Patient activation: One practice’s journey

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4/16/2018

Pamela Ballou-Nelson, RN, MSPH, PhD, CMPE

We are talking a lot about patient activation or engagement these days. We recognize — or at least I hope we do — that if we plan to bend the cost curve and improve outcomes in this country, we need to have consumers, patients and clients with the knowledge, skill and confidence to manage their health and healthcare in both illness and wellness.

Patient activation goes beyond simply complying with a set of orders; it also asks "why" and "how" and "what if." Activation requires a shared decision approach on the part of both patient and the clinician, not just a patient following orders. Research from more than 400 peer-reviewed articles provides insight into patient activation, including the following:

Many behaviors we are asking of people are only done by those in the highest level of activation.
When we focus on the more complex and difficult behaviors, we discourage patients who are least activated.
When we ask patients to start with behaviors that are more feasible, we increase their opportunity to experience success.
Multiple behaviors change in the same direction as activation increases.
Patients who are least activated gain the most when appropriately supported.
It is the higher-activated patients who show up when self-management resources are offered.

Supporting activation requires a shift in focus from traditional disease management toward management and improvement of patient health behaviors. As payments become more closely linked with patient outcomes, understanding how to increase patient activation will become a priority.

Medical group practices are teaming up with MGMA, which has partnerrf with Insignia Health, to measure patient activation through PAM® surveys and coaching.

The journey of one health system focused on patient activation included:

Improving health outcomes for more than 3,800 patients within its primary care and specialty care clinics
Increasing patient activation in their own healthcare as a means of improving health and wellness, chronic disease management and disease prevention
Decreasing unnecessary use of healthcare resources, such as avoiding unnecessary emergency department visits, preventing unnecessary hospital readmissions and optimizing utilization of lower cost resources through a primary care clinic
Using the PAM® score to guide patient-specific care plans, educational efforts and motivational coaching, all to spark improved health outcomes
Empowering nonlicensed team members as health coaches to improve the impact of their interactions with patients
Positioning the practice for success in a value-based purchasing reimbursement environment

Practice leaders who choose to use PAM® know that cultural and operational change includes small steps toward significant change in their approach to patients.
While working to overcome initial resistance of team members, one practice observed the following challenges and solutions:

Team members felt they were continually being asked to do more.
- PAM® makes current efforts more productive, more impactful. The tools enable us to stop wasting time and effort.
- By not accurately understanding patients’ knowledge, skills and confidence, we are working in the dark and disconnected, with misunderstanding on both sides.
- Aligning patient activation with our history and mission of “meeting patients where they are” helps us “walk the talk.”
Team members repeatedly said, “I don’t have time for that.”
- PAM® empowers clinicians to work smarter, not harder.
- Survey administration really is quick, and most patients complete it independently.
- Some team members didn’t understand their individual role — what adjustments were needed to current methods and what actions were expected.
  - Education, particularly on roles and expectations, became the focus.
- Inertia was also an issue. Practice leaders addressed this challenge through the power of inclusion, champions and repetition:
  - Executive leadership supported patient activation efforts from the very start.
  - Coaching for activation was included across the practice in a wide variety of roles
  - The practice created a steering committee of champions, whose peer-respected voices have had great impact.
  - PAM® is visible daily. Issues are discussed every morning at interdisciplinary huddles, team meetings, all staff meetings and organizational newsletters.
- Some team members wanted to integrate PAM® and Coaching for Activation® faster.

Creating workflows to support patient activation is a key strategy for success.
The practice approach included strategically integrating PAM® surveys first and coaching for activation second. The practice:
- Gained PAM® concept buy-in by training clinicians and team members in PAM®
- Integrated PAM® survey administration in clinic and health homes care management
- Administered a Clinician Readiness Survey to assess an internal baseline for coaching for activation
- Began building patient activation workflows for patients whose PAM® level or score was documented in the practice's EHR
Moving forward, Coaching for Activation® will be embedded in all clinic and health homes workflows in 2018.
Lessons learned to date:
- Early efforts already show improved PAM® scores.
- Funding for workflow integration is key to speeding adoption rate and impacting outcomes.
- When clinicians and health homes care managers can tie patients’ individual efforts to improving PAM® scores, patient engagement significantly increases, sparking additional momentum.
- Celebrate the successes
Summary
Research finds that consumer health behavior or self-management, the leading nonmedical determinant, accounts for 40% to 50% of health outcomes. Add environmental and social circumstances to this mix, areas where increased individual engagement can mitigate these influencers, and the rate increases to 70% .¹

The importance of nonmedical determinants is clear: Consumers hold the keys to improved population health. Join other practices and health systems in their journey toward improved patient activation. Contact MGMA for more information.

Note:
1. Schroeder S. “We can do better — Improving the health of the American people,” New England Journal of Medicine, Sept. 20, 2007; 357: 1221-1228.

Written By

Pamela Ballou-Nelson, RN, MSPH, PhD, CMPE

Pamela Ballou-Nelson, RN, MSPH, PhD, has more than 30 years of experience in healthcare management, focusing on practice process transformation, patient-centered medical homes (PCMH), workflow analysis, quality measures, care management, population health and patient activation across the continuum of care. Nelson has worked with both provider and payer organizations to help them work toward alternative care and payment models. As clinical quality director for Adventist Health Network in Chicago, Nelson was responsible for leading physicians and hospital directors in their clinical integration process. Nelson has also worked with numerous commercial payers on quality outcomes and effectiveness measures, including compliance with Medicaid care management programs, along with Medicaid insurance contracts and high-risk and dual-eligible patient programs. She has also trained, advised and mentored more than 80 practices in various levels of readiness, preparing them for value-based payment reform, process improvement, improved quality outcomes and increased efficiency through PCMH recognition with 2011 and 2014 standards. She has a BSN from the University of Utah, an MA from Wheaton College, and an MS and PhD in Public Health from Walden University. In addition, she is an NCQA 2014 PCMH certified content expert and frequently speaks on PCMH transformation for accountable care organizations and population health initiatives.