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    Pamela Ballou-Nelson, RN, MSPH, PhD, CMPE

    Value-based care (VBC) is emerging as a transformation of the care delivery system as well as payment reform for healthcare providers and facilities. VBC puts forth the hope that value-based models are a solution to address rising costs, clinical inefficiency and duplication of services, and to make it easier for people to get the care they need.

    In value-based models, physicians and practices are paid for keeping people healthy and for improving the health of patients with chronic conditions in a cost-effective, evidence-based way. The value-based approach is designed around patients. Medical care teams focus on individual needs, whether preventive, chronic or acute. The patient is to benefit from a team that coordinates care and technology that connects the patient with providers and information to get the right care across the care delivery system.

    As the healthcare industry continues to work toward coordinated care and technology that connects the patient across the healthcare system, the patient, as a consumer, plays a big role in VBC.

    A recent Commonwealth Fund study explored how the success of care depends in part on accurately identifying patients at high risk for poor health outcomes as well as preventable and costly health events. Current healthcare risk-stratification approaches typically focus on clinical markers. The Commonwealth Fund-supported study explored whether considering a patient’s self-management skills — as predicted by the Patient Activation Measure (PAM) — might help care delivery systems pinpoint high-risk patients who could benefit from supportive interventions. The measure assigns patients a score of 0 to 100. The patients can be further grouped into four activation levels, with level 1 representing patients with the most limited self-management skills.

    Researchers found “that patients who did not feel competent to manage their own health or navigate the healthcare system were more likely to develop a chronic disease over a three-year period than ‘activated’ patients with good self-management skills,” according to an August 2016 report from lead author Judith H. Hibbard, professor, health policy, University of Oregon, Portland, Ore. Patients with low activation levels were linked “to significantly greater likelihood of hospitalization and emergency department (ED) use for ‘ambulatory care-sensitive’ conditions — those that are avoidable if managed properly.”

    Defining patient activation

    Patient activation is defined as a person with skill, knowledge and confidence to manage his or her health and healthcare in illness and wellness. We know from more than 300 peer-reviewed research documents that activation is developmental and the healthcare professionals influence the development of patient activation. Part of the reason it is so hard to activate patients is the current makeup of our conventional healthcare industry, which focuses on empowering doctors and hospitals to heal sick patients rather than empowering people to keep themselves fit with healthy lifestyles and realistic expectations.  

    Figure 1, based on a patient survey originally published by AARP, shows the effect of patient activation on multiple behaviors.

    One size does not fit all

    Too often a practice’s coaching techniques and education take a one-size-fits-all approach, targeting guideline behaviors and leaving low-activated individuals overwhelmed. This leads to very little positive change in behavior and ultimately to the overuse or abuse of healthcare services.  

    The care team then considers this person noncompliant or unconcerned about following the healthcare advice. Tailoring support to activation level recognizes that individuals possess differing levels of knowledge, skill and confidence in managing their health. The typical approach to coaching and care planning drives a sense of urgency, emphasizing where a patient should be instead of what a patient can do based upon his or her current activation abilities.

    Coaching for activation belongs at all levels of the care team. Coaching offers guidance based upon extensive consumer behavior research into health activation and its relationship to health. To date, more than 250 health-related characteristics have been mapped to activation, offering valuable insight into how best to approach behavioral change opportunities. Looking at patients with the eye of activation removes a burden from staff and clinicians alike. Coaching for activation provides evidence-based tools to guide the front desk, medical assistants, registered nurses, care manager and all clinicians in their interactions with patients. Seeing patients become empowered and acting toward improved health is rewarding for both patients and practice staff.

    Hibbard, who is the primary developer of PAM, writes that patients progress through four stages or levels as they become activated. They move from level 1, where they are overwhelmed, disengaged and seeing no connection to their behavior and symptoms, to level 2, where they become convinced that they can do something about their health. At this point they develop the learning and confidence to “act on their own behalf.” In level 3, “they actually act,” Hibbard writes. Level 4 in the continuum sees patients who are confident and educated enough that they can advocate for themselves “even under stress.”1

    VBC entails controlling costs and achieving care quality improvements. Achieving these goals requires the participation of activated and informed consumers and patients. VBC looks at a different set of measures that reduce risk of chronic disease, are prevention oriented and improve functionality. The key question is, what would it take for consumers to become effective and informed managers of their health and care? What skills, knowledge, beliefs and motivations do they need to become ‘‘activated’’ or more effectual healthcare actors? These are essential questions to answer if we hope to improve the care process and care outcomes while also controlling costs. This is true especially regarding the 99 million Americans with a chronic disease. Those with chronic illness account for a large portion of healthcare costs, and encouraging their activation should be a priority.


    1. Hibbard JH, Stockard J, Mahoney ER and Tusler M. “Development of the patient activation measure (PAM): Conceptualizing and measuring activation in patients and consumers.” HSR: Health Services Research, 39:4, Part I (August 2004).

    Additional Resources
    Across the healthcare industry, the push is to deliver value rather than volume with value-based payment programs being the financing mechanism to drive change. Roadmaps to Value-based Profitability: A Practice Transformation Guide is the perfect starting point to gather information about how to prepare for, and maximize, your participation in value-based payment models. Preview Now>

    Written By

    Pamela Ballou-Nelson, RN, MSPH, PhD, CMPE

    Pamela Ballou-Nelson, RN, MSPH, PhD, has more than 30 years of experience in healthcare management, focusing on practice process transformation, patient-centered medical homes (PCMH), workflow analysis, quality measures, care management, population health and patient activation across the continuum of care. Nelson has worked with both provider and payer organizations to help them work toward alternative care and payment models. As clinical quality director for Adventist Health Network in Chicago, Nelson was responsible for leading physicians and hospital directors in their clinical integration process. Nelson has also worked with numerous commercial payers on quality outcomes and effectiveness measures, including compliance with Medicaid care management programs, along with Medicaid insurance contracts and high-risk and dual-eligible patient programs. She has also trained, advised and mentored more than 80 practices in various levels of readiness, preparing them for value-based payment reform, process improvement, improved quality outcomes and increased efficiency through PCMH recognition with 2011 and 2014 standards. She has a BSN from the University of Utah, an MA from Wheaton College, and an MS and PhD in Public Health from Walden University. In addition, she is an NCQA 2014 PCMH certified content expert and frequently speaks on PCMH transformation for accountable care organizations and population health initiatives.

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