Judith Hibbard PAM presentation

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RWJ story

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It is about helping people understand their own role in the care process It is when people have the skill and feel capable of taking on the job of self-management

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13 items– used RASCH to create a measure that much stronger than most social science measures

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In depth interview Percent of people at the low end…

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When consumers at each talk about their health levels differences are very apparent. At L1 – not culpable for their health, disengaged. At the other extreme, L4, very active, realize they must be their own advocate in partnership with their physician Taken for two studies – UO Study and Pfizer Health Solutions Study Can very easily connect these quotes to our Attitudes, Motivations, Emotions and Learning Preferences Study

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What about people who are not activated, are we just discouraging them further? start with behaviors that are feasible– whether the clinical encounter– telephonic coaching– employer communications– -- the idea is to help or People gain a sense of competency: Experiencing success Physician support is important Encouragement Seeing others like them succeed.

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Discusses the development objectives for each level of activation This is a progressive model, not a bucket model. We want to move folks from one level to the next, leaving behind the characteristics of the previous level Even at level 4 there is work to do! Our portfolio products (training, CFA, Flourish) address these levels of activation – we start where the individual is and help them realize success through small steps

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Who are you are touching– not touching those we most need to reach

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71% high, 29% low CTM Low score = 23% readmitted Overall in the study – 14% readmit, 15% returned Study population – Age 50 to , At least one serious chronic condition

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Intervention and control coaches both spend an average of 16 minutes per call. Intervention (coaches know pam level) coaches spend an average of 18 minutes per call with activation level 1 patients. They spend an average of 16 minutes per call with level 4 patients. Control group (coaches do NOT know patient pam level) spend an average of 16 minutes with both level 1 and level 4 patients (this difference between intervention and control -- broken down by pam level, is statistically significant at .05)

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Intervention group went from 64.3 to 68.9 (six months or less-- this is from their first pam to their 3rd pam) control went from 65.6 to 67 (also 1st to 3rd pam). most of the gains in the intervention group were in levels one and two. The intervention group was coached using a tailored to pam level approach. the control group got "usual coaching”in the intervention group (where coaches knew activation score) talk times are significantly shorter among those who are more activated. In the control group (where coaches did not know activation score) talk times are significantly LONGER for patients who are MORE activated.

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Oct 08 – Dec 2009 – Regence grant period

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

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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

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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

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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

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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

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What Does it Mean to Be Activated ?

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Patient Activation Measurement (PAM) Difficulty Structure of 13 Items Unidimensional Interval Level Guttman-like Measurement Properties Uni-dimensional Interval Level Guttman-Like Scale

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PAM 13 Question * Related instruments: PAM 10, PAM 2, Clinician PAM 8

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

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New Insights--Emotion plays a profound role in patient activation

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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”

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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

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Level of activation is linked with each behavior Source: US National sample 2004

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

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Behaviors in Medical Encounter by Activation Level

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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

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Activation level insights guide support toward what is realistic and achievable for a given level 17

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New Insight---When activation changes several behaviors change. Implications for how to start this process 11 of 18 behaviors show significant improvement within the Increased Growth Class compared to the Stable Growth Class

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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

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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

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21 National Study 2004 Medication Adherence by Level of Activation for Different Conditions

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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

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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

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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.

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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.

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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

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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

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Use PAM in Coaching in 4 Ways Assess activation level Tailor coaching to activation level Visual scan to open a productive discussion Track progress

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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

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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

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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

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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.

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Coaches allocated more talk time to lower activation participants when they had access to PAM scores

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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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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

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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

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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

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# of Patient Visits to ED or Urgent Care PeaceHealth Medical Home Program

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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

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

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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)

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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

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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

Summary: Increasing patient activation to improve health and reduce costs, using the PAM (Patient Activation Measure)

Tags: healthcare e-patient patient activation

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