Tailoring DM to patient improves outcomes

Study shows reduced hospitalizations, ED visits

People with chronic conditions who received telephonic disease management coaching based on their level of health activation had fewer visits to the hospital and emergency department than people coached in the usual way, a study has shown.

The study, conducted by Judith Hibbard, PhD, and her colleagues at the University of Oregon, compared the behavior of individuals receiving standard telephonic disease management coaching with that of those who received more tailored coaching based on their "activation level." The study was funded by the Health Industry Forum at Brandeis University.

Hibbard is a professor of health policy in the department of planning, public policy, and management at the University of Oregon and a clinical professor in the department of public health and preventative medicine at Oregon Health and Sciences University.

A patient's activation level is determined based on his or her responses to the Patient Activation Measure (PAM), a tool developed by Hibbard and her colleagues, which measures a person's knowledge, skills, and confidence in playing a role in his or her own health care.

Participants in the study who received the tailored coaching showed a 33% decline in hospital admissions compared to the control group, resulting in an average savings of $145 per person per month.

The group receiving the tailored intervention also had a 22% decline in emergency department visits compared with the control group, for an average savings of $11 per person per month. Among participants in the control group, hospital admissions remained flat for patients in the control group. Emergency department visits for the control group increased by 20%.

The group that received tailored coaching experienced significant improvements in diastolic blood pressure and LDL cholesterol levels compared to the control group and increased their adherence to recommended immunization and drug regimens.

The study was conducted at two call centers staffed by RN health coaches.

The call centers were selected based on the similarity of the nurse coaches' tenure and years of experience.

The nurse coaches were trained on coaching skills and how to administer the PAM tool.

At one of the centers, the researchers trained the coaches on how to use the tool to tailor their coaching to each individual. The nurses at the other center, who worked with the control group, were just told to administer the PAM tool at least twice during the six months of the study period.

The team analyzed the gains in the PAM score, adherence to the treatment plan, clinical indicators such as LDL cholesterol and blood pressure, and utilization.

"The results showed that coaching to the patient's activation level was more effective in every measured considered, whether it was clinical indicators, clinical outcomes, cost, or utilization," says Mary Jane Osmick, MD, vice president and medical director for LifeMasters Supported SelfCare Inc., an Irvine, CA-based provider of health improvement and condition management programs and services, which operates the call centers.

The Patient Activation Measure includes a series of questions that focus on the role the person plays in his or her own health care. Patients answer the questions on a scale that ranges from "strongly disagree" to "strongly agree."

One question asks if the patients know what medication they are on and how to take them. Another asks if they know how to take care of themselves when they get sick.

"Each question focuses on a specific area where people fall down or are very good at being an advocate for themselves," Osmick says.

Based on responses to the questions, each person is assigned an "activation score" ranging from one to 100, with most people falling in the 35 to 85 range, Hibbard says.

"Research suggests that people pass through four different levels of activation on their way to becoming effective self-managers," Hibbard says.

Patients on Level 1 tend to be overwhelmed and unprepared to play an active role in their own health. Patients on Level 2 lack the knowledge and confidence for self-management. Patients begin to take action on Level 3 but may not have the confidence or skill to support their behaviors. At Level 4, patients have adopted behaviors to support their health but may not be able to maintain them in the face of life stressors, she says.

Patients with low activation feel overwhelmed by the task of managing their health.

"They don't have good problem-solving skills; they have experienced failure, and are discouraged. They aren't focusing on their health because it is a difficult topic for them," Hibbard says.

Individuals whose score indicates that they are highly activated are more likely to have health screenings, immunization, and other preventive care and to exhibit healthful behaviors such as maintaining a healthy diet, exercising, monitoring their condition, adhering to treatment, and seeking information about their condition and their health, Hibbard adds.

"People fall at different points ranging from low activation to high activation. If disease managers understand where people are and support them in understanding their barriers and issues, they can help them become more activated and, in doing so, learn to take better care of themselves," Hibbard says.

Clinicians are trained to educate people about their health conditions, give them directions, and expect them to follow them, Osmick says.

"In disease management, we sometimes unwittingly ask people to do more than they are capable of doing. That doesn't work. It often turns people off and drives them more deeply into becoming less activated in their own health care. When we talk to someone at Level 1 about goals and action plans, monitoring blood pressure and blood sugar, it can be overwhelming," she says.

Patients on Level 1 of the activation scale feel they can make no impact on their own health, and asking them to monitor their blood pressure or weigh themselves may be a waste of time. Instead, the nurses help them understand how what they experience can be related to their health. Coaches work with them specifically to support them achieving a higher level of activiation, Osmick adds.

"We use this tool to help us throttle back and find out where someone is, then carry them forward by working with them to increase their knowledge, skills, and confidence," she says.

For instance, during the study, the nurse coaches worked with patients at Level 1 to build self-awareness and understanding of their behavior patterns. They worked to build a foundation to enable the patients to go on to the next challenge.

When patients were on Level 2, the nurses worked with them on making small changes in their behaviors, such as eating smaller portions, taking the stairs instead of the elevator, and reading food labels at the grocery store.

The nurse coaches took small steps and worked on one issue at a time, rather than overwhelming the patient with a whole list of goals, Hibbard says.

"The coaches work on one thing that the patient wants to do and focus on building confidence by taking small steps. Instead of asking them to go the gym five days a week, the coaches ask them to take smaller steps, like walking to the corner and back. As they experience success, the patients start to feel more confident, and that builds motivation to start managing their own health," she says.

The coaches work with the patients who are low on the activation scale to build a foundation to go on to the next challenge.

LifeMasters has adapted the tool as part of its disease management model and uses the tool for every client who willing and capable of answering the questions, Osmick says.

"Using this tool is like taking a patient's vital signs. It helps us begin to identify the person's needs and to coach to the level that will be most effective. When we know the participant's level of activation, we can specifically coach to that level and avoid overwhelming the program participants," she says.

LifeMasters' overarching goal is to improve the activation among the population it serves, Osmick says.

"We know this leads to lower cost, higher adherence, improved clinical measures, and better outcomes. It is heartening to see the progress we made when we used the PAM tool. Effective coaching is about helping people develop the information, skills and motivation to do the right thing for their health. That is a challenge we must respond to," she says.

(For more information on the PAM tool, see www.insigniahealth.com.).