Top Patient Engagement Metrics to Improve Healthcare Quality

Patient Activation Measure

The patient activation measure (PAM) is a 100-point, quantifiable scale determining patient engagement in healthcare. The PAM was created by a group of researchers in an effort to define patient activation. After noticing a gap in the literature, researchers Judith A. Hibbard, Jean Stockard, Eldon R. Mahoney, and Martin Tusler set out to create a first-of-its kind assessment for patient activation for any and all health and wellness behaviors.

Hibbard et al. created the PAM using a four-step process. First, the team looked at existing definitions for patient activation, breaking the term down into 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 health care system

From there, the team created 22 survey items within four levels of patient activation. Those levels include

• Believing the patient role in activation is important
• Having the confidence and knowledge necessary to take action
• Proactively taking action to maintain and improve one’s health
• Staying the course even under stress

In 2005, the same group of researchers led by Hibbard created a short-form version of the PAM. The 13-item survey removed measures that would not have a significant impact on outcomes in an effort to reduce provider burden.

The 13 measures that remained at the end of the new survey’s development include but are not limited to

• When all is said and done, I am the person who is responsible for managing my health condition
• I know what each of my prescribed medications do
• I understand the nature and causes of my health condition(s)
• I am confident I can figure out solutions when new situations or problems arise with my health condition

Many healthcare organizations have adopted PAM as a way to evaluate the efficacy of certain patient engagement strategies. For individual providers, PAM can help healthcare providers tailor their patient engagement efforts based on patient preferences and needs.

Patient health literacy

Health literacy is a baseline necessity in patient engagement and can fall into two categories: personal health literacy and organizational health literacy.

Per the CDC, personal health literacy is “the degree to which individuals have the ability to find, understand, and use information and services to inform health-related decisions and actions for themselves and others.”

Personal health literacy gives patients the know-how and vocabulary to understand their own healthcare issues. A patient with high health literacy will be able to understand healthcare concepts and treatment options and therefore be better equipped to make healthcare decisions and understand the “why” behind their treatment plans.

However, that high level of health literacy isn’t common.

According to the Center for Health Care Strategies, nearly a third of US adults have low health literacy. Low health literacy is more common among low-income individuals and Medicaid enrollees.

Healthcare providers can screen for low health literacy. The Agency for Healthcare Research and Quality (AHRQ) has short and rapid assessments for health literacy available in both English and Spanish. Many healthcare organizations also use the Health Literacy Tool Shed for health literacy screenings.

By measuring health literacy, healthcare providers can better tailor individual patient-provider communication, while organization leaders can assess how it can cultivate higher health literacy population-wide.

Notably, low health literacy is an expensive problem in the US, per the Center for Health Care Strategies. Between higher rates of medical errors, more illness and disability, loss of wages, and impact on public health, low health literacy can rack up a price tag of up to $236 billion every year, the Center estimated.

Meanwhile, organizational health literacy is “the degree to which organizations equitably enable individuals to find, understand, and use information and services to inform health-related decisions and actions for themselves and others.”

The concept of organizational health literacy is somewhat new, or at least the name for it is. The term was only recently added as part of the Healthy People 2030 goals. In a paper published in Public Health Management and Practice, the folks behind the expanded definition said that organizational health literacy acknowledges that health literacy is not the sole responsibility of the patient.

“By taking action to reduce the complexity of health information and health systems, with particular attention to the needs of diverse populations, producers of health information and services can contribute to the Healthy People 2030 overarching goal of attaining health literacy, eliminating health disparities, and achieving health equity,” they wrote.

Clinical quality measures

Although clinical quality measures are intended to assess the process and outcomes of the care delivered to patients, they can also indicate how the patient interacted with that care. A few clinical quality measures germane to the patient engagement issue include medication adherence, readmission rates, and access to follow-up care.

This is because these items depend on patient activation.

Medication Adherence

Medication adherence is defined as taking one’s medications as prescribed. Poor medication adherence is a billion-dollar problem because it can result in a patient’s illness deteriorating. Most poor medication adherence manifests as skipping doses, rationing pills, splitting pills in half, and not filling a prescription at all.

But although medication adherence can be a proxy of patient activation, it’s more complex than that. Most patients do not skip their doses because they are stubborn; it is because the cost of the medication is high, and they want the prescription to last longer.

To that end, medication adherence is a measure that can indicate when patients need more comprehensive medication management.

Healthcare providers who observe low medication adherence should counsel patients on drug affordability. The most effective drug a patient can take is the one they can afford, so selecting a cheaper alternative or a generic may be effective.

Tools like dose packaging and medication reminders can be helpful for patients who miss doses due to complex medication regimens.

Readmission Rates

Hospital readmission rates measure the proportion of patients who are readmitted into the hospital after an acute care episode.

This measure can be an indicator of patient engagement because hospital readmissions can sometimes happen when a patient does not follow a self-management regimen. A patient who does not follow wound care instructions, for example, may be readmitted into the hospital with an infection.

Ultimately, this can indicate a lapse in patient-provider communication upon discharge. Some studies have shown that hospital readmission rates improve when there is better family and patient engagement during the discharge process. Self-management tools plus strong patient outreach in post-acute care can also reduce hospital readmissions by supporting the patient in care management and coordination.

Access to follow-up care

Accessing follow-up care can signal patients who are willing and able to participate in their own care management. Follow-up care can be a part of post-acute care management or can be a part of the preventive screening process, such as when an initial screen comes back positive and the patient gets referred for further testing.

In December 2022, Dutch researchers found that patient navigation challenges, decision-making challenges, limited patient-provider communication, and the ability to self-monitor deter many patients from accessing follow-up care.

In these cases, provider communication and endorsement would go a long way in engaging patients, the researchers said. Providers should outline the benefits of certain screenings and services, the risks, and other treatment options to engage patients in shared decision-making.

Separate studies have also indicated that costs can deter patients from follow-up care. While initial preventive screenings are free in the US, insurance coverage for follow-up appointments is variable. Mediating the costs of follow-up care likely requires a policy change, researchers said, but clinicians can help stem the impact of those high costs by discussing them with patients early.

That will help clinicians set expectations for patients, endorse access to follow-up care, and give patients the information necessary for making their own care decisions.

No-show rates

Similar to access to follow-up care, no-show rates can give organizations and idea of how well they connect with patients to get them in for care. No-show rates are the proportion of patients who do not show up to a scheduled appointment and are considered a revenue loss for organizations.

Patients may no-show for numerous reasons, the most common of which include not having a ride and forgetting about the appointment.

Data in Annals of Family Medicine looking at pediatric clinics showed that no-show rates are higher for underserved kids than their more affluent counterparts. This is because those kids are more likely to experience social determinants of health, such as transportation, that block care access.

These kids are also more likely to have parents who cannot take time off work or pass up an extra shift to supplement their income. These access barriers can be mirrored in the adult population.

Some organizations are working to ameliorate this through partnerships with rideshare companies like Uber and Lyft. Through patient outreach, organizations can uncover when transportation is a barrier to care and arrange a ride for the patient to ensure access.

That outreach can also come with an appointment reminder. Because patients must make appointments so far in advance—the average appointment wait time in 2022 was 26 days—it is not uncommon for them to forget them.

Follow-up phone calls closer to the date of the appointment can be effective for ensuring the patient will come or rescheduling for a better time.

Patient satisfaction surveys, online reviews

Patient satisfaction surveys and online provider reviews provide the patient perspective of the overall experience of care. These are different from quality metrics like readmission rates because experience surveys look at how patients perceived their care.

Healthcare organizations can use many different tools to measure patient satisfaction and experience, including but not limited to

• CAHPS surveys
• Press Ganey
• NRC Health
• Qualtrics
• Feedtrail
• Quality Reviews
• Customized patient satisfaction surveys
• Real-time patient satisfaction indicators
• Online provider reviews

Using these tools can be instrumental in assessing the patient perspective of care, industry leaders told KLAS Research in a December 2021 market assessment.

“Across vendors, the most commonly reported outcomes include improved visibility into the patient experience and greater clarity on where to focus improvement efforts,” KLAS wrote in the report.

This is especially true for organizations using real-time patient experience surveys. These tools, which are installed on bedside tablets and other patient-facing technologies, let users report their experiences while they are still inpatients.

This gives providers the opportunity to connect with the patient and remedy the situation even before the patient has been discharged. That has the dual benefit of improving the experience for the patient and preventing a potential bad survey score or online review.

Still, those online reviews can be helpful for organizations that cultivate a good online reputation. Around three-quarters of patients look at online provider reviews before selecting a new provider, which helps organizations focused on patient volumes as a revenue source.

Healthcare organizations can also use these tools to remediate relationships with patients. Those confronting a negative online review can have their patient relations or marketing teams reach out to the patient to remedy the issue, ideally prompting the patient to change their review.

Patient portal utilization, health IT use

Patient portal use, plus utilization of other health IT, have long been key patient engagement indicators. During the days of the Medicare and Medicaid EHR Incentive Programs (meaningful use), the federal government used patient data access as a proxy for both using the EHR and adequately engaging patients in care.

Indeed, patient data access can be linked to other behaviors associated with patient activation, like medication adherence and asking more questions during a medical appointment. Getting more users to access the patient portal could result in overall more informed and engaged patients.

However, it should be noted that health IT use is not a perfect measure of patient engagement, given the structural barriers that can block access.

In April 2022, the All of Us Research project from NIH showed that, although patients acknowledge the utility of health IT, many don’t access it. Factors like digital health literacy and affordability of wearables and other devices get in the way.

Poor access to broadband, limited patient education on the tools, and poor usability have also blocked patient portal adoption and utilization.

These structural barriers don’t necessarily indicate a poorly engaged patient. Instead, healthcare providers need to work with patients to discuss the utility of the patient portal and related connected health devices. Providers, plus healthcare navigators, may also be instrumental in overcoming the digital health literacy issues that stand in the way of use.

As healthcare continues its embrace of patient-centered care, using patient engagement metrics will be key. Organizations can use these measures to put in place better supports that help patients connect more deeply with their care both inside and outside the hospital or clinic.