Judith Hibbard, Jessica Greene, Rebecca M. Sacks, Valerie Overton, and Carmen Parrotta
J. H. Hibbard, J. Greene, R. Sacks et al., “Improving Population Health Management Strategies: Identifying Patients Who Are More Likely to Be Users of Avoidable Costly Care and Those More Likely to Develop a New Chronic Disease,” Health Services Research, published online Aug. 23, 2016.
After reviewing medical records for approximately 98,000 adults, researchers found that patients who did not feel competent to manage their own health or navigate the health care system were more likely to develop a chronic disease over a three-year period than “activated” patients with good self-management skills. Low patient-activation levels were also linked to significantly greater likelihood of hospitalization and emergency department (ED) use for “ambulatory care–sensitive” conditions—those that are avoidable if managed properly.
The success of population health management depends, in part, on accurately identifying patients at high risk for poor health outcomes as well as preventable and costly health events. Risk-stratification approaches typically focus on clinical markers. This Commonwealth Fund–supported study explored whether considering a patient’s self-management skills and confidence—as predicted by the commercially available Patient Activation Measure (PAM)—might help health care delivery systems pinpoint additional high-risk patients who could benefit from supportive interventions. The Patient Activation Measure assigns patients a score of 0 to 100. Patient can be further grouped into four activation levels, with level 1 representing patients with the most limited self-management skills.
"Understanding the patient’s capability for self-management is a key part of understanding the risk of health declines and of avoidable utilization."
A patient’s activation score, or self-management skill level, helps predict future risk of developing a chronic disease and using expensive and avoidable medical services. Growing evidence suggests that it is possible to increase activation levels and helping patients become more skilled in managing their health and health care. By stratifying populations by patient activation scores, health care delivery systems can identify and help those patients with limited self-management skills in time to prevent poor outcomes and unnecessary utilization. When working with patients with low activation levels, health care providers should recommend small steps to achieve behavioral changes, the authors say, since too much information or too many changes at once may be overwhelming to those patients.
This retrospective study focused on 98,142 patients at Minnesota’s Fairview Health Services who had a Patient Activation Measure score recorded in the electronic health record in 2011 and visited a primary care clinic at least once in 2012, 2013, and 2014. The researchers evaluated the potential of the Patient Activation Measure in determining future chronic disease burden and ambulatory care–sensitive hospitalizations or ED visits.
A patient’s activation level, or ability to self-manage health and health care, is linked to risk of developing a chronic disease and using expensive and avoidable health care services in the future. By stratifying populations by activation level, health care delivery systems might better identify and support patients with limited self-management skills, helping to improve outcomes and prevent unnecessary costs.