Patient Activation in Practice.

This Peak Health Coaching (PHC) information briefing offers a short introduction to ‘patient activation’ and how it can play an important role in supporting self-management and quality of life among patients. This subject has been researched internationally for over a decade and the evidence suggests that more highly activated patients…

Make more informed choices Are better with self-management and prevention Partner in their care Use less healthcare resource. Report higher QoL Are more satisfied with care they receive.

So how do we know how ‘activated’ a patient is?A significant amount of research has been undertaken to develop ways of understanding patient activation better. The model we introduce and use in our courses is based on work by Hibbard et al. (2000-2004 and onwards), who have developed a questionnaire called the Patient Activation Measure (PAM®).

What is the PAM®? The PAM® is a questionnaire designed to measure the knowledge, skills and

confidence (ACTIVATION) that a person has to manage their own health and healthcare.

The PAM results in a percentage score and a level of activation from 1 (low) to 4 (high).

How was the PAM® developed?Following a literature review and consulting experts and patients, Hibbard and colleagues tested a wide range of questions on 480 selected patients with a range of conditions. They went onto test the questions on 1500 members of the public in a phone survey to check validity, reliability and consistency. Ultimately, the questions were reduced in number without a significant reduction in sensitivity and specificity from 22 to 13 and finally to 10. The final PAM questionnaire uses the domains of knowledge, skills and confidence to understand what makes up someone’s self-management capability. The detail of their methodology from the original paper can be found here.

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What about the use of PAM® in the UK? The Health Foundation published a study in August 2018 involving 9000 people in Islington, London. In this postal survey they found that those least able to manage their health conditions were on average, 67 years old and had at least two long term conditions. 39% also had a mental health condition and 55% lived in the most deprived areas. In other words, low levels of activation were evident regardless of age and deprivation.

The study compared people at PAM level 4 (high activation) to PAM level 1 (low activation) and found that they had…

38% fewer emergency admissions 33% fewer A&E attendances 32% fewer A&E attendances with minor conditions 18% fewer GP appointments

They conclude that, for those least able to manage their conditions, improving their activation by 1 level has the potential to reduce 6% of admissions and 5% of A&E attendances. Click here for further information.

This study was in line with previous findings (Picker Institute UK study 2005 below), that patients lower in activation reported more visits to their doctor.

(Source: Insignia Health 2017)

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From the above chart we can see 51 % of people at level 1 visited their GP more than 5 times in the previous 12 months compared to just 23% of people at level 4.Just over a quarter of people at level 1 visited their GP 9 times or more, compared to less than 1 in 10 people at level 4.

By increasing activation, the hope would be that there would be less pressure on appointment systems across the healthcare sector. This is a clear motivator for health care colleagues to think more about activation and what we can do to influence it.

Patients low in activation are more likely to be admitted unnecessarily.The study (below) looked at people with Ambulatory Care Sensitive (ACS) conditions – in other words long-term conditions (COPD, Asthma, IHD, Diabetes…), where it is possible to prevent and reduce the need for hospital admission through better self-management and community care. For those not familiar with odds ratios, if it is more than 1, then it is more likely to happen, if less than 1 it is less likely to happen. As you can see in the graph below, they took people who are highly activated (level 4) as their reference – odds ratio 1 and compared those lower in activation to them.

(Source: Insignia Health 2017)

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As you can see, people at level 1(low activation) were 1.62x (62%) more likely to be admitted unnecessarily than people at level 4 (high activation). Even at two years later (the blue bar), people lower in activation were 31% more likely to be admitted unnecessarily.

People with lower levels of activation report less productive interactions with their care providers.This study (below) asked people about their experience with their health care providers and specifically whether they helped them to set goals to improve their diet and exercise or taught them how to self-monitor their condition. The point here is that the health providers didn’t do anything different. So, it seems that there is something different about what was picked up from the consultation, depending on your level of activation. It is likely that as one becomes more activated, one is more aware of the goal-setting and self-monitoring advice and ready to receive and recall it. People at lower levels of activation are less goal-focussed, so perhaps ‘goal-setting’, is more appropriately used when people are ready to receive it. As time is a precious and scarce health and social care resource, we need to consider how we spend it.

(Source: Insignia Health 2017)

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People low in activation are less likely to engage in self-management behaviours such as understanding their medication, monitoring their conditions, exercising and eating 5 portions of fruit and vegetables a day. (see below)

(Source: Insignia Health 2017)

As you can see in this study in people with diabetes, lower in activation, were less likely to … understand their medication check blood glucose Keep a journal of blood glucose levels Exercise Eat 5 fruit/vegetables

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Patients low in activation feel overwhelmed and struggle emotionally.

(Source: Insignia Health ©2017)

You’ll notice that at PAM level 1, positive and negative emotion are closely matched. People at this level feel overwhelmed and are not goal focused. This is worth bearing in mind as you start to tailor the way you work with them. You can see that as activation increases so does positive emotion (blue line) and they become more goal-focused. Also, their negative emotion and feeling of being overwhelmed diminishes, allowing them to take on more complex goals.

Questions to consider

1. From what you already know and the above, what is the information that most interests you?

2. How might increasing a person’s activation help in your area of work?

3. What questions have you still got about the PAM®?

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