved.” All rights reserved Insignia Health, LLC 2008 (Used with permission) Patient Activation

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Patient Activation “Patient Activation Measure; Copyright 2003-2005, University of Oregon. All Rights reserved.” All rights reserved Insignia Health, LLC 2008 (Used with permission)

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Patient Activation Measure “Patient Activation Measure; Copyright 2003-2005, University of Oregon. All Rights reserved.” All rights reserved Insignia Health, LLC 2008 (Used with permission)

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Patient Activation Measure http://www.ncbi.nlm.nih.gov/pubmed/15230939 The Patient Activation Measure (PAM) is a 22- item measure that assesses patient knowledge, skill, and confidence for self-management. The PAM is valid, highly reliable, and unidimensional.

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http://www.ncbi.nlm.nih.gov/pubmed/17610432 Positive change in activation is related to positive change in a variety of self-management behaviors. Results suggest that if activation is increased, a variety of improved behaviors will follow. Patient Activation Measure

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Chronic Disease Management: Health Literacy and Patient Activation Low health literacy Less likely to engage in self-care and chronic-disease management Less likely to comply with recommended treatment Low patient activation Less likely to engage in self-management Less likely to follow through on lifestyle changes and comply with treatment plans

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Chronic Disease Management: Diabetes Project IDEAL (Improving Diabetes Education, Access to Care and Living) Clinical and patient survey data were obtained on 249 participants from 11 primary care community health clinics serving low-income populations in North Carolina (Anderson RT, Balkrishnan R, Camacho F, Bell R, Duren-Winfield V, Goff D. Patient-centered outcomes of diabetes self-care. Associations with satisfaction and general health in a community clinic setting. N C Med J. 2003 Mar-Apr; 64 (2):58-65.) http://www.ncbi.nlm.nih.gov/pubmed/12774734

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http://www.ncbi.nlm.nih.gov/pubmed/12774734 Chronic Disease Management: Diabetes

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Chronic Disease Management Knowledge is not enough Self-management skills must be included Education and support needs to be continuous Health literacy and patient activation should be considered as strategies to improving patient-centered care Evaluate and meet patients where they are

Slide 17

Source: US National sample 2004 “Patient Activation Measure; Copyright 2003-2005, University of Oregon. All Rights reserved.” All rights reserved Insignia Health, LLC 2008 (Used with permission)

Summary: This presentation is an expanded version of a webinar sponsored by Krames Patient Education. Low health literacy is a barrier to care, and populations with chronic diseases are at higher risk. Research suggests activation may help compensate for lower literacy skill. This series explores effective methods to increase patient activation and to address the needs of patients with low health literacy.

Tags: doug seubert health literacy communication communications activation patient engagement empower

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