Patient Engagement Strategies for Improving Patient Activation

IDENTIFYING ACTIVATED PATIENTS

The first step of any patient activation improvement activity is understanding individual patient activation levels. Many healthcare professionals use the Patient Activation Measure (PAM), a 100-point scale that determines how involved a patient is in her own health.

The PAM was first introduced in a 2004 paper published by Hibbard and her colleagues Jean Stockard, PhD, Eldon R. Mahoney, PhD, and Martin Tusler, MS. The group sought to define patient activation and offer clinicians a tool with which they can identify activated patients.

The measure uses patient-facing survey questions to cover six different patient characteristics:

• Ability to self-manage illness or problems
• Ability to engage in activities that maintain functioning and reduce health declines
• Ability to be involved in treatment and diagnostic choices
• Ability to collaborate with providers
• Ability to select providers and provider organizations based on performance or quality
• Ability to navigate the healthcare system

The PAM survey also includes 22 items, each of which is weighted differently to comprise the 100-point scale. The survey questions cover four central themes, including believing the patient role in activation is important, having the confidence and knowledge necessary to manage health, proactively taking action to maintain and improve one’s health, and staying the course even under stress.

Hibbard and her colleagues also developed a shorthand version of the PAM, reducing the survey to 13 questions. Those survey questions assess:

• Whether the patient believes she is ultimately in charge of her health
• Whether she knows what each of her prescribed medications does
• Whether she understands the nature and causes of her health conditions
• Whether she can find solutions when a new health issue arises

This patient survey can be integrated into the EHR. Many doctors ask patients to complete the survey at the beginning of an appointment, in the waiting room, or using the patient portal before arriving at the clinic.

After collecting patient responses for the PAM, clinicians can make decisions about their patient engagement strategies. Less activated patients may not easily adopt a new engagement technology or a more complex or demanding health behavior change, for example. Simpler engagement strategies will resonate with low-activation patients and allow those patients to experience success, thus further encouraging and activating them.

ARMING PATIENTS WITH KEY HEALTH INFORMATION, EDUCATION

Patients cannot meaningfully engage in self-management activities if they are not familiar with their conditions, treatments, and other health issues.

A 2024 article published in Patient Education and Counseling showed that a patient education curriculum carried out during hospital discharge sparked increases in patient activation, as measured by the PAM.

The researchers tested a nurse-led hospital discharge education system tailored to help patients better understand their post-discharge care management protocol. Educational sessions were tailored to patients’ clinical complexity and existing patient activation levels—or their ability and readiness to manage their own healthcare.

The intervention worked, showing higher PAM scores among patients getting the education compared to those receiving usual discharge care.

At discharge, the intervention group had an average of 63.5 on the PAM, compared to the control group’s 57.2. Between 7 and 10 days post-discharge, the difference in PAM scores persisted, coming in at 64.8 and 57.6, respectively.

The researchers hypothesized that the personalized nature of the patient education was crucial to their positive results. One size does not fit all when it comes to patient education, and providers need the tools to tailor their educational efforts based on patient needs, clinical complexity, and current health literacy levels.

Providers should use clear, simple language when educating patients. They should also use their assessments of patient activation and health literacy to inform their educational strategies – a patient with higher activation and health literacy can absorb more complex information, for example.

Popular patient education strategies can include patient teach-back, the use of written handouts, and patient portal and data access.

ENGAGING PATIENTS IN SHARED DECISION-MAKING

Shared decision-making, or the practice of engaging patients in selecting a certain treatment path, puts patients in the middle of their own care. By doing so, patients may become more activated in their care management and wellness goals. Shared decision-making gives patients a stake in their treatment and can ultimately improve care outcomes.

Of course, shared decision-making also relies on an activated patient. In October 2019, researchers explained that there is a bidirectional relationship between patient activation and successful shared decision-making.

In particular, patients need enough information about their current diagnosis, potential treatment options, and possible side effects to effectively participate in shared decision-making. Building a patient’s confidence and competence with key healthcare topics can be helpful when beginning to use shared decision-making.

But once that baseline is set, shared decision-making can spark stronger activation among already activated patients.

A 2018 study published in the American Journal of Surgery found that patient-reported outcomes for hypertension management suffered when care encounters lacked shared decision-making, or when the shared decision-making was not up to a certain standard.

Subpar shared decision-making was tied to higher emergency department utilization, lower use of statins or aspirin, and lower physical and mental health scores, the researchers reported.

These results do not necessarily mean that shared decision-making itself leads to better health. Instead, the study indicated that shared decision-making results in patient activation and self-management, which in turn can result in better health, the researchers explained.

Shared decision-making can be integrated into patient care encounters when providers do the following:

• Assess patient preferences for shared decision-making
• Educate patients about all possible treatment options and how they fit into a patient’s current health status
• Discuss patient values and health-related goals
• Come to a treatment decision with the patient
• Evaluate patient decisions

Of course, adopting shared decision-making strategies will require providers to rework some of their clinical workflows. Most clinicians find themselves pressed for time and have little room for further health discussions with patients.

Use of patient engagement tools such as paper or digital decision aids will help providers save time during the patient education process. Decision aids are helpful for all patients, but 2022 FAIR Health data showed that they can specifically engage racial minority patients who traditionally see less engagement in shared decision-making.

SUPPORTING PATIENTS OUTSIDE OF THE OFFICE

Since patients spend much more time outside the clinic than in it, providers should keep communication channels open and ensure patients remain activated in their care.

Health IT can play an important role in this. Patient portal messages and other digital patient outreach tools allow providers and patients to message back and forth to answer questions, check in on new interventions, and mitigate other health concerns.

They also provide an opportunity for providers to give a personalized nudge to a patient who may be less activated in self-management.

Text messages or phone calls can remind patients to receive preventive care, take a certain medication, or adopt a new healthy behavior.

Medication adherence apps have proven effective at improving care outcomes for patients, for example.

These patient nudges can boost patient activation and, ultimately, yield better clinical quality outcomes. In 2022, researchers tested a text message patient outreach campaign for patients discharged from the hospital. Text messages were opt-in, and they generally asked patients how they were doing and prompted basic care management activities.

Patients receiving the text messages saw a 41 percent decline in their risk for 30-day hospital readmission. Patients getting the texts were also 33 percent less likely to visit the ED 30 days after discharge, but this finding was not statistically significant, the researchers said.

It will be important for clinicians to balance their interpersonal skills with automated patient outreach technology. Although automated tools can make it easier for providers to reach more patients quicker, a personal connection via patient portal message or personal phone call can also be key for motivating patients.

Appointment reminders, medication adherence nudges, or drug refill notifications may be good fits for automated technology, while evaluation of a healthy behavior change, or attending to irregularities observed using remote patient monitoring technology may be best addressed with a personal message.

Assessing patient activation levels, patient education, shared decision-making, and patient outreach each on their own are key patient engagement strategies. Taken together, these strategies can help providers increase patient activation levels.

As patients become more empowered in their care, they are more likely to adopt new healthy behaviors and engage in self-management, ideally improving care outcomes and cutting healthcare spending.