Hardwired Results: Issue 22

Dr. Judith Hibbard is a researcher at the University of Oregon and is a consultant to Insignia Health.

JH:When people talk about engagement, I think what they’re really trying to achieve is “greater activation” on the part of the patient—to get them involved in their own care or to create involvement opportunities.” Their hope is that these will result in increases in patients’ knowledge, skill, and confidence to manage their own health (the definition of activation).

JH: Our research—starting in the early 2000’s—came about because we saw that some people are passive and some are very proactive about their health. If we could measure that then we could better understand patients and provide more tailored support to them to help them move forward. To excel in a value-based environment, accountable care organizations (ACOs) must help their patients become more “activated” or more proactive in managing their health.

It turns out that we can actually measure activation in a robust way based on 10 general questions about how patients understand their role and their feelings of competence for taking on that role. We used a Rasch analysis to create the PAM (patient activation measure) which measures people on a 0 to 100 scale. You can study any population group—like Medicare or Medicaid patients, for example—and still see a full range of people on that continuum. Activation is not dependent on demographics.

JH: We learned that patients who score low on activation were often overwhelmed, had little confidence about managing their health, poor problem-solving skills, and felt their role was to be a passive recipient of care. As a result, we recommend interventions for less activated patients focusing on small steps that are easily achieved by patients.

Our most recent insight comes from our new research on being able to identify those at risk for using costly and unnecessary care… an issue critical to ACOs. The paper, which was just published in Health Services Research, explains how PAM scores can predict whether individual patients are more likely to have emergency department visits or hospitalizations that could have been prevented. It also showed that PAM scores are able to predict the likelihood of developing a new chronic disease one, two, or even three years later. (See sidebar to read paper.)

JH: One of my big “aha’s” was that when we offer patients engagement opportunities—such as a patient portal or a chronic disease selfmanagement class—it is the patients with high PAM scores who show up or sign up. That is to say, we often are using our resources to help the “already engaged.” You won’t know which are which until you start measuring. However, we know we can increase activation if we support patients in the right way.

Once you do measure, you can design different approaches to best suit each group. The low scorers, because they are more passive, will engage better through a “high touch” approach. The high scorers, who are more ready to use information, will do well with a more “hightech” approach, such as providing web-based resources.

But to be successful, this must truly be integrated into how organizations and care teams think about and manage individual patients and whole patient populations; it needs to be integrated into the very DNA of the organization.