Application of the Patient Activation Measure® to Improve ... · Source: Fairview Data 2010, n=33,147. High risk = Top quartile shaded at the top of each activation level bar Hibbard,

© Insignia Health 2015. All rights reserved

Application of the Patient Activation Measure®to Improve Health Outcomes

July 30, 2015

© Insignia Health 2015. All rights reserved 2

Today’s Discussion

• PAM Overview

• Targeting resources & tailoring support to activation levels

• Integrating PAM into patient care

• Best practice PAM administration

• Questions?

• Additional information – PAM based online support – Flourish®


Addressing patient activation starts with measurement

The ability to measure activation is important:

• To know who needs more support

• To tailor the support and information patients need to be successful self-managers

• To measure performance and to have a marker for quality care

© Insignia Health 2015. Proprietary & confidential


PAM® evaluates a persons underlying self-management ability or activation

Addressing patient activation starts with measurement

Developed at the University of Oregon by Dr. Judy Hibbard & colleagues

3 key domains assessed – Knowledge, Skills, Confidence

Measures an underlying or latent construct – one’s ability to self-manage

Two key metrics – score on a 100 point scale and four levels of activation

Patient Activation Measure®


An extensive base of research validates PAM and informs our approach to increasing patient activation

200+Patient Activation Measure® (PAM®) published studies

PAM validated in 28 languages / countries thus far

32+ conditions covered in PAM research


Activation is developmental

Overwhelmed & disengaged

Becoming aware, but still struggling

Taking action and achieving many behaviors at guideline levels

Maintaining behaviors and pushing further

Level 1

Level 2

Level 3

Level 4

0-100 point scale

10-20% 10-20% 25-30% 20-25%

© Insignia Health 2015

PAM Level 1 Profile

• Lack basic knowledge

• Poor self-awareness

• Self management is following Dr. orders

• Poor medication adherence

• Few self-management skills developed

• Very passive

• Do not grasp importance of their role

• Very low confidence

• Little goal orientation

7

“I don’t know (the nature and causes of my condition) … probably because I smoked so much”

“I was really confident before I go sick. I smoked, drank. I felt fine. Then, I had to have open heart surgery. I don’t know if I’ll ever feel confident about my health again”

“My doctor takes care of me”

“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 trying to stop smoking and trying to eat better, but it’s hard”

“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”

Copyright © 2015. Insignia Health

PAM Level 3 Profile

• Recognise responsibility for their health

• Taking action

• Have had some success

• Collaborate with healthcare providers

• Developing confidence

• Good goal orientation

• Good medication adherence

• Knowledgeable on their health

8

“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 went to classes to learn about my diabetes … I eat healthier. I gave up sugar and soda. I was only diagnosed in November and I’ve already lost 20 pounds”

“It takes most of my time dealing with my back … in order to remember to do certain things but sometimes my mind jumps from thing to thing and it’s easy to forget things – medicine, stretching, to walk”

“I’m responsible. I can’t just sit around”

Copyright © 2015. Insignia Health


12% 14%

8%12% 12%

25%27%

23%

29%

24%

47% 46%50%

43%46%

16%13%

19%16%

18%

Level 1 Level 2 Level 3 Level 4

Hypertension Heart Disease Diabetes Lung Disease Cancer

Patients Managing Long Term ConditionsPAM Level Segmentation

Source: Picker Institute UK Study 2005. N=2,890. Patients managing LTCs

Patient segmentation is consistent across conditions


% o

f st

ud

y p

atie

nts

by

Act

ivat

ion

Le

vel


PAM’s Predictive Power



A PAM score is predictive of utilization and outcomes

PAM levels reside along a 100 point continuum. Most individuals score between 35 and 80. There are rough 12 points between levels

For illustration

Diabetes Patients


($1,126)

($684)

($135)

($38)

-$1,200 -$1,000 -$800 -$600 -$400 -$200 $0


Source: Regional Health Plan 2012 data, allowed cost

All Patients in Study (n=31,148)

US Dollar cost change for a single point PAM score increase

Increasing activation generates significant cost savings at the lower two levels of activation

Impact on Hospital Cost for a Single Point PAM Score IncreaseBy each Activation Level

12


0%

20%

40%

60%

80%

100%

45%(top quartile)

33%(top quartile)

24%(top quartile)

19%(top quartile)


Source: Fairview Data 2010, n=33,147. High risk = Top quartile shaded at the top of each activation level bar

Hibbard, J. Greene, J., Overton, V. Patients With Lower Activation Associated With Higher Costs; Delivery Systems Should Know Their Patients’ ‘Scores’. Health Affairs, February 2013

Op

tum

/In

gen

ix P

rosp

ecti

ve R

isk

Sco

re Q

uar

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Clinical risk model fails to identify 55% of Level 1 and two-thirds of Level 2 patients

PAM identifies risk missed by clinical risk models and then guides interventions (how to increase activation)

55% 67% 76% 81%

PAM Level % Identified in Top Quartile of Clinical Risk


Targeting Resources & Tailoring Support to Activation Levels



Engaging the low activated is key to improving outcomes

Source: 2012 Insignia Clients using Insignia’s survey system

7.9

9.3

3.2

-1.3-2

0

2

4

6

8

10

Average time between

administration of 4 months

PAM Score Change

The degree of change in PAM score is dependent on program design, coaching fidelity, and the population being supported. 6 to 8 points of change over 6 months is normative


Twelve years of research insight aligned to activation levels guides the application of a PAM score and level


PAM levels guide patient support – knowing where to start relative to a guideline objective is key

30%

20%

10%

33%

45%38% 36%

49%53%

48% 46%

60%54%

50%55%

63%

Check blood glucose3x/week or

more

Keep a journal ofblood glucose levels -

always

Exercise everyday/almost every

day

Eating 5fruits/veggies everyday or almost every

day

Diabetes Patients

Source: Picker Institute UK Study 2009. N=254


Emotional disposition and goal orientation must be recognized to be successful with the low activated



More clinically significant skills are developed once a based of knowledge and confidence is established

One size support does not fit all


Guideline behaviors are pursued once a base of knowledge and confidence is established

Diabetes Example


PAM-based Coaching for Activation® provide coaches (clinical or non-clinical) with level appropriate guidance

21

Key areas of self-management

Goals and action steps are tailored to a level of activation

Resources support coaching guidance and can be viewed,

printed and emailed

This tool stands alone and is embedded in the Flourish coach portal


Goals and action steps are tailored to a level of activation

Diabetes Diabetes

Level 1: Knowledge, self-awareness and confidence is developed

Level 3: Guideline skills are pursued

This same PAM based approach anchors Flourish, a patient facing online program


Level 1Build basic knowledge, promote basic self-awareness, and start to grow confidence.

Level 2Increase knowledge, basic skill development, and connect behaviors and outcomes.

Level 3Close knowledge gaps, initiate new behaviors, and strive for best practice/evidence-based guidelines.

Level 4Maintain behaviors, learn to get back on track trouble-shoot difficult situations, and strengthen lifestyle related behaviors.

Become aware of… Develop understanding of…

Develop a plan… Learn techniques to get back on track…

Develop a solid understanding of…

Begin to… Improve habit of… Look for ways to rework or improve…

Become familiar with… Develop a stronger understanding of…

Master use of… Maintain guidelinebehaviors…

Small step skill: Learn to use …

Increase skill development…

Get to the right… Stretch goals…

Small step skill: Small change in…

Improve awareness… Put it all together…

Notice the theme of goals …


Case Study: Tailoring Support to Activation Levels in Telephonic Condition Management

Medication:

• Intervention group increased adherence to recommended immunization and drug regimens to a greater degree than the control group. This includes 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

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.

PAM based coaching outperforms support that emphasizes compliance


Source: PeaceHealth’s Team Filingame Uses Patient Activation Measure to Customize the Medical Home, Center for the Health Professions Research Brief, May 2011

Program Design

• PAM® and Coaching for Activation® Integrated into primary care clinics in OR & WA

• PAM score used in resource allocation model (image to right)

• Support tailored to a patient’s level of activation

• Core team included one physician, one nurse practitioner, one RN care manager, one care facilitator, one wellness coordinator, and three health coaches

• Case study practice supports 1,500 patients/year

Case Study: Tailoring Support to Activation Levels in a PeaceHealth Primary Care Clinic Setting


• Statistically significant improvement in 8/10 clinical measures

• Improved adherence

• Increase in controlled blood pressure from 56% to 76%

• Improvement in A1c & LDL

• 47% of patients improved PAM scores

• 24% increase in office appointments

• Increased patient satisfaction

Source: PeaceHealth’s Team Filingame Uses Patient Activation Measure to Customize the Medical Home, Center for the Health Professions Research Brief, May 2011

ER/Urgent care visits cut 42% over 18 months; significant improvement in clinical measures

Case Study: Improving Primary Care (continued)


Methods of PAM Administration

What other methods are in use or consideration?


A variety of survey administration, scoring and reporting resources are available

By paper or telephone with online scoring and reporting


Establish baseline PAM score• Patient completes PAM on paper, online, iPad• Clinician or administrative staff administers PAM

Administrative staff enters patient’s answers to calculate PAM score/level

Low activated patient is identified for telehealth, in home visits and/or eHealth support

PAM Administration and Application in Care Setting


Administering PAM



Introducing PAM to Reduce Bias

Key Points

No right or wrong answers

Be truthful

Will help me (your coach) personalize support

Take 3-4 minutes to complete

Your responses will be held in confidence/be private


Introducing PAM to Reduce Bias

Possible Example: “I am glad we have a chance

to talk today. To get us started, I’d like to learn a

bit about how you view your health. I am going

to read some statements that people

sometimes make when they talk about their

health. I will then ask how much you disagree or

agree with each statement. This will only take a few minutes and will

help me get a better idea of how best to work with you. There are no

right or wrong answers, people answer these question in a variety of

ways, just answer what is true for you. Also, know that it is completely

confidential. If this is ok with you, let’s get started.”


PAM Administration for valid and reliable results

• Read the statements in the order they appear on the survey

• Read each statement exactly as it appears on the survey. Do not add, remove or interpret words

• Provide the member with the list of possible responses after each statement (Disagree Strongly, Disagree, Agree, Agree Strongly, or NA)

• If a member answers “Yes” instead of “Agree” or “Agree Strongly”, clarify if they “agree” or “agree strongly”

• If a member does not know the answer, does not believe it applies, or refuses to respond, mark NA

• Allow member time to respond - don’t expect to rephrase or interpret the statement for a quicker response


Interpreting PAM Responses

INDIVIDUAL RESPONSE INTERPRETATION

Agree Strongly Yes, the question is true about me. This is a definite “yes”.

Agree Sometimes this is true about me or is potentially true about me.

Disagree / Disagree Strongly This is not true for me.

NA This does not apply to me. I do not know how to answer. I refuse to answer.


Starting the conversation

Use PAM as an opportunity to understand the member’s viewpoint –Identify key area of focus and perceived barriers

• Recommended timing

– 3 to 4 months following initial PAM administration

– A minimum of 2x over 12 months

• Why re-administration is important

– Gauge the effectiveness of coaching/support

– Document change

– Realign resources

– Tailor a care plan / focus of discussion accordingly

36

PAM Re-administration

Closing Thoughts

37

► Low activated individuals are poor self-managers, but are capable of making significant gains in activation

► Even a single point gain in PAM score is meaningful and associates to a 2% to 3% improvement in outcomes (medication adherence gain, A&E and non-elective impatient admit declines, improved biometrics)

► PAM has demonstrated it’s ability to predict cost and outcomes over one, two and four year periods

► Targeting resources and tailoring support to activation levels increases the efficiency and efficacy of coaching and education programs

▶ Using PAM to guide patient interaction has proven consistently to increase activation and improve health outcomes





Two portals, one mission, person centered support

Coach Portal Consumer (User) Portal

► Challenges guide users through information, goals and action steps

► A system of rewards (intrinsic & extrinsic) recognize achievement and support intrinsic motivation

► Coaches can interact with individuals online – recommend challenges & program content, view progress, send/receive messages

► A dozen conditions & wellness/disease prevention are supported


© Insignia Health 2015. All rights reserved 40© 2015 Insignia Health. Proprietary & confidential

Flourish applies a decade of PAM research to deliver a holistic and dynamic patient self-management programme

CoachInterac onthroughtheintegratedcoachportal

Levelappropriatecoachsupport

Challenges TipSheets Ar cles Videos Journaling Trackers

Pa entnavigatedsupportandeduca onresources

(Q42015)





(Q42015)





(Q42015)





(Q42015)


PAM assessment anchors tailored support

Patient use of the program (logins, time, challenges accepted/completed, page views, etc.) and time determine automated PAM re-administration. PAM administration can also be triggered manually.

© 2015 Insignia Health. Proprietary & confidential


Programs are built upon a series of challenges. Action steps bring a challenge to life

Flourish Patient Engagement Structure

42© 2015 Insignia Health. Proprietary & confidential

Challenges – Nutrition track

Diabetes Nutrition

© Insignia Health 2015. All rights reserved 43© 2015 Insignia Health. Proprietary & confidential

Challenges and related action steps guide a user

Step 1Challenge Accepted

Step 2Read Article

Step 3Journal Entry

Step 4Biometric Tracker

Progress indicator


Articles

Videos

Tip Sheets

Action steps leverage a variety of resources to inform



Action steps leverage a variety of methods to apply information

Quizzes

Health Trackers (Apps & Wearable's)

Journaling

Social Connections



Achievement is recognized and the next challenge unlocked

© 2015 Insignia Health. Proprietary & confidential


An integrated coach portal extends and strengthens support

Capture client information


Administer PAM & view results

Track client progress


View and recommend level appropriate resources

Send/receive messages

An integrated coach portal extends and strengthens support



• Baseline PAM Score/Level Post PAM Score/Level Question response trends

• Logins Challenges started Challenges completed

• Articles completed Journal entries Tracker entries

• Other questions fielded (from 30+ offered to custom development)

Program evaluation is supported through a variety of captured metrics across the groups/subgroups established by a client


Documents

Application of the Patient Activation Measure® to Improve ... · Source: Fairview Data 2010, n=33,147. High risk = Top quartile shaded at the top of each activation level bar Hibbard,