Patient Activation and Motivational Interviewing

Presented by:Susan Butterworth, PhD, MSAssociate ProfessorOregon Health & Science UniversityPresident, Q-Consult

Objectives

• Introduce construct of patient activation and Patient Activation Measure

• Present theory of the relationship between patient activation and MI

• Explore value of patient activation scores in MI-based intervention

Give a man a fish and you feed him for a day. Teach a man to fish and you feed him for a lifetime.

- Chinese Proverb

Knowledge/Skills

ACTIVATION

Empowerment Confidence

Patient ActivationJudy Hibbard, PhD

Why is activating the patient so important?

Healthcare resources are scarce; it is increasingly

important for people to take an active role in managing

their care Lifestyle management is the key to prevention and

treatment of chronic conditions Activation can be influenced in a brief intervention and, in

turn, influences the person across all risk factors Patient activation is correlated with multiple outcomes

Activation is related to many outcomes

Patient Activation Measure

• PAM 13 Low Literacy

Activation is Developmental

Addiction Diabetes 1Asthma Diabetes 2CAD Chronic Pain COPD Heart Failure Mental Health

~10,000 survey participants: No association between having chronic condition and low PAM scores.

HRA Research

Implications: Healthcare industry may want to re-examine how they identify people for intensive interventions

Patient Activation and MI:How can multiple behaviors be changed even when all the behaviors for each participant are not being treated?

Motivation

Ambivalence

Self-

efficacy PATIENTACTIVATION

Health Coach

MI

Change Talk

CommitmentStrength

Skills

Knowledge

Patient Activation and MI:Focusing on patient activation as overarching targeted behavior

Patient Activation

Patient Activation

Managing fluids

Takin

g

meds

Ask

ing D

r

questio

ns

Under-

standing disease

Impro

ving

self-

effic

acy

Study #1: MI-based Health Coaching as Chronic Care Intervention

• Quasi-experimental design over 8 month period

• Employees at large medical university

• Chronically ill group enrolled in health coaching

• Staff extensively trained in MI; little training in patient

activation

• Outcome measures

▫ Perceived global health

▫ Self-efficacy for managing chronic illness

▫ Patient Activation

▫ Stage of change for most important behavioral risk

▫ Lifestyle management

MI-based Health Coaching Intervention

Total Employees(n=8,500)

Employees taking HRA(n=3,832)

Completing survey once(n=2,815)

Chronically Ill(n=830)

Coached(n=184)

Non-Coached(n=646)

Completing survey twice(n=1,017)

Chronically Ill(n=336)

Coached(n=106)

Non-Coached(n=230)

Outcome for Patient Activation

Control Treatment*69

70

71

72

73

74

75

76

77

Baseline**

PAM Score

* p = 0.02** IPTW adjusted

Outcomes

• As compared to control group, treatment group also had significant improvement in:

▫ Perceived global health

▫ Self-efficacy for managing chronic illness

▫ Stage of change for most important behavioral risk

▫ Lifestyle management

Tailored Coaching Study•Disease management organization•Minimal training for all staff in MI•Extensive training in tailoring coaching based on

patient activation level for staff in treatment arm• Intervention group coached on activation level. •Control group received ‘usual care’ coaching•Outcome measures: claims data, clinical indicators

and activation levels•6 month intervention period

Outcome for Patient Activation

Outcomes

•Those who received coaching with the PAM:▫33% decline in hospital admissions compared to the

control group, which remained flat▫22% decline in emergency room visits compared with

an increase of 20% in the control group.▫Significant improvements in diastolic blood pressure

and LDL cholesterol levels relative to control group▫Significantly increased adherence to recommended

immunization and drug regimens

What does a PAM score tell us?• May be overwhelmed or depressed

• May need to take smaller steps and have more contact

• May not understand disease or how treatments work

• May not have confidence about managing condition

• Menu of options, empathetic reflections, empowering

affirmations may be helpful

Low Patient

Activation Score

• May have high level of knowledge or understanding

• May resent someone telling him/her what to do

• May have strong opinions about treatment options and have

researched issues on their own

• May be used to success and feel frustrated

• E-P-E, supporting autonomy, putting pt in driver’s seat may be

helpful

High Patient

Activation Score

Case #1

• Maria Gonsalves has had diabetes for 20 years and has just been diagnosed with Congestive Heart Failure. Her patient activation score is low. She seems preoccupied when you try to talk to her and close to tears.

• What is your approach with her? • What is your goal for the first couple of sessions?• In your small group, role play at least 2 different approaches

that you could use. Which approach can you use that will help address/improve patient activation?

Case #2

• William Bickle has been going to your clinic for 5 years. He has a reputation as being difficult. You are newly assigned to him as care manager. His labs have generally been good but you notice that they have recently been out of range in a number of areas. His patient activation score is high.

• What is your approach with him? • What is your goal for the first couple of sessions?• In your small group, role play at least 2 different approaches

that you could use. What approach could you use that will support his patient activation?

Case #3• Rose Ann Yardley has been a patient of yours for a while and

you have good rapport. She has low patient activation and you have noticed that she is not proactive about her health, depending on you and the doctor to tell her what to do. She also listens to patients in dialysis give advice and sometimes gets confused. You have approached her about moving from a catheter to a fistula but another patient has told her a horror story about how his didn’t work out. In an initial brief discussion, she told you that she doesn’t want to change her catheter and why. This is your second session with her.

• What is your approach with her? • In your small group, role play at least 2 different approaches

that you could use. What approach could you use that will address/improve her patient activation?

In Summary

•Patient activation may be an important underlying mechanism of MI

• It may be helpful to provide training to healthcare providers/coaches in patient activation in addition to MI

•Patient activation scores can be used to:▫ Identify patients at risk;▫Provide additional risk factor information to healthcare

staff;▫Guide health coaching approach;▫Measure outcomes of an MI-based intervention.

Resources

•For more information on PAM, go to www.insigniahealth.com

•For list of citations regarding patient activation, email me at butterwo@comcast.net