Case managers can use the Patient Activation Measure (PAM) to assess patient populations and guide case management goals and tactics.

  • The goal of value-based care is to keep patients healthy and prevent new chronic conditions.
  • Activation involves helping patients improve self-management and create better habits.
  • PAM can risk-stratify a patient population.

As case managers work harder to meet their organizations’ patient engagement goals — particularly in the value-based care model — evidence-based tools can help them succeed.

One such tool is the Patient Activation Measure (PAM), a scale that describes four stages of activation. Research showed the tool to be a valid and reliable instrument to measure activation and to help patients individualize care plans.1

“It’s important to have a tool to measure patient engagement,” says Heidi Steinhebel, RN, BSN, CCM, CCP, senior associate director of care management at IHA in Ann Arbor, MI. “It’s not just how much the patient will interact with you, but also how well the patient has confidence in managing their own healthcare. It’s important to not make assumptions.”

With PAM, case managers might discover their patients are more engaged than they expected, or less so. “The tool looks at their confidence, their ability to engage, and their ability to make behavior change,” Steinhebel says.

Value-based care is about providing patients with all the care they need for their chronic conditions, explains Martha M. Walsh, MD, MHSA, FACOG, chief quality and population health officer at IHA. It also is about keeping patients healthy and preventing new chronic conditions or exacerbating existing ones.

“Patient engagement in their own health is at the heart of value-based care,” Walsh says. “If patients are engaged, they are more likely to get their quality metrics met, such as breast cancer screening and colorectal cancer screening.”

Patients also are more likely to take their medications for better control of their chronic conditions, and more likely to exercise, lose weight, and engage in other healthy behaviors. “Patient activation is associated with certain self-management behaviors,” says Richard Ginnetti, DHA, director of performance improvement at IHA. “Having pre-treatment measures of the patient’s activation level may provide additional information to providers, allowing for more robust tailoring of care plans, while maximizing the patient’s ability to self-manage their care.”

Through care management, patients become more engaged, more knowledgeable, and confident in making decisions and implementing routines and healthy practices. “It can be a simple as getting a scale and weighing themselves daily to changing their eating behaviors to lose weight,” Steinhebel says.

Case managers could help patients with engagement through motivational interviewing and talking with them about their goals and what is important to them. “We use [PAM] because it’s a good tool for care managers,” she says. “It allows us to personalize the interventions we do with patients, based on that level.”

The most significant benefit of using PAM is its ability to risk-stratify a patient population by adding the activation level component lacking in traditional medical risk calculation. “The combined information provides a wealth of patient information, allowing the care management group the ability to manage their patient population through panel management effectively,” Ginnetti says. “One area that needs focus is ensuring patients can sustain their improvements and continue self-managing their health.”

IHA uses a couple of tools to stratify patients for care management, including PRISM, which is used to stratify discharged patients based on predictor of mortality and readmission at the time of their emergency department visit. “An additional stratification is built into our electronic medical record. It utilizes patient factors, such as patient diagnosis, to assign a score,” Steinhebel says. “IHA risk-stratifies their patients in order to effectively manage their patient populations and to improve patient outcomes. “Traditional risk stratification lacks a key component of patient activation, as well as social, behavioral, and environmental factors, to fully understand a patient’s total active risk.”

Care management eligibility includes patients who are hospitalized, diagnosed with multiple comorbidities, and are not successfully self-managing. Also, patients with a new diagnosis that requires education, need coordination of services and resources, and are not able to handle these independently are eligible for case management, Steinhebel adds.

“At IHA, we evaluate patients’ medical risks, their social determinants of health risks, and their engagement risk,” Walsh says. “Depending on the patient, certain aspects put them at higher risk for unnecessary healthcare utilization and disease progression.”

For example, a patient with diabetes may not have access to healthy food due to cost and other barriers, she says. This social determinant of health risk puts the person at a disadvantage for disease control, and case managers need to address it.

“Engagement risk really means that a patient is not engaged in their own healthcare, so they are at risk of not having disease control or not staying healthy,” Walsh explains. “An example of this may be a diabetic who eats whatever they want and does not check their blood sugar.”

If case managers can set a goal based on the patient’s engagement, then help the person control their blood glucose levels, the patient will be less likely to experience complications, she adds.

IHA uses PAM to guide patient care and improve engagement and education through studying results among patients in the program.

“The primary focus of the program assessment, which was a retrospective study, was to assess the effectiveness of the coaching for activation [CFA] tools, coupled with our homegrown risk prediction algorithm, PRISM, to better care for our patient population,” Ginnetti says. “The study also looked at the use of CFA and its impact on clinical outcomes, i.e., A1c, blood pressure, HDL, LDL, compared to the care management, care-as-usual program.”

They collected data from a multipractice, cluster-randomized control study of patients in case management. All patients in the program had taken PAM’s 10-statement questionnaire, starting April 12, 2018, and continuing with analysis and assessment through Dec. 31, 2019. The resulting sample included 2,024 patients.

“The assessment showed the impact that a care management program has on patient’s health and utilization,” Ginnetti says.


  1. Hibbard JH, Stockard J, Mahoney ER, et al. Development of the patient activation measure (PAM): Conceptualizing and measuring activation in patients and consumers. Health Serv Res 2004;39:1005-1026.