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

2. 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

3. 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)

4. 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©

5. 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©

6. 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©

7. 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

8. 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

9. 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

10. 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

11. 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

12. Privileged and Confidential
Measuring Impact
PAM© Score Change
7/ /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

13. 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