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© 2008 University of Oregon Increasing Patient Activation to Improve Health and Reduce Costs Judith H. Hibbard, DrPH Institute for Policy Research and Innovation University of Oregon
© 2008 University of Oregon 2 The Need to Do Better with Less Patients are an important resource in health care. We won’t reach quality goals and improved outcomes without patient engagement
© 2008 University of Oregon 3 There is great variation in patient activation in any population group Measurement would allow us to: ▶ To know who needs more support ▶ To target the types of support and information patients and consumers need ▶ To evaluate efforts to increase activation ► To Evaluate quality
© 2008 University of Oregon 4 Measurement of Patient Activation Share key insights Implications Applications to improve care and outcomes
© 2008 University of Oregon 5 What Does it Mean to Be Activated ?
© 2008 University of Oregon 6 Patient Activation Measurement (PAM) Difficulty Structure of 13 Items Unidimensional Interval Level Guttman-like Measurement Properties Uni-dimensional Interval Level Guttman-Like Scale
© 2008 University of Oregon PAM 13 Question * Related instruments: PAM 10, PAM 2, Clinician PAM 7
© 2008 University of Oregon 8 Activation is developmental Source: J.Hibbard, University of Oregon
© 2008 University of Oregon 9 Emotion plays a profound role in patient activation
© 2008 University of Oregon 10 Activation Level is Predictive of Behaviors Research consistently finds that those who are more activated are: – Engaged in more preventive behaviors – Engaged in more healthy behaviors – Engaged in more disease specific self- management behaviors – Engaged in more health information seeking behaviors
© 2008 University of Oregon 11 Level of activation is linked with each behavior Source: US National sample 2004
© 2008 University of Oregon 12 Behaviors in Medical Encounter by Activation Level
© 2008 University of Oregon 13 Insights ▶ Use activation level to determine what are realistic “next steps” for individuals to take ▶ Many of the behaviors we are asking of people are only done by those in highest level of activation ▶ When we focus on the more complex and difficult behaviors– we discourage the least activated ▶ Start with behaviors more feasible for patients to take on, increases individual’s opportunity to experience success
© 2008 University of Oregon 14 When activation changes several behaviors change 11 of 18 behaviors show significant improvement within the Increased Growth Class compared to the Stable Growth Class
© 2008 University of Oregon 15 Multivariate analysis which controlled for age group, gender, race, comorbidities and number of diabetes-related prescriptions. Carol Remmers. The Relationship Between the Patient Activation Measure, Future Health Outcomes, and Health Care Utilization Among Patients with Diabetes. Kaiser Care Management Institute, PhD Dissertation. Activation can predict utilization and health outcomes two years into the future for diabetics % change for a 1 point change in PAM Score 10 Point Gain in PAM Score 54 (L2) vs. 64(L3) P Hospitalization 1.7% decline17% decreased likelihood of hospitalization.03 Good A1c control (HgA1c < 8%) 1.8% gain18% greater likelihood of good glycemic control.01 A1c testing 3.4% gain 34% greater likelihood of testing.01 LDL-c testing
© 2008 University of Oregon 16 Low activation signals problems (and opportunities) 16
© 2008 University of Oregon 17 Using the PAM to Improve Care ► Evaluations ► Improve efficiencies ► Improve efficacy ► Population based approaches ► Individual tailored approaches
© 2008 University of Oregon 18 Tailoring Support to Activation Levels
© 2008 University of Oregon 19 Tailored Coaching Study ▶ Intervention group coached based on level of activation. Control group was “usual care” coaching (DM company) ▶ Examined changes in claims data, clinical indicators, and activation levels ▶ 6 month Intervention period.
© 2008 University of Oregon 20 Coaches allocated more talk time to lower activation participants when they had access to PAM scores
© 2008 University of Oregon 21 PAM tailored coaching resulted in a statistically significant greater gains in activation N.=245 in intervention group; N=112 in control group. Only those with 3 PAM scores are included. Repeated measures shows that the gains in activation are significant in the intervention group and not significant for the control group (P<.001)
© 2008 University of Oregon 22 Adherence to Recommended Treatments PAM-tailored Intervention vs. Usual Coaching Control
© 2008 University of Oregon 23 Tailored coaching can improve adherence and reduce unwarranted utilization 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 Clinical Indicators* Medications: intervention group increased adherence to recommended immunizations and drug regimens to a greater degree than the control group. This included 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. A1c: Both intervention and control showed improvements in A1c. *Using repeated measures, and controlling for baseline measures
© 2008 University of Oregon 24 Tailoring had a positive impact on all patient outcomes Findings consistent across all outcome measures Results are compared to usual coaching Valuable Implementation lessons learned along the way
© 2008 University of Oregon 25 Greater Activation is Related to Better Outcomes (in multivariate analysis) Prevention Colon Mammograms Pap Smears.00.02***.01** Clinical Indicators in Normal Range Healthy Behaviors Not Obese Not Smoking Costly Utilization Lower Hospital Lower ER.04***.02***.00***.01*** Systolic Diastolic HDL Triglycerides A1C.01**.00.02***.01***.01* Controlling for age, income, gender, and number of chronic diseases
© 2008 University of Oregon 26 Providers are increasing paid on outcomes – Total costs – Clinical outcomes – Patient Experience – Panel size Will they tap into the resource that patients represent?
© 2008 University of Oregon 27 ► Brief interventions in the clinical setting– with follow-up. Medical home ► Team approach– and differential allocation of resources ► Care transitions and reducing hospital re-admissions ► Wellness, disease management Applications
© 2008 University of Oregon 28 Being Patient Centered: Means meeting people where they are Providing behavioral support that meets the individual’s needs Measurement is key to making progress in this area
© 2008 University of Oregon Engaging Consumers to Improve Health and Reduce Costs Judith Hibbard, DrPH Professor University of Oregon.
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