Tar­get­ing the right pa­tients for sup­port

Modern Healthcare - - BEST PRACTICES - By Mau­reen McKin­ney

Dr. Ralph Fillingame was fed up. The fam­ily physi­cian’s ag­ing pa­tients had com­plex health­care needs, in­clud­ing mul­ti­ple chronic ill­nesses such as hy­per­ten­sion and di­a­betes, but progress in man­ag­ing those ill­nesses was slow.

Some of the pa­tients he treated at the Santa Clara PeaceHealth Med­i­cal Group clinic, in Eu­gene, Ore., part of Van­cou­ver, Wash.-based PeaceHealth, seemed un­able or stub­bornly un­will­ing to take an ac­tive role in their own care.

“I re­al­ized it didn’t mat­ter how ac­cu­rate the di­ag­noses were or how good the med­i­ca­tions were,” he said. “If the pa­tient was not con­fi­dent enough or will­ing to carry out those in­ter­ven­tions them­selves, we were just fool­ing our­selves.”

Nu­mer­ous stud­ies have demon­strated the crit­i­cal role that pa­tient en­gage­ment plays in med­i­ca­tion ad­her­ence, healthy eat­ing and other com­po­nents of suc­cess­ful dis­ease man­age­ment.

“These pa­tients see a doc­tor once in a while, but they live with their chronic dis­eases 24/7,” Fillingame said.

Some hos­pi­tals and health sys­tems are us­ing the Pa­tient Ac­ti­va­tion Mea­sure, or PAM, as a tool to help pre­dict which pa­tients are best equipped to en­gage in their care and which ones will be overwhelmed and in need of additional sup­port.

De­vel­oped by a team led by Ju­dith Hib­bard, a pro­fes­sor of health pol­icy at the Univer­sity of Ore­gon, the PAM tool is a 10- or 13-item sur­vey that as­sesses ac­ti­va­tion by mea­sur­ing pa­tients’ agree­ment with sim­ple state­ments such as, “I know what my pre­scribed med­i­ca­tions do.”

Based on their an­swers, pa­tients re­ceive a score on a 100-point scale and are placed into one of four lev­els, with lower scores in­di­cat­ing less ac­ti­va­tion. Re­search led by Hib­bard and oth­ers has shown low PAM scores are strongly as­so­ci­ated with poorer health out­comes, higher costs, greater emer­gency-depart­ment uti­liza­tion and higher read­mis­sion rates.

“We have found that people who mea­sure low on the scale of­ten don’t un­der­stand their role in the care process,” Hib­bard said. “For what­ever rea­son, they don’t seek out in­for­ma­tion and that makes them much more vul­ner­a­ble to ad­verse events.”

Not sur­pris­ingly, many in­sur­ers have en­thu­si­as­ti­cally adopted the PAM as­sess­ment as a way to iden­tify high­risk pa­tient groups and con­trol uti­liza­tion, Hib­bard said.

One such in­surer was Regence Blue Cross and Blue Shield, which ap­proached Fillingame in 2008 with a propo­si­tion: Regence would pro­vide grant fund­ing for an 18-month med­i­cal-home pi­lot us­ing the PAM tool. Fillingame agreed and the project kicked off in Oc­to­ber of that year.

Fillingame used the PAM as­sess­ment to cus­tom­ize his team’s ap­proach to each pa­tient’s care. Low-scor­ing, less-ac­ti­vated pa­tients with more-com­plex health­care needs, for in­stance, re­ceived more-in­ten­sive care co­or­di­na­tion and coach­ing ser­vices, while high-scor­ing pa­tients re­ceived a more hands-off ap­proach. He used the grant funds to hire a full-time med­i­cal of­fice as­sis­tant who helped with coach­ing, as well as a half-time be­hav­ioral health specialist.

Fillingame gave the ex­am­ple of a for­mer male pa­tient who suf­fered from a num­ber of chronic ill­nesses, in­clud­ing hy­per­ten­sion and early di­a­betes, and who was a Level 2 on the PAM scale. “He was overwhelmed, but we worked with him to set small, at­tain­able goals, which we kept mod­i­fy­ing as he made progress,” Fillingame said, adding that the pa­tient lost 40 pounds and saw marked im­prove­ment in his health.

Dur­ing the pi­lot, the aver­age num­ber of quar­terly ER vis­its dropped more than 40%. Fillingame’s team also saw im­prove­ments in pa­tient-sat­is­fac­tion scores and in the per­cent­age of pa­tients with con­trolled hy­per­ten­sion.

Un­for­tu­nately, when the pi­lot con­cluded, the prac­tice didn’t have the re­sources to keep the in­ten­sive ap­proach in place, said Fillingame, who has since left for a job in pub­lic health.

That’s not sur­pris­ing, said Chris De­laney, CEO of In­signia Health, Port­land, Ore., which has exclusive li­cens­ing rights for the PAM tool and cur­rently has 130 clients, in­clud­ing 40 to 50 hos­pi­tals and health sys­tems. He says the PAM tool is a dif­fi­cult sell in a fee-for-ser­vice en­vi­ron­ment where keep­ing pa­tients well re­duces rev­enue. Still, he ex­pressed op­ti­mism that the move to value-based care will heighten the fo­cus on ac­ti­va­tion.

“Rais­ing a PAM score by just 1 point is worth a 2% de­cline in ER use, a 2% im­prove­ment in A1c lev­els and a 2% im­prove­ment in med­i­ca­tion ad­her­ence,” he said. “It’s a very pow­er­ful met­ric.”

PeaceHealth is still us­ing the PAM tool in its am­bu­la­tory-care-man­age­ment pro­gram and has plans to even­tu­ally em­ploy it across the sys­tem, said Shel­ley Buettner, PeaceHealth’s pa­tient-cen­tered med­i­cal home pro­gram man­ager. “It’s a work in progress and there are chal­lenges, of course, but if we can work with commercial pay­ers and CMS to try to change in­cen­tives, that’s all the bet­ter.”

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