Targeting the right patients for support
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.”