Assessing Patient Activation Among High-Need, High-Cost Patients in Urban Safety Net Care Settings

Napoles TM, Burke NJ, Shim JK, Davis E, Moskowitz D, Yen IH
Source: J Urban Health
Publication Year: 2017
Patient Need Addressed: Chronic Conditions, Patient satisfaction/engagement
Population Focus: Complex care
Demographic Group: Racial and ethnic minority groups, Urban
Intervention Type: Best practices
Study Design: Review
Type of Literature: White
link: https://www.ncbi.nlm.nih.gov/pubmed/28597203
Abstract

We sought to examine the literature using the Patient Activation Measure (PAM) or the Patient Enablement Instrument (PEI) with high-need, high-cost (HNHC) patients receiving care in urban safety net settings. Urban safety net care management programs serve low-income, racially/ethnically diverse patients living with multiple chronic conditions. Although many care management programs track patient progress with the PAM or the PEI, it is not clear whether the PAM or the PEI is an effective and appropriate tool for HNHC patients receiving care in urban safety net settings in the United States. We searched PubMed, EMBASE, Web of Science, and PsycINFO for articles published between 2004 and 2015 that used the PAM and between 1998 and 2015 that used the PEI. The search was limited to English-language articles conducted in the United States and published in peer-reviewed journals. To assess the utility of the PAM and the PEI in urban safety net care settings, we defined a HNHC patient sample as racially/ethnically diverse, low socioeconomic status (SES), and multimorbid. One hundred fourteen articles used the PAM. All articles using the PEI were conducted outside the U.S. and therefore were excluded. Nine PAM studies (8%) included participants similar to those receiving care in urban safety net settings, three of which were longitudinal. Two of the three longitudinal studies reported positive changes following interventions. Our results indicate that research on patient activation is not commonly conducted on racially and ethnically diverse, low SES, and multimorbid patients; therefore, there are few opportunities to assess the appropriateness of the PAM in such populations. Investigators expressed concerns with the potential unreliability and inappropriate nature of the PAM on multimorbid, older, and low-literacy patients. Thus, the PAM may not be able to accurately assess patient progress among HNHC patients receiving care in urban safety net settings. Assessing progress in the urban safety net care setting requires measures that account for the social and structural challenges and competing demands of HNHC patients.

Insights Results

Overview of article

  • This article examines existing literature using the Patient Activation Measure (PAM) or Patient Enablement Instrument (PEI) with high-need, high-cost patients receiving care in urban safety net settings to determine its utility among this patient population. Given the low activation of this patient population, there is a need to track patient progress towards improved patient activation (i.e., one’s ability and willingness to manage one’s health and healthcare), especially in safety net hospitals and community health centers who provide a disproportionate amount of care to high-need, high-cost patients
  • PAM was developed in 2004 to assess patient knowledge, skill, and confidence for self-management and is now widely employed to manage patient panels and identify patients most likely to improve after clinical intervention. Respondents are asked to indicate their level of agreement with 22 statements, or 13 statements with the PAM short-form. Questions inquire about an individual’s role in healthcare and their relationship with their provider such as “I know what each of my prescribed medications do and I am confident that I can tell a doctor concerns I have even when he or she does not ask”. The PAM has been validated with a national random sample of individuals living with and without chronic illnesses. The PAM is also commonly used by many private health insurers, hospitals and systems. It was also identified as a Merit-Based Incentive Payment System (MIPS) measure and has been used to assess the implementation of health equity centered models and programs (e.g., Washington State Health Homes Program)
  • In practice, the raw PAM score is converted to an activation score between 0 and 100, where a higher score equates to a higher level of activation. The activation score is then used to classify respondents into 1 of 4 activation levels, or stages, based on cut-off points. If respondents score at stage 1 (≤47), they are categorized as “believing the patient role is important (but not having the confidence to take
    action).” Likewise, if a respondent scores at the highest level, stage 4 (≥67.1), they are “taking action to maintain and improve one’s health” and able to “maintain these behaviors even under stress.”
  • The PEI focuses on patient centeredness and empowerment, and ability to understand and cope with the health and illness. This tool has also been used to assess the quality of primary care among chronically ill individuals

Methods of article

  • This literature review included a search in PubMed, EMBASE, Web of Science, and PsycINFO for articles published between 2004 and 2015 that used the PAM and between 1998 and 2015 that used the PEI. The search was limited to English-language articles conducted in the United States and published in peer-reviewed journals. To assess the utility of the PAM and the PEI in urban safety net care settings, HNHC patient sample was defined as racially/ethnically diverse, low socioeconomic status (SES), and multimorbid

Results

  • 114 articles from the literature review met inclusion criteria and were evaluated. Of those, only 9 studies included high-need, high-cost populations who receive care in urban safety net settings
  • Of those 9 studies, many used the PAM, with other patient-centered tools and instruments, to assess either improvement in patient engagement and self-management. The majority of patients had multiple chronic conditions and/or serious mental disorders
  • The PAM-13 was the more commonly used version of PAM
  • After evaluating the 114 articles that discussed the appropriateness and utility of PAM, these studies suggest that PAM may not be an appropriate measure for chronically ill, older, and low-literacy populations of color

Key takeaways/implications

  • Results indicate that research on patient activation is not commonly conducted on racially and ethnically diverse, low SES, and multimorbid patients in the U.S.; therefore, there were few opportunities to assess the appropriateness of the PAM in such populations. While recent studies using the PAM have documented its ability to predict important outcomes such as patient satisfaction, hospitalizations and emergency department use, and overall cost of care, PAM studies are still by and large conducted among White, college educated, and insured samples reporting higher incomes and good to excellent health
  • Given the broad-based use of the PAM by Medicaid and other stakeholders, there is a need to ensure that the tool captures the extent to which people feel engaged and confident in taking care of their health, accurately assesses patient progress in a diversity of settings. An appropriate tool for the measure of patient activation is needed in the urban safety net care setting for high-need, high-cost patients
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