More Articles in This Series
ASA's Healthcare and Aging Network is discussing chronic diseases and their management. These recent articles cover a variety of care management and health improvement ideas and practical programs.
Why Measure Patient Engagement?
What It Means to Self-Manage a Disease
By Judith Hibbard
Efforts encouraging patients to be more involved in their care are key in health initiatives aimed at improving outcomes and restraining costs. The Affordable Care Act (ACA) incorporates approaches that support patient self-management and collaboration between patients and providers. It is dawning on the medical community that supporting patient self-management, particularly for older patients and those with chronic disease, is an essential element of high quality care. Research shows that involved patients engage in more healthy behaviors, have better health outcomes and cost less.
Being an activated patient implies more than simply following medical advice; it means taking a proactive role in one’s health. Measuring such activation means figuring out the degree to which a person understands his or her role in maintaining and promoting their health, and the extent to which he or she thinks he or she can succeed in this role. Patient engagement is a global construct reflecting an individual’s overall knowledge, skill and confidence in self-management.
The Patient Activation Measure (PAM) is a 13-question form designed to measure how well a patient can manage their health. Developed by my colleagues and I at the University of Oregon, PAM measures activation on a 0 to 100 scale. In addition, activation or engagement can develop over time, with patients traversing phases or levels as they become more competent self-managers.
Providers have always played a role in encouraging needed behavioral changes in patients. However, supporting behavior change and supporting patient activation is not the same thing. Instead of focusing on getting patients to “comply” with medical advice or to change a specific risk behavior, the focus of engagement or activation is on teaching the skills, knowledge and confidence necessary for an individual to take an active role in their own health. Patients need to feel they have ownership and a sense of control over events related to their health and healthcare. Building confidence through experiential learning in small steps is the key strategy for increasing activation.
What is the best way to do this? How do you encourage patients to take a more proactive role in managing their health? The answer, I believe, begins with measurement.
In healthcare we measure what matters. The whole quality improvement movement has shown that we cannot manage what is not measured; we cannot improve something when we do not know the scope and parameters of the problem. Imagine trying to improve cholesterol levels in patients if you had no lab values to tell you cholesterol numbers.
Patients, particularly those with chronic illness, need a variety of skills to manage their health on a day-to-day basis. And they differ in their readiness and skill level to take on self-management tasks.
According to an article by my colleagues and I in a 2005 issue of Health Services Research, there are four levels of patient activation, which are as follows:
- Patients tend to be passive and feel overwhelmed when managing their health.
- Patients may lack the knowledge and confidence for managing their health.
- Patients appear to be beginning to take action, but may still lack confidence and skill to support their behaviors.
- Patients have adopted many of the behaviors to support their health, but may not be able to maintain them in the face of life stressors.
And following are steps providers can take to support these activation levels:
- At level 1, focus on building self-awareness and on understanding behavior patterns, and begin to build confidence through small steps.
- At level 2, work with patients to continue small steps that are “pre-behaviors,” such as adding a new fruit or vegetable each week to their diet; reducing portion sizes at two meals daily; and begin to build basic knowledge.
- At level 3, work with patients to adopt new behaviors and to ensure some level of condition-specific knowledge and skills. Supporting the initiation of new “full” behaviors (e.g. 30 minutes of exercise three times a week) and work on developing problem-solving skills.
- At level 4, focus on preventing relapse and handling new or challenging situations as they arise. Problem-solving and planning for difficult situations help patients maintain their behaviors.
By measuring activation in patient populations we can know which patients have the skills and knowledge to manage, and which do not. Measuring can also help us know how best to support patients who are at different points along the activation continuum, and how to help them gain skills and confidence to move up the activation continuum. Supporting patients this way is truly “patient centered.”
Judith Hibbard, Dr.P.H., is a professor Emerita and senior researcher at the University of Oregon. Her work focuses on patient engagement in health and healthcare and she is the lead author of the Patient Activation Measure.
This article is brought to you by the Editorial Committee of ASA’s Healthcare & Aging Network (HAN).