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Tailoring DM interventions could improve patient outcomes, lower utilization

One size does not fit all in almost every aspect of life, so why should healthcare think differently of population health and disease management (DM)?

But that’s typically the case, as DM programs often differ depending on the disease rather than the individual. Not all diabetics are the same, but they are often treated the same way.

One way to better understand the individual is the Patient Activation Measure (PAM) developed by Judith H. Hibbard, DrPH, professor of health policy at the University of Oregon’s department of planning, public policy, and management in Eugene.

By determining the individual’s knowledge, skill, and confidence in managing his or her health and healthcare, coaches can tailor programs that accurately reach patients at their level. The PAM, which is now licensed and marketed by Insignia Health in Portland, OR, consists of a 10- or 13-question survey that asks individuals about their beliefs, knowledge, skills, and confidence in engaging in a wide range of health behaviors. Based on the responses, each person is assigned an activation score and level.

There are four progressively higher activation levels. At the lowest end are people who passively manage their health and may not see a connection between their behaviors and health outcomes. At the other end are people who understand the relationship and self-manage their health.

The Center for Studying Health System Change released a study in 2008 that suggested that more than 20% of U.S. adults are at the low end of the activation scale, which makes caring for them and improving their health difficult.

Hibbard and her University of Oregon colleagues recently conducted a study with members of Irvine, CA–based health improvement company LifeMasters Supporters SelfCare, Inc., that looked at whether a DM program that used the PAM could improve patient outcomes. They compared patients who received standard telephone DM coaching with those who received tailored intervention based on their activation level.

The researchers found that patients with chronic disease who received tailored coaching based on their PAM level improved clinical outcomes, according to the study that was published in the June The American Journal of Managed Care.

In addition, findings suggest that tailoring coaching to patients’ activation levels and using those metrics to track programs can improve patient outcomes and DM program efficiency. Patients who received coaching tailored to their level of activation showed greater improvements in their biometrics and adherence to recommended regimens. Those patients also showed greater reductions in hospitalizations and ER utilization than patients who were coached without use of the PAM.

Coaches who systematically assessed patient knowledge, skill, and confidence for self-management can be more targeted and efficient in allocating their time and effort.

And tailored coaching improved a patient’s PAM score (i.e., activation level) in the intervention group more than the control group. (See Figure 1 below.)

Researchers also found that the coaching call talk times were similar between the two groups (see Figure 2 below), which shows that it’s not the time spent with the patient that is important, but the quality of that time.

Patients in the intervention group improved A1c, blood pressure, and cholesterol levels (see Figure 3 on p. 3), as well as adherence to recommended treatments (see Figure 4 on p. 3) and fewer hospital visits (see Figure 5 on p. 4). In fact, patients who received tailored coaching experienced a 33% decline in hospital admissions compared to the control group, which remained flat, and a 22% decline in ER visits compared with a 20% increase in the control group.

Results point to lower healthcare costs

“Based on cost figures derived from the claims data used in this study, a decline of 0.02 average hospital admissions translates into a savings of $145 per person per month (based on an average cost of $7,259 for a hospital admission). Similarly, the average 0.02 ED visit reduction would yield an average savings of $11 per person per month (based on an average ED cost of $545),” the researchers wrote.

“We have learned that deploying targeted interventions rather than using a one-size-fits-all approach is a critical success factor,” says Mary Jane Osmick, MD, vice president and medical director at LifeMasters. “These findings reinforce our understanding that improved activation is an overarching measure of success that leads to significant clinical improvement and financial savings.”

Although pleased with the results, Osmick says it’s important to realize that infusing the PAM into health coaching is not simple. “It requires a great deal of thought and guiding the patient, as well as nurse and coach, in how to use it,” she says.

This education includes teaching coaches motivation interviewing and how to understand patients’ pre- behaviors, which greatly helps in understanding the individual and how to improve his or her health status and activation.

One of the biggest challenges is making accurate suggestions. The worst a coach can do is push a patient too much, which could cause the patient to fail and revert to a worse activation level.

To accomplish this, coaches must occasionally test the patients with the PAM to see whether they have moved on the activation scale.

“When people experience crises in their lives with their health or just in their lives, they often fall back on the activation level,” says Hibbard. “If the coach thinks that’s happened, it’s good to readminister whatever the time frame is and know where the person is so they can deal with the person appropriately.”

The secret sauce, so to speak, is tailoring interventions, working with the individual consistently, knowing the person’s activation level and possible fluctuations, and respecting the fact that not all patients will reach the highest activation level, says Osmick.

“The thing that is exciting about it is you can move activation,” she says.

Through her research of the PAM, Osmick has come to realize that it taps into an underlying construct. For example, something such as self-esteem is an underlying construct that affects various parts of a person’s life. The PAM is similar.

“If you knew about someone’s self-esteem, you would be able to predict how they behave in certain situations. I think the PAM is also an underlying construct,” says Hibbard.

“I thought of it just in the health arena, but it may be broader than that. It might be more of a feeling control of your life. I don’t know, but that seems to be what that suggests,” she added.