Using the Patient Activation Measure (PAM) to Promote Patient Engagement Mary Jo Muscolino, RN, MPA, CCM, CASAC Director, Behavioral Health Services YourCare Health Plan
Objectives Discuss patient engagement and compliance from the patient and clinician perspective Identify the barriers and challenges to patient engagement What is PAM and how it is used?
The Scream 5/5/2017 3
Ever Felt Like This?
In your experience, what percentage of patients are not compliant with their medication and/or treatment regime? According to National Polls 30-60% Question
The Holy Grail of Health Care The key to patient adherence and improved health A key foundation of achieving the Quadruple Aim in Health Care Patient Engagement is
Activation is not easily observed
Experts agree it is the individual who in reality makes the choices that affect their health. The person is in control and experiences the consequences of his or her choices. Once a person leaves their provider office they can veto any of the recommendations that providers make. The key is to agree on an action plan that is acceptable and workable by the individual. 5/5/2017 9
Factors that Influence Engagement
Although we try to do our best Many practitioners fail to provide information that patients need in a culturally sensitive manner Even with good information, patients feel overwhelmed Individuals with low levels of health literacy and activation find it difficult to adhere to treatment Challenges and Barriers
Fear of increased risk Belief only certain types of people can be engaged Self management not as effective as professional management Increased time to allow patient to structure the session/ask questions Challenges and Barriers
One size doesn t always fit all Coaching for Activation
Patient Activation Measure
Individual s Knowledge, Skill and Confidence Patient Activation
PAM focuses on understanding the drivers of health and improved health outcomes not just symptoms Self-management behaviors (ex. Medication taking, nutrition, exercise, coping with stress) Healthcare Utilization (ex. ER visits, Hospital admits, Readmission) Care Experience Knowledge Biometrics (BP, A1c, BMI, etc.) Skills Emotional functioning Personal Support System Confidence Typical approach: Look to the past and/or rely upon what is easily observed and then address deficits by pushing guideline behaviours Insignia approach: Measure the members ability to understand their role, then, tailor support to addresses underlying competencies. Achieve guideline behaviours as knowledge, skill and confidence is developed 4
PAM-10
PAM-10
Patient Activation Scale
Increase ROI by adjusting resources to behavioral ability Out-bound contacts, high-touch, frequent, multi-modal Out-bound contacts, high-touch, frequent, multi-modal reminders/ to-do s In-bound phone & web. Every interaction must have a specific purpose In-bound phone & web. Make tools avail for patients to pull 20
PAM accurately predicts.. Lower patient activation is associated with higher rates of hospitalization / ER visits A PAM score is predictive of future utilization and costs Lower patient activation is associated with poor disease self-management, including medication taking & self-monitoring Higher patient activation is associated with stronger lifestyle behaviors and increased use of preventive care services Higher patient activation is associated with increased use of decision support resources Higher patient activation associates with more productive encounters with healthcare providers
Low activation signals problems (and opportunities)
54 year old male Lives alone Is a Medicaid recipient Out of work for past 3 years due to depression and an old injury Overweight Minimal physical activity In ED several weeks ago due to disorientation, fatigue and blurred vision No PCP or medical care in past 3 years Meet John
John s PAM Score
Check Blood Glucose per MD order Manage medication (right amount, right time, right way) Recognize the signs and symptoms of hypo/hyperglycemia Follow appropriate diet/manage carbohydrate consumption Develop healthy exercise plan Develop a stress management plan Schedule and keep appointments for yearly care, screening and testing HbA1c LDL-C Retinal eye exam Nephropathy screening test BP monitoring Diabetes Management Plan
Activation Level as a Predictor of Self Management Behavior
John missed his dietician appointment, the cab didn t come for him He filled his prescription for oral medication but only takes it when he feels tired or thirsty Walked to the corner grocery store 2x in past 6 weeks Used all of his food stamps in the first 2 weeks of the month and has gotten food from the food cupboard for the remainder of the month Complained to the doctor that the medication isn t working to give him more energy Talked to his neighbor who has diabetes and says that he doesn t need to take medication so why do I? John s 6 Week Visit Update
John was not compliant with the provider s plan of care The provider reminded John that he needs to follow this plan or he will get sicker Reviewed all of the complications from untreated diabetes Rescheduled the dietician appointment and referred John to Diabetes Group for education Non-Compliance
Don t Use fear as a tactic Narrow the horizon of the patient s planning efforts Build a plan for the patient Overwhelmed with too many problems at once Do Determine patient s main concern Help them plan Acknowledge barriers and difficulties Arrange a way to check progress Allow patient to talk about what they can and will do Break larger goals into smaller increments Do s and Don ts of Patient Engagement
Keep in mind the emotional outlook of the patient Overwhelmed, no health goals Used to failure Difficulty connecting behavior to health Winning Interventions Give permission to feel overwhelmed and to take small steps Show empathy Give permission to collaborate with providers Help connect behavior to how he feels What to do?
Possible Care Plan Goals
John worked with his Case Manager to plan out a menu and went to the public market to get fresh produce Substituted fruit for chips 2x during the month Agreed to take medication every day for 2 weeks and compare how he feels to when he only took it as needed Agreed to talk to his doctor about his depression symptoms 12 Week Check with John
Progress to Level 2
Possible Care Plan Goals
John has been able to successfully complete a task to improve his health Staff feel a sense of accomplishment that what they did made a difference in their patients health John has not returned to the ED and is committed to keeping his doctor appointments Patient and Staff Win!
Overall satisfaction with CM is consistently >90% >90% of respondents answer YES to the following: Do you feel you know what to do to manage your health and are prepared and able to do it? Do you feel that you doctors and nurses are aware of what really bothers you and give you the support and information you need? Outcomes
80% Percentage of clients showing positive change on PAM Scores from opening to closing 70% 60% 50% 40% 30% 20% 10% 0% Q12014 Q22014 Q32014 Q42014 Q12015 Q22015 Q32015 Q42015 Q12016 Outcomes
Q12016 Q22016 96% 92% 90% 89% 69% 78% 78% 77% CM helped me to set goals to manage my condition or health care needs Know what to do to manage health and are able to do it PCP and nurses are aware of what is bothering you and give support Helped me to know when to call the doctor Did we make a difference?
Planned Care Model Wagner, Md, W.A. MacColl Institute, Group Health Cooperative of Puget Sound In Closing
References Insignia Health http://www.insigniahealth.com