Patient activation—which refers to a person's motivation, confidence, and skills to manage their own health—is key to sustainable self-management, but incredibly difficult to foster for a few key reasons. Notably, our systems are incentivized in a way that pushes care away from individual patient needs, making patient behavior difficult to change. Further, providers are often too pressed for time to educate patients effectively and promote good chronic disease self-management.
In an ideal world—where our systems are built to help patients become stewards of their own care—systems would build pathways that reflect clinical and non-clinical needs with patients at the center. We would also have a more personal understanding of patient need, allowing us to tailor a care pathway that helps address each patient's root-cause barriers to self-management.
Obviously this is no simple task, but we have seen systems begin to make headway here. Here are the three biggest self-management questions we are hearing from our members and our take on each of them.
1. What's the biggest barrier to successful self-management?
One of the biggest barriers to 'success' in self-management is the disconnect between health and social care. A lack of effective communication and decentralized social and clinical care pathways often means that patients don’t feel empowered or knowledgeable enough to engage in their own health care and instead move along passively.
One social action organization in the UK, York Centre for Voluntary Service, found one way to alleviate this communication gap in its "Ways to Wellbeing" program. Using a centralized coordinator to connect any patient needing support with community services and develop individualized programs accordingly, the project resulted in a 75% increase in self-confidence in 80% of users. This, in-turn, led to better self-management habits, which freed up capacity for PCPs to support other high-risk patients. Overall, the program reduced the number of user PCP appointments by 20%.
2. What criteria should we consider when identifying candidates for self-management programs?
While some self-management programs overlook certain candidates, assuming they will never 'get with the program', others include too many and are overwhelmed by the number they need to care for. This begs the question—who should be included in a self-management program?
Evidence suggests that almost all chronic patients are good candidates and do want to manage their own condition(s), but there is a caveat. To make the best use of your resources, it's vital to identify how ready patients are to manage their own conditions. Luckily, there is a tool that does just this—the Patient Activation Measure (PAM). PAM allows us to evaluate patient activation levels on a four point scale, and then formulate individualized pathways based on clinical needs and activation levels for each patient.
This was exemplified by VA San Diego, who used PAM to measure activation levels for their heart failure patients, allowing them to personalize each in-person visit and phone appointment to improve a patient’s overall self-management skills. Our research shows PAM to be consistently useful in tracking activation levels, preparing patients for self-management, and providing insight necessary to enable services to intervene earlier.
3. Who should design and deliver self-management programs?
For self-management programs to work, it is vital to involve multiple sources of support. This doesn't just include clinicians, but also charities, community-based organizations, and non-traditional support such as peer groups. This inclusive structure reflects the fact that most barriers to self-management are non-clinical in nature, and not related to the diseases themselves.
Along those lines, in terms of actually managing a patient journey, the general rule of thumb is that the worker capable of addressing a patient's 'most at-risk needs' should be in charge of the pathway. That might mean a COPD patient at-risk of readmission is paired with a nurse manager, whereas a patient over-utilizing the system due to homelessness is paired with a housing or social worker. Systems who improve self-management at scale spread out this responsibility across these clinical and non-clinical providers.
Next, view our new research report on PAM
It’s difficult to activate a patient without a clear understanding of where the patient is and what we can do to support them. The patient activation measure—or PAM—is an emerging tool to help us direct and focus this work.
This is an assessment based on the current use of the tool in health care settings—a crash course in PAM and its various applications.