Patient Activation for Population Health: Shifting From A Fee-for-Service Model Toward A Proactive, Preventive Approach with Increased Engagement

In cases where medical care is an absolute necessity, physicians are able to focus their expertise, while PCMH team members handle the practice’s other responsibilities: Nurses triage non- critical cases; care coordinators communicate with patients and/or caregivers regarding compliance and follow-up; and, social workers connect patients with community resources. Before that collaboration can take place, however, providers must determine which set of services would most benefit their patients. Using a PHM approach, those patients are grouped together based on shared criteria. Once providers identify those issues that negatively affect their patients’ health, PCMH team members can be assigned to work directly with patients to rectify those issues.

For example, a PHM approach can be utilized to identify patients who routinely miss appointments due to a lack of reliable transportation. Knowing that, a care coordinator can reach out and connect those patients with community resources that help remove that particular obstacle to care compliance. Other ways PCMHs are striving to keep individual patients healthy is by sending out reminders related to vaccinations, mammograms, etc., ensuring timely care in a way that engages patients even further.

Although PCMH is a fundamental building block of PHM— one intended to deliver higher quality care while lowering overall medical costs, in support of population management— it is necessary to explore financing models which are more flexible; ones which empower provider networks to decide where, within their systems, they should be directing their dollars in order to achieve the best possible outcomes for patients. That alone would shift the bulk of the risk from payors to networked providers. Those networked providers could then generate cost savings by avoiding the need for unnecessary procedures or hospitalizations. Those savings could then, theoretically, be reinvested in prevention and other patient wellness programs to bring the cycle of proactive care, preventive care and patient engagement full circle and encourage delivery of medical care and services in a way which is both more holistic and financially sound.

 

“Never doubt that a small group of thoughtful, committed citizens can change the world; indeed, it is the only thing that ever has.” – Margaret Mead

 

 

Lastly, a key requirement of PHM is increasing patient involvement in self-management and risk- or behavior- modification activities, yet patient compliance routinely proves to be a challenge. There are ways in which health care organizations can better engage and empower the patients under their care. Namely, through care coordination, technological innovation and community outreach activities— which remove barriers to care and give patients a reason and the motivation to actively participate in the health care process. Indeed, research has shown that patients who are more active in attending to their health and participating in the health care process are more apt to stay current with their medications, be lively and engaged during medical encounters, seek out health-related information and, in addition, eat healthy foods, exercise and get preventive care.7 However, fewer than half of U.S. adults are currently activated in that way.8

DEFINING AND DELVING INTO PATIENT ACTIVATION

The term patient activation refers to a patient’s likelihood to participate in actions and behaviors which improve their chances of recovery.9 According to Dr. Judith Hibbard, a professor of health policy at the University of Oregon’s Department of Planning, Public Policy and Management:

“An active patient is one who is armed with the skills, knowledge and motivation to be an effective member of the health care team.”10

Along with Dr. Bill Mahoney and other colleagues at the University of Oregon, Hibbard developed the Patient Activation Measure™ (PAM), a self-assessment tool that measures traits associated with managing one’s own health and health care activities. PAM , which is licensed and marketed by Insignia Health, consists of a 10- to 13-question survey that makes inquiries into people’s beliefs, knowledge, skills and confidence when it comes to engaging in a wide range of health behaviors. Based on their responses to the survey, consumers are assigned individual activation scores and are segmented into one of four progressively higher activation levels.

At the low end of the spectrum, individuals tend to be passive about managing their health and may fail to see the connection between their own behaviors and related health outcomes. At the high end, individuals have a strong understanding of that relationship and have become good self-managers. Still, it is important to note that even high-activation-level individuals show opportunities for improvement and can benefit from coaching which helps them stay on course, particularly in times of stress or when experiencing changes in their care routine.

Once a patient’s activation level is defined, health care providers, health plan administrators and wellness coaches can approach the individual with ideas for creating a tailored plan which makes sense given their activation score; plans they are more likely to adopt and carry out, in an effort to improve their own levels of wellness. For instance, rather than ask a patient with a low activation level to run two miles a day, it would be more beneficial to ask them to consider getting their exercise by walking around the block a few times per week and/or parking farther away from their destination, whether they go shopping, out to eat, etc.

“Pounding people over the head doesn’t work,” says Hibbard. “Understanding the person and meeting them where they are is the key, (as is) having a standardized approach for supporting patients and, finally, having a way to track progress.”11

PAM, PHM AND OTHER RELATED RESEARCH

At least 85 studies have documented PAM’s ability to effectively measure patient activation and to predict a range of behaviors (even in instances of wide demographic and socioeconomic variability). Research has also shown that there is a direct correlation between increased patient activation and improved levels of self-care, with the Hibbard study demonstrating that PAM scores increased an average of 4.6 points among members of intervention groups while scores among control group participants increased an average of 1.4 points, demonstrating that increased patient activation also leads to an increase in patients’ ability and desire to more successfully manage their conditions.12

Hibbard indicates that, based on 2010 research from the Center for Studying Health System Change (HSC), patients who are able to do the following are likely to achieve better health outcomes at a lower cost overall:13

• Navigate the health care system

• Collaborate with various care providers

• Self-manage health-related symptoms/problems

• Involve themselves in the treatment and diagnostic process

• Engage in activities which maintain functioning and reduce health declines

• Select providers and provider organizations based on performance or quality

CONCLUSION

A “small group of thoughtful, committed citizens,” as Margaret Mead suggested of change itself, can create a noticeable shift and make a meaningful difference in the lives of osteopathic physicians, staff and patients. With patient activation as the end goal, a proactive and preventive approach to health care which is supported by a quality-of-care-based reimbursement system and bolstered by disruptive innovation can reduce the cost of medical care and achieve desired results where patient involvement is concerned.

As America’s political and health care leaders debate whether or not the most sustainable way to manage medical costs is by offering preventive care, the osteopathic community can begin to take a grassroots approach to actively addressing that problem. After all, a dramatic shift often begins with a series of small, first steps away from outmoded ideologies, practices and procedures (i.e., a fee-for-service model) toward behaviors, beliefs and policies which are simultaneously more proactive, preventive and proven to activate patients.

REFERENCES

1. Envisioning the National Healthcare Quality Report, 2001. Institute of Medicine, National Academy Press. Accessed at http://books.nap.edu/ openbook.php?record_id+10073&page=41 on March 10, 2014.

2. Envisioning the National Healthcare Quality Report, 2001. Institute of Medicine, National Academy Press. Accessed at http://books.nap.edu/ openbook.php?record_id+10073&page=45 on March 10, 2014.

3. University of Rochester Medical Center. Pressure Points. From Intervention to Prevention: Demystifying Population Health Management. URMC Pulse, October-November 2012 http://www.urmc. rochester.edu/news/publications/pulse/oct-nov-2012/story1.cfm

4. University of Rochester Medical Center. Pressure Points. From Intervention to Prevention: Demystifying Population Health Management. URMC Pulse, October-November 2012 http://www.urmc. rochester.edu/news/publications/pulse/oct-nov-2012/story1.cfm

5. American Hospital Association. American Hospital Association Committee on Research. Patient-Centered Medical Home. AHA Research Synthesis Report. 2010 September

6. University of Rochester Medical Center. Pressure Points. From Intervention to Prevention: Demystifying Population Health Management. URMC Pulse, October-November 2012 http://www.urmc. rochester.edu/news/publications/pulse/oct-nov-2012/story1.cfm

7. Shaw, G. (2010). HealthLeaders Online. Retrieved January 2, 2011, from http://www.healthleadersmedia.com: http://www. healthleadersmedia.com/page-1/MAG-238742/The-Patient-of-the- Future

8. Population Health Insider. (2010). Retrieved January 3, 2011, from Health Leaders Media: http://www.healthleadersmedia.com/HOM- 225720-4625/More-than-one-in-five-US-adults-at-lower-activation- levels

9. Richard L. Skolasky, S. e. (2008). Patient Activation and Adherence to Physiotherapy in Persons Undergoing Spine Surgery. Spine , 784–791.

10. Cunningham, J. H. (2008). How Engaged Are Consumers in Their Health and Health Care, and Why Does It Matter? Washington D.C.: Robert Wood Johnson Foundation.

11. Cunningham, J. H. (2008). How Engaged Are Consumers in Their Health and Health Care, and Why Does It Matter? Washington D.C.: Robert Wood Johnson Foundation.

12. Hibbard, D. J. (2009). Improving the Outcomes of Disease Management by Tailoring Care to the Patient’s Level of Activation. American Journal of Managed Care , 353–360.

13. Population Health Insider. Retrieved January 3, 2011, from Health Leaders Media: http://www.healthleadersmedia.com/HOM-225720- 4625/More-than-one-in-five-US-adults-at-lower-activation-levels)