Activating people to partner in health and self‐care: use of the Patient Activation Measure (2024)

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PMC9328281

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Med J Aust. 2022 Jun; 216(Suppl 10): S5–S8.

Published online 2022 Jun 5. doi:10.5694/mja2.51535

PMCID: PMC9328281

PMID: 35665937

Tina Janamian,^1,² Michael Greco,^3,⁴ David Cosgriff,^5,⁶ Laurence Baker,⁷ and Paresh Dawda^8,⁹

Author information Article notes Copyright and License information PMC Disclaimer

Summary

Patient activation is a behavioural concept and is at the heart of personalised care. It is defined as an individual’s knowledge, skill and confidence for managing their health and health care.
Evidence indicates that patient activation scores can predict health behaviour and are closely linked to various clinical outcomes: reduced unnecessary emergency department visits, hospital admissions and re‐admissions. Patients with lower activation levels (25–40% of the population) are less likely to adopt healthy behaviour, and more likely to have poorer clinical outcomes and higher rates of hospitalisation.
Effective interventions can improve a patient’s activation level, and positive change in activation equates to positive change in self‐care behaviour. But to improve patient activation, we must first measure it using a robust evidence‐based tool such as the Patient Activation Measure (PAM) survey.
Armed with the patient’s PAM score, providers can tailor their care and help patients achieve better self‐care, which can improve outcomes of care and reduce unnecessary health care utilisation.
The PAM is also useful for population segmentation and risk stratification — to target interventions and health strategies to meet the needs of patients who are at different points along the activation continuum, to measure the performance of health care systems, and to evaluate the effectiveness of health care interventions.
The role of patient activation requires further serious consideration if we are to improve the long‐term health and wellbeing of all Australians. The PAM tool is a feasible and cost‐effective solution for achieving the Quadruple Aim — improving population health, the cost‐efficiency of the health system, and patient and provider experience.

Keywords: Health systems, Primary health care, Chronic disease, Physician‐patient relations, Preventive medicine, Community health planning, Cost of illness, Delivery of healthcare, Education, public health, Health communication, Health promotion, Health services research

“Better health for all, through better self‐care by all” is the vision of the Self‐care for health policy blueprint.¹ We need this vision because medical care only partially contributes to overall health: 89% of health comes from genetics, behaviour, environment and social circ*mstances — all factors outside the clinical setting.² We see the influence of a person’s behaviour on health outcomes in everything from preventing illness to managing long‐term health conditions.³ Therefore, it is vital that people are engaged with adopting positive health behaviour and partnering in health and self‐care. The World Health Organization defines self‐care as “the ability of individuals, families and communities to promote health, prevent disease, maintain health, and cope with illness and disability with or without the support of a health‐care provider”.⁴ This concept of self‐care incorporates the capability to care for oneself (knowledge, skills and confidence) as well as self‐care activities.¹ The underlying determinants and enablers of self‐care include factors beyond the individual, spanning environmental, economic and social factors. The importance of strategies to support self‐care are captured in Australia’s Primary Health Care 10 Year Plan.⁵

The self‐care perspective introduces a way of conceptualising and measuring engagement that is known as patient activation. Patient activation is defined as an individual’s knowledge, skill and confidence for managing their health and health care.⁶ It is a behavioural concept covering several core components of a person’s involvement in their health and health care, each of which is important for active engagement and participation. Positive change in activation equates to positive change in various aspects of self‐care behaviour.⁶ Evidence from the United States,⁷^,⁸^,⁹^,¹⁰ the United Kingdom¹¹^,¹²^,¹³ and more recently Australia¹⁴^,¹⁵^,¹⁶ shows how using patient activation to intervene in the delivery of health and health care can help achieve the Quadruple Aim — improving population health, the cost‐efficiency of the health system, and patient and provider experience.¹⁷

The Patient Activation Measure survey is the most common measurement tool

In health care, measurement is vital for effectively improving care. The Patient Activation Measure (PAM) survey, created in 2010¹⁸ and owned by the University of Oregon, is the most used measure of patient activation that has been validated globally.³ Across more than 700 published studies, the PAM has been extensively validated with diverse populations (in more than 30 languages and countries), covering different ages, genders, education, income and ethnicity, and including patients significantly affected by social determinants.¹⁹ Further, the relationship between patient activation and health outcomes is well understood, and has been demonstrated across populations and health conditions.⁷

Self‐care behaviour varies significantly depending on activation level. Higher PAM scores, regardless of illness type, are associated with improved patient self‐management behaviour (eg, medication adherence, healthy diet, engagement in regular exercise, and stress management).³^,⁶^,⁷^,²⁰ This is reflected in all types of preventive behaviour, meaning that a person’s activation level is a predictor of self‐care.⁶ There is also substantial evidence that higher PAM scores are closely linked with improved clinical outcomes,³^,⁸^,²¹^,²² and reduced unnecessary emergency department visits, hospital admissions and re‐admissions.⁹^,¹¹^,²³ Activation levels are also highly predictive of health care costs; an increase in activation is associated with reduced health care costs, particularly in high‐risk populations.⁸^,⁹^,²³^,²⁴ In general, 25–40% of the population have low levels of activation, which means they have low levels of knowledge, skill and confidence relating to self‐care.³

The PAM uses statements to assess a patient’s knowledge, skill and confidence to understand their self‐care ability. It takes 3–5 minutes, and can be easily administered via phone, tablet, email or paper in a home, office, clinic or hospital setting. It combines answers to give a single score that is between 0 and 100.²⁰^,²⁵ While a person’s PAM score lies within this range, for the purpose of intervention, patients are often subdivided into four groups known as levels of activation. Box 1 shows activation levels 1 to 4, where level 1 is the lowest and level 4 is the highest (20–25% of people are at the highest level).²⁰^,²⁵

Box 1

The four activation levels of the Patient Activation Measure*

Open in a separate window

*Image reproduced with permission from Insignia Health, a Phreesia company. ◆

The PAM administration platform offers real‐time data to clinicians; each patient’s PAM score and activation level are instantly available to the clinician via an online portal once the patient completes the survey, along with their previous data. Health services can access a dashboard of real‐time aggregated data that includes: total surveys completed; PAM level breakdown (current state); score changes (capturing changes in activation over time); PAM re‐administration; and outlier rates. Health organisations can also generate reports of PAM data on a population by region, program, clinician or any relevant factor so they can track improvements on a continuum. Return‐on‐investment reporting is also available, to show expected savings to the health care system based on mean PAM score change and expected behaviour change in the patient population of interest. It would save clinicians time if the PAM level was integrated into general practice or health services software to provide seamless access to this vital sign.

Health interventions tailored to a patient’s activation level are likely to improve their activation level, and positively affect their health outcomes and experiences as their activation level improves.²⁰^,²⁶ Therefore, it would be worth exploring how the PAM could be incorporated into existing primary care assessments, continuous quality improvement initiatives and chronic disease management programs to increase the benefits from these interventions. The PAM could be administered as part of the annual health assessment or mental health assessment and incorporated into the GP Management Plan or Team Care Arrangement.

The value of a single point change in PAM score is significant and well understood, as is the shift between activation levels.³^,⁹ Patients with lower activation levels and those with long‐term conditions benefit most from patient activation. At the lower end of activation, a 1‐point incremental change equates to an improvement in health outcomes of about 3% and a reduction in health costs of about 3%. It is expected that patients with lower activation levels (any group of patients and any chronic medical condition) would achieve a 7–10‐point change with targeted interventions within 4–6 months.⁷^,⁹^,²²

The PAM has three key uses: risk stratification and profiling of a population based on activation levels (thereby assisting with improved resource allocation); tailoring patient support to PAM levels; and measuring the effects of health care programs and interventions (eg, a program targeted at patients with type 2 diabetes, to reduce their HbA_1c levels).³^,²⁷ Traditional risk models rely on past utilisation and have been shown to miss more than half of the people in the two lower activation levels.

The clinician can tailor care to the patient’s needs by using different communication techniques, interventions and strategies, and providing an appropriate level of support, making it more likely that the patient will adopt behaviour that contributes to better health.³^,⁶^,²⁷ Using the PAM, the clinician can also determine how to gradually increase the patient’s knowledge, skill and confidence so that their health and wellbeing outcomes improve. By re‐administering the PAM every 3–6 months, clinicians can understand the impact of patient support strategies and programs much sooner than they would with traditional outcome measures.⁷

Tailoring care can increase patient activation

Well designed interventions for disease management, including tailoring care, can increase patient activation and positively improve self‐management behaviour.²⁰^,²²^,²⁷ A 2020 scoping review identified two critical success factors: the clinician understanding the value of the PAM, and the clinician being supported by well defined and flexible administration processes.²⁰

Client Focused Evaluation Program Surveys has adapted the Advanced Development Programme,²⁸ which includes online micro‐learning modules, videos, webinars and other resources aimed at helping clinicians to develop advanced skills to apply the PAM, tailor care to each patient, and activate patients along the PAM continuum (Box 2). The training also provides clinicians with skills to support and motivate their patients to take an active role in their self‐care. Evidence shows that to improve chronic disease‐related health outcomes, health care providers should implement interventions tailored to activation level and strengthen the patient’s role in managing their health care.⁷ There are no eligibility criteria for the training and participants receive continuing professional development hours from their college for completing the online modules.

Box 2

Care along the activation continuum: training to support tailoring care to activation level

The training helps the clinician to nimbly adjust their consultation to suit each patient’s activation level, as measured with the PAM. The online modules address each activation level and can include interactive webinars and face‐to‐face training for care providers. The training is usually delivered once the clinician is familiar with using the PAM and the survey reports are readily available through electronic health records. Training occurs over time and between sessions, clinicians identify specific advanced techniques to add to their repertoire of communications skills.

The PAM survey is increasingly being used in Australian settings. Some examples include:

▪
several Primary Health Networks (https://www.health.gov.au/initiatives‐and‐programs/phn), which are independent organisations working to streamline health services to better coordinate care;
▪
Remedy Healthcare (https://www.remedyhealthcare.com.au/), a private community health organisation that provides virtual and in‐home health care services;
▪
Osana (https://osana.care/), a group of private general medical practice clinics with a model of care that focuses on prevention and wellbeing;
▪
Integrated Living Australia (https://integratedliving.org.au/), a not‐for‐profit organisation that provides a range of health and wellbeing options such as aged care and disability support for individuals and their families in the community;
▪
EACH (https://www.each.com.au/), which provides a range of health, disability, counselling and mental health services across Australia; and
▪
Central Gippsland Health (https://www.cghs.com.au/about‐us/), a subregional integrated health service that provides a broad range of primary, secondary and tertiary services, including a near comprehensive range of Home and Community Care services, through to adult intensive and coronary care.

In line with findings in Australian and overseas studies,⁷^,⁸^,⁹^,¹¹^,¹⁴^,¹⁵^,¹⁶ the use of the PAM by these health services has been effective in various ways, including risk stratification, program evaluation and tailoring care, and has shown improvement in the mean PAM score for patients at lower activation levels (levels 1–3) over time (unpublished data). Care providers were trained to tailor care to a patient’s activation level — making sure that the level of support they provided was appropriate to the patient’s needs, and gradually increasing the patient’s levels of knowledge, skill and confidence relating to self‐care, to improve health outcomes. Remedy Healthcare also used health coaching as an intervention. In Australia, further research should address how PAM‐tailored interventions can be integrated into clinical practice, and how they can guide the patient–clinician interaction in ways that help improve the quality of patient care.²⁰

We must seriously consider the role of patient activation in Australia

Worldwide, the PAM is being used across populations. For example, the Centers for Medicare and Medicaid Services (the federally funded health care system in the United States for people aged 65 years and older and lower income individuals not covered by commercial insurance) are using the PAM through alternative payment models with up to 5 million patients.⁹^,¹⁰ Within NHS England (England’s publicly funded health care system), trusts (hospitals), clinical commissioning groups and integrated care systems are using the PAM to support more than 10 million patients.¹¹^,¹²^,¹³

Delivering better patient‐centred care with a focus on self‐care and patient activation is essential to the long‐term health and wellbeing of all Australians. Using a reliable and evidence‐based patient‐reported measure such as the PAM across the population to measure activation (or self‐care ability) and implementing PAM‐tailored interventions to each patient’s activation level can have many benefits. These include substantially improving self‐care and disease prevention, improving health outcomes (particularly for patients with chronic conditions), reducing health care costs, and enhancing the patient and care provider experience — the four elements of the Quadruple Aim.³^,⁶^,⁷^,⁸^,⁹^,¹¹^,¹²^,¹³^,²¹^,²²^,²³

In Australia, patient activation is noted as an enabler of the Primary Health Care 10 Year Plan, which focuses on delivering person‐centred care and aims to achieve the Quadruple Aim to optimise health system performance.⁵ We must seriously consider the role of patient activation, and pursue and evaluate the utility, feasibility and cost‐effectiveness of the PAM on a larger scale in Australia, as has been done in the US and UK health systems.

Open access

Open access publishing facilitated by The University of Queensland, as part of the Wiley ‐ The University of Queensland agreement via the Council of Australian University Librarians.

Competing interests

No relevant disclosures.

Provenance

Commissioned; externally peer reviewed.

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