07.21.16 By Sanofi Le Hub
Judith Hibbard is Research Professor in the Health Policy Research Group at the University of Oregon. Her research is based around behavioral science and helping patients to better manage their health and their healthcare.
She has led the development of the Patient Activation Measure (PAM), an innovative tool that helps to measure how engaged patients are in managing their health.
We spoke to Judith about her work, patient activation in healthcare and how behavioral science can help improve patient outcomes.
I became interested in working in the area of patient activation in healthcare by simply observing that some people are very proactive about their health and other people are very passive. Why is that? What makes the difference?
If we could measure a person’s activation level, we could likely understand how best to help them. We could be more effective at meeting patients where they are, and help them move forward.
One has to have a clear definition of a concept, before one can try to measure it. Our definition was: activated patients are individuals who have the knowledge, skills and confidence to manage their health and their healthcare. The tool we developed has strong measurement properties on a 0-100 scale.
Having robust measurement has given us new opportunities to fully understand patients who are at different points along this continuum from being passive about their health to being pro-active. We have been able to learn about people at different points on this continuum, how they understand their situation and how they cope. This opened up a lot of insights into how we can help these patients to move forward.
At this point there have been hundreds of studies using the PAM and we are learning from all these efforts. We now know that patient activation is related to most health behaviors and to many health outcomes.
We’ve seen that the PAM score is predictive of preventative behaviors like screening and immunization, it is predictive of healthy behaviors like eating well and exercising and in management behaviors like monitoring and adherence – the PAM is predictive of all of those type of behaviors, it’s not specific to one condition or any one type of behavior.
The measurement is now being used around the world – it’s been translated into 27 languages and we see the measurement works across language and culture.
We measure patient activation using either a 10- or a 13-item questionnaire, with the outcome measuring activation on a scale of 0 to 100.
Usually there is a beginning measurement and then follow-up measurement. The change in the PAM score indicates whether progress is being made. The frequency of re-measurement depends on how intensively the healthcare provider is working with the patients. Most providers measure every 3-6 months, but at least once per year.
The measure can be self-administered, it can be done on the web or over the phone … there are various modes of administration.
One of the surprising things is that activation is only weakly related to age, education, income and gender. This is really an important fact because we often assume that if someone is disadvantaged, then they are going to be less activated, but that’s not true. This indicates that you can’t make assumptions about someone’s health management just because you know something about their demographics.
We also found that when activation changes, multiple behaviors change. Until now we’ve thought of behavior change acting on one behavior at a time. This has important implications because it suggests that if we are effective in supporting activation, multiple positive health behaviors can result.
The least activated patients actually move up the scale and become activated when they are appropriately supported. This is very optimistic because a lot of delivery systems say, ‘oh they’re not going to change, so we’re not going to bother with those patients’ and that’s the wrong approach.
We’ve learned a lot about people who measure low on the activation scale. They are often overwhelmed with the task of managing their health, they lack confidence, often they think their role in the care process is to be a passive recipient, and often they have poor problem solving skills. These insights are important. Helping patients become confident is the key goal for less activated patients.
We also know less activated patients tend to have more experience of failure, so it’s important to start with a behavior change that’s achievable so that they can experience success, for example a small step. We’ve found motivation and activation increase once they’ve experienced some success. These small steps may not be clinically meaningful, but it does increase motivation for going on to the next challenge.
HCPs use the PAM to tailor the way they coach, communicate and support patients. So they use the PAM to work out how low or high the patient is. They then break things down into smaller steps for the less activated, provide encouragement, and help problem-solve barriers.
Any time you can make it easier for the patient to do the right thing – to exercise or to take their medication – by removing barriers or helping them problem-solve those barriers, that’s empowering and it can help improve outcomes.
Some delivery systems are also segmenting their populations based on their PAM scores, together with a clinical score, so they can tailor programs for patient segments. So patients who have high disease burden and a low PAM score might be given more intense support and active outreach, while patients with high activation and low disease burden might get web-based support instead. So it’s more of a population health management approach and an efficient way to use resources.
The healthcare professionals seeing the best outcomes from PAM are offering a tailored approach to coaching and counselling. They’re spending more time with the less activated, perhaps using a trained medical assistant to offer additional support.
They are also often explicit about their role – they say, ‘I’m going to be there every step of the way but it’s up to you to do it.’ This is important for less activated patients who are often mistaken about their role in the care process
They’re also being pro-active in their use of the activation score. For instance, one program that works with women has a policy whereby if a woman with low activation is due for a mammogram but comes in for something else, she gets a mammogram that same day as well. They recognize that she is low activated and may not come back at a later date for the mammogram. A high activated patient would just be given an appointment for the mammogram for another day.
So it’s also about meeting patients where they are, based on the PAM score, to get a better outcome.
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