PAM©: Moving from Measurement to Action Jessica Steinhart, MPH, PCMH CCE Director, Ambulatory Care Initiatives, Staten Island PPS

Staten Island Performing Provider System (SI PPS) Goal: Improve the quality of care and transform the healthcare delivery system of Staten Island Partners: Over 75 engaged organizations Impact: 4 out of 10 Staten Island residents impacted by DSRIP

Patient Activation Project Purpose: Identify person’s knowledge, skills, and confidence in managing his/her health and healthcare Predict healthcare behaviors, including utilization Tailor health education, goal setting, and services to person’s level of activation Link uninsured and low/non-utilizing Medicaid enrollees to primary care and behavioral health services, as appropriate   Goals: 1) Improve PAM® score 2) Reduce ED use by uninsured 3) Increase use of primary care services for low/non-utilizing Medicaid enrollees Target Audience: 135,000 Medicaid enrollees 50,000 uninsured (estimated)

PAM©: Empirically Measuring Human Behavior Patient Activation: Possessing the knowledge, skill and confidence to actively engage in your health and change behaviors where needed to achieve better health outcomes. The Science of Activation developed at the University of Oregon & validated by more than 260 third-party, peer reviewed, published studies and dozens of third-party white papers Used in over 3 dozen countries and nearly 4 dozen languages; valid across cultures Studied over many conditions and chronic diseases Adapted from Insignia Health©

Knowledge Confidence Skills Healthcare Utilization (ex. ER visits, Hospital admits, Readmission) Typical approach: Look to the past and/or rely upon what is easily observed and then address deficits by pushing guideline behaviors Biometrics (BP, A1c, BMI, etc.) Care Experience Emotional functioning Self-management behaviors (ex. Medication taking, nutrition, exercise, coping with stress) Personal Support System Insignia approach: Measure the members ability to understand their role, then tailor support to addresses underlying competencies. Achieve guideline behaviors as knowledge, skill and confidence are developed Knowledge Confidence Skills Adapted from Insignia Health©

Activation is Developmental Maintaining behaviors and pushing forward Achieve lifestyle behavior guidelines, develop techniques to prevent relapse Level 4 Taking action Skills development, pursue guideline behaviors Level 3 Becoming aware but still struggling Increase in knowledge, initial skills development, grow confidence Level 2 Overwhelmed and disengaged Build knowledge base, self-awareness & initial confidence Level 1 One Size Support Does Not Fit All Adapted from Insignia Health©

Community Based Organizations Primary Care Practices Project Implementation Community Based Organizations Primary Care Practices 80,000 Staten Islanders (43% of eligible residents) 7 5 Navigation and Outreach Accessing appropriate care and linkages to social services Clinical Care Disease management and preventive care Emergency Departments Behavioral Health Providers 3 12

PPS Support Project Management Workgroup facilitation Sharing of best practices Technical assistance Educational and marketing materials Relationship development Training Coaching for Activation© Motivational Interviewing Care Coordination Community Health Worker Skills Database Management Quality assurance Data management Account generation Data analysis

Partner Integration of PAM© Staten Island University hospital Staten Island Mental Health Society 714 bed teaching hospital with two campuses offering full spectrum of services Institution-wide staff buy-in and universal administration of assessment Invested in 2 health educators to manage a caseload of patients for Coaching for Activation© Invested in 5 ED social workers to engage patients with avoidable visits and navigate them to community-based care Mental health services to 5,000 children and their families annually ParentPAM© assessment across program areas Monthly review of Level 1 and Level 2 clients to identify those not yet enrolled with care coordination Health coaches use Coaching for Activation© to guide care planning

Privileged and Confidential Assessing Activation 7 partners 11,690 people 50% Medicaid 50% uninsured 18 partners 25,056 people 59% Medicaid 41% uninsured Privileged and Confidential Prepared in accordance with the Public Health Law Section 2805 j through m and Education Law Section 6527

Enhancing Patient Engagement 660 outreach activities 380 PCP appointments Privileged and Confidential Prepared in accordance with the Public Health Law Section 2805 j through m and Education Law Section 6527

Privileged and Confidential Measuring Impact PAM© Score Change 7/2015-10/2017 Change in Average ED Visits Year 1 90 Days Pre/Post Assessment 0.24 Level 1 Level 2 Level 3 Survey Counts 1087 1700 5107 Initial PAM Mean Score 39.59 50.59 62.68 All PAMs 52.68 57.07 64.27 Mean Point Change from 1st 13.08 6.48 1.58 % Improved 69.83% 59.24% 50.32% 0.22 0.22 0.21 0.19 0.19 0.19 0.18 Level 1 Level 2 Level 3 Level 4 Privileged and Confidential Prepared in accordance with the Public Health Law Section 2805 j through m and Education Law Section 6527

Next Steps Telephonic surveys Clinical Care Partners Re-focus on coaching/self- management plans Integration of coaching resources into patient database Outreach and Navigation Partners Diversify outreach locations Develop educational and marketing materials