Case managers continually learn new methods to educate and engage patients. The key is to find the right method for case managers to achieve their patient education goals.

Patient activation may be one such method.

“What it means is patients are engaged and understand what they need to do to improve their health, and they’re motivated to do it,” says Mary McLaughlin Davis, DNP, ACNS-BC, NEA-BC, CCM, senior director of care management for the Cleveland Clinic Health System.

Davis describes three important patient activation methods and tools:

• Use the PAM method. The patient activation measure (PAM) was founded by Judith H. Hibbard, DrPH, who published this tactic for measuring activation in patients in a 2004 paper. (More information on the method can be found at:

PAM is based on the theory that there is a great deal of variation in patient activation/engagement in a patient population. Some patients need more support, and should be evaluated to see what works.

“When a case manager engages with patients, is the case manager able to connect so that patients clearly understand what they need to do to help themselves get better and stay better?” Davis says.

Patients who are passive in their own care, even if they are adherent and compliant to their health regimen, struggle more than patients who are engaged and taking charge of their own health, she adds.

These are the PAM levels:

- First level: A patient has no idea how to improve his or her health. This could be a patient who recently suffered a stroke and is in the neural ICU. To this person, there is no connection between his or her daily doughnut habit, high cholesterol, and stroke, Davis explains.

- Second level: At this stage, a patient is starting to accept that there is a cause and effect between diet, exercise, smoking, and health crises. “They start to say, ‘Maybe eating all that junk food really did have this kind of impact,’” she says.

- Third level: “At the third level, patients make a connection and they own it, saying, ‘Yeah, I’m going to have to cut back on those doughnuts,’” she adds.

“They might say, ‘Instead of eating two doughnuts a day, I’ll eat one a week.’”

- Fourth level: This is where the person is in stroke rehabilitation and in a stroke support group, and he or she is picking up people and driving them to the stroke support group, Davis says.

“They’re baking healthy cookies or bringing fruit for stroke support. They are taking care of themselves, exercising, and being fully engaged,” she explains.

“You can go in and out of those stages,” Davis adds. “You could be a level four as far as the stroke is concerned, and then you get a cancer diagnosis, which understandably throws you for a loop, so you digress to a three or two.”

• Learn patient activation assessment. The patient activation assessment (PAA), developed by Eric Coleman, provides another model for coaching patients to improve their health. (Learn more at: PAA includes four columns:

- Medication: There are 10 questions/points, including this example: “Demonstrates ability to accurately update medication list.”

- Red flags: This includes questions about the patient’s condition and whether the patient knows if it is getting worse. There also are questions about signs and symptoms of another episode.

- Follow-up: This ensures patients know how to get help when they need it. One item is: “Can schedule and follow through on appointments.”

- Personal health record: Case managers ensure patients understand their personal health information, know how to keep it updated, and carry the book to all appointments.

“I’ve found that if patients do not have a certain level in their activations scoring in both tools, they are not able to be discharged from acute rehabilitation,” Davis says.

• Try motivational interviewing. This involves asking patients questions that will link their skills to a goal they might achieve to improve their health. Motivational interviewers are trained on the values of quality, openness, generosity, and respect. (More information and tips can be found at:

For example, Davis recalls a patient who had been a scientist prior to a devastating stroke. He lacked physical function and was in rehabilitation.

“He had a tremendous interest in technology, so the nurse working with him found an app that could measure his blood sugar and help him with managing his blood sugar,” she says. “He really liked the app, and it gave him some independence.”

Through motivational questioning, the nurse was able to find out what the patient’s interests were prior to the stroke. His answers gave her the idea for a technological solution that would work for him, Davis says.

The methods are difficult to employ, particularly when a patient is in an acute care setting, Davis notes. But a patient activation strategy can work in a hospital setting.

“It also is a great strategy for case managers to use in ambulatory settings or telephonic work,” she adds. “Often, patients have goals that have nothing to do with their health, and my job as a teacher and case manager is to bring a patient to their goal and use motivational interviewing to do it. Taking the doughnut analogy, a patient could be comfortable with his doughnut habit, but over the years it adds weight and raises glucose levels.” A person with the doughnut habit could become diabetic and have high cholesterol levels.

“So, you say to the patient, ‘Now, you’re in kind of a predicament. Where would you like to see yourself in three months?’” Davis says.

“The patient might say, ‘I’d really like to take my 4-year-old granddaughter to a baseball game like I could before. In fact, she’s the one I have doughnuts with.’”

The case manager can say that with therapy, this goal could be attained. Also, the case manager might ask the patient to think about how he could take better care of himself so he can spend more time with his granddaughter, she adds.

“You could tell him, ‘Instead of two doughnuts per day, how about three doughnuts with your granddaughter each week, making it a special time when you go out for doughnuts?’” Davis says.

“Don’t take everything away from patients because that is so hard,” she adds. “But encourage them to take things away from themselves because they see the value in it.”