Patient Engagement Occurs One Step at a Time

One of the steps toward achieving quality care is getting patients more engaged in their health by working with their providers to better understand the treatment they are receiving.

Not surprisingly, some patients are far more motivated and engaged—asking questions or searching for more detailed information. Others, not so much. But all patients can—and should—have the ability to be more involved in their care, according to one healthcare expert.

Judith Hibbard, a professor of health policy at the University of Oregon, noted patients usually encounter a one-size-fits-all provider approach when it comes to finding ways for them to manage their chronic conditions. However, if providers had more information on their patients' abilities to engage and self manage their conditions, they might be better able to target and support a patient's healthcare needs, she said.

"We've found that tailoring support to the patient's level of [engagement] is an important way to help [patients] become more activated and to be able to do all the behaviors we're asking them to do," she said.

Hibbard and her colleagues developed a measure to assess skill, confidence, and knowledge among patients about managing their conditions. With the measurement, they've been able to find new ways "to actually do a better job of engaging people," she said last week at a forum on "Exploring the Promise of Patient Engagement" sponsored by the Alliance for Healthcare Reform in Washington, DC.

"One of our very first insights was how much variation there is in any population group. If you take a Medicaid population, a Medicare population, or a sicker population, you will see people who are at the high end of [the measure's] dimension and people who are at the low end of this dimension, and everywhere in between," she said.

"No one seems surprised to hear that," she said. "But what is surprising is that we treat [all patients] the same—as if they actually did have the skill and knowledge they the need to do the job. And, we know that many do not."

One of the insights gained through early measurements is that this is a "developmental process" that people go through on "their way to becoming effective self-managers," she said.

In interviews with individuals, they found that people at the lower end of the measure are "very disengaged and not activated," she said. "They've had a lot of experience with failure, they are overwhelmed, they are discouraged . . . they don't feel they can have a positive impact. They may not have the understanding that this is their job."

"Think about this low-activated person and what their experience is with healthcare—especially if it's chronic illness, they probably go in and see their doctor and they're told to do 17 different things about how they are to live their lives," she said. For someone who is overwhelmed and discouraged, "the usual response to that is to do nothing."

"So by not understanding where people are, we may be further discouraging them," she said. "By not knowing what their skill set is for doing the job, we're . . . essentially throwing non-swimmers into the deep end of the pool and hoping for the best."

Engagement or activation by the patient is important because "activation is related to every type of health behavior: those who are more activated are more likely to engage in all of these types of [productive] health behaviors," she said.

But this doesn't mean individuals who are less engaged—and have less confidence—should be left behind. "And how do people get confidence? They experience success," she said. "We saw that there are some behaviors that are realistic for people who are less engaged to start with."

These strategies can involve peer support or learning problem-solving skills. "Provider support makes a very big difference with giving people strategic help in how to learning how to manage conditions and monitoring set goals," she said.

Later on, the patient can becomes more persistent in asking questions when they don't understand something in the medical encounter. "Turns out only the most activated [patients] do that, and sadly it's only the most activated who know where to get quality information and actually use it," she said.

"Many of the things that we are asking consumers to do are actually well beyond many of them," she said. "So, thinking about what is realistic—and helping people break them down into smaller steps—is going to help people to feel that they can actually [become more engaged]."

Activation and engagement are important because they are related to better outcomes, she said. She cited earlier studies where more engaged patients are found to be less likely to be readmitted to hospitals within 30 days of discharge. Patients who are engaged also have been found less likely use emergency rooms for care.

In one Kaiser Permanente study, measuring the activation level among diabetic patients was found to correlate with hospital readmission rates within a two-year period: Higher rates of engagement were related to less hospitalization.

"What we've learned overall is that we can do a better job," she said. "We know that we can help people gain in their confidence and their skills and ability to self-manage, but we have to move away from a one-size-fit-all approach. In doing so we can do a better job."

"And, we don't have to throw people into the deep end of the pool."