The Patient of the Future

deBronkart is not angry at the healthcare system; he believes in partnerships between physicians and patients. "I got superb treatment," he says. "I'm an example of somebody who became a patient empowerment advocate without being shafted by the system."

—Gienna Shaw

Patients who are "activated" in their health are more apt to stay current with their medications, be engaged during medical encounters, seek out health information, and are more likely to eat healthy foods, exercise, and get preventive care.

But fewer than half of U.S. adults are actually activated in their health, which can affect the success or failure of chronic disease programs and consumer-driven health plans, studies show.

Knowing that higher activation leads to better health, Judith H. Hibbard, DrPh, professor of health policy at the University of Oregon's department of planning, public policy, and management, designed the patient activation measure (PAM) to assess a person's knowledge, skill, and confidence in managing his or her health.

The PAM asks respondents about their beliefs, knowledge, and confidence in several health behaviors. Based on the responses, each person is given an activation score of 0 to 100 and placed into one of four activation levels, which reflects whether the person will obtain preventive care, maintain good diet and exercise practices, use self-management behaviors, and seek health information.

With the activation level, healthcare providers, health plans, and wellness coaches are able to know how to approach the individual and create a plan to improve the person's wellness. For instance, it doesn't make sense to ask a person at the lower activation levels to run two miles a day. That will actually alienate him. Instead, ask that person to walk around the block a few times a week or park further from the mall entrance in order to get exercise.

"Pounding people over the head doesn't work," says Hibbard. "Understanding the person and meeting them where they are is the key and also having a standardized approach for supporting patients, and finally having a way to track progress."

A recent study of LifeMasters Supported SelfCare Inc. members, which was led by Hibbard, found that coaching to patient activation levels through motivational interviewing techniques actually improves disease management outcomes in the areas of reduced hospital and emergency room utilization. The study found that those who received coaching with the PAM experienced a 33% decline in hospital admissions and a 22% decrease in emergency room visits over a six-month period.

But using the PAM doesn't mean simply finding the activation level and then handing the results to nurse coaches or healthcare providers to begin intervention. Mary Jane Osmick, MD, vice president and medical director at LifeMasters in Irvine, CA, says they need to understand patients' "pre-behaviors," and how to integrate the activation levels with tailored interventions. Not all healthcare professionals are comfortable with the tools, while some easily integrate the PAM into their health coaching.

"We see that some healthcare professionals immediately see value in understanding the activation levels. It helps understand the person . . . Some people are just better at understanding motivational interviewing than others," says Osmick.

Inspiring those at the lower end of the PAM is not easy, but Hibbard says there are two small steps that can help spark a person's belief in himself and activate him in his healthcare:

• Find out what the person wants to target first, which will help the person feel a level of control. For instance, a person who is a smoker, obese, and diabetic may first want to cut back on the junk food. The healthcare professional may rather the person focus on smoking cessation, but it's better to start with what the individual wants, and then nudge him to the next issue.
• Break down lifestyle changes into easy-to-accomplish, smaller tasks so the person can succeed. One example is asking a person who needs to improve her diet to start eating one high-fiber, low-fat meal once per week.

Hibbard says the PAM taps into an "underlying construct" that goes beyond the health arena. Much like how a person's self-esteem influences parts of an individual's life, a person's activation level also goes beyond health.

"I think physicians who understand and are skilled at this are actually more efficient, especially with chronic disease patients, because they are able to fully leverage the most important resource on their team—the patient. So they get better results," says Hibbard.

—Les Masterson

The patient activation measure (PAM) includes a 13-item scale that asks respondents about their beliefs, knowledge, and confidence in a number of health behaviors. The resulting score, or activation level, influences the approach to engagement.

PAM's four activation levels are:

• Level 1 (lowest level): People are passive and may not feel confident enough to play an active role in their health.
• Level 2: People may lack basic knowledge and confidence in their ability to manage their health.
• Level 3: People appear to take some action but may still lack confidence and skill to support necessary behaviors.
• Level 4: People support their health, but may not be able to maintain behaviors because of life stressors.