Document 6517181

TAKING
CHARGE:What is the Relationship Between Patient Activation and Motivational Interviewing?
Verna Burden, MS, RD; Laura Blue, MPH; Susan Butterworth, PhD, MS; Ariel Linden, DrPH
Developed by Dr. Judy Hibbard and colleagues at the University of
Oregon, the Patient Activation Measure (PAM) is a valid, highly reliable
Guttman-like scale that reflects a developmental model of activation. (Hibbard et. al, 2004; Hibbard et. al, 2005). The PAM measures the extent to
which: 1) patients know how to manage their condition, 2) have the skills
and behavioral repertoire to manage their condition, and 3) have the
confidence that they can collaborate with their health providers, maintain
functioning, and access appropriate and high quality care.
Could Patient Activation be an underlying mechanism of how MI works?
Self Efficacy and Patient Activation:
Self efficacy varies
across and within a
domain.
• Supporting client autonomy to enhance the client’s perception of
choice about change
Preventative
Behaviors
Knowledge
Consumeristic
Behaviors
Self-care
Behaviors
The Patient Activation Measure is comprised of 13 questions categorized
under the four domains they are intended to measure.
35-40% of the population
• Directing toward the target behavior that the client chooses
Various Health Behaviors
“Give a man a fish and you feed him for a day.
Teach a man to fish and you feed him for a life time.”
-Chinese Proverb
Design: Quasi-experimental study design
Four levels of ‘activation’ or self-management competency
20-25% of the population
• Evoking to facilitate the client’s discovery of their own path to
change
• Expressing empathy to value and reinforce the client’s experience and understanding
MI-based health coaching shows increase in Patient Activation
Confidence
10-15% of the population
Patient activation
can be influenced,
but tends to hold
steady across and
within a domain.
Patient Activation Measure
Various Health Behaviors
Skills
MI spirit and characteristics in light of Patient Activation
• Collaborating to identify the client as having knowledge, skill and
confidence regarding the change process
Self-efficacy
What is Patient Activation?
25-30% of the population
Several studies have demonstrated the PAM’s ability to effectively
measure activation and predict health-related behaviors and outcomes.
• A positive change in activation was associated with positive changes
in fruit and vegetable consumption, regular exercise and stress
management (Hibbard et. al, 2007).
• An inverse association between patient activation and length of stay
during hospitalization and inpatient admissions after emergency
department visits was demonstrated (Hibbard et. al, 2009).
• In patients with diabetes, higher PAM scores were associated with
improved self-care, medication adherence, higher quality of life, and
lower emergency room and hospitalization use (Mosen et. al, 2007).
To date, no research has focused on the possible relationship between
MI and PAM.
Setting: A large medical university in the Northwest United States
Method: 106 chronically ill program participants completed a
health risk survey instrument prior to enrollment and
again at approximately 8 months. Outcomes were
compared to 230 chronically ill non-participants who
completed the survey twice over a similar time frame.
Inverse probability of treatment weights were used in conjunction with the propensity score to correct for
selection bias.
Results: Compared to non-participants, program participants
improved on patient activation (P=0.02), self efficacy (P=0.01), lifestyle change score (P=0.01), and perceived health status (P=0.03).
Conclusion: These results support motivational interviewing-based
health coaching as an effective chronic care management intervention in impacting outcome measures that could also serve well as a proxy in the absence of other clinical or cost indices.
A randomized controlled trial with MI-based health coaching
Traditional medical model:
Expert treats health condition
Patient activation construct:
Empowerment of the patient is key
give a
person
a fish
teach
a person
to fish
Patient Activation:
The degree to which a person is engaged in managing health conditions
= The degree to which a person is engaged in fishing
Motivational Interviewing:
A guiding method of communication to elicit and strengthen motivation
to fish
Where the rubber meets the road
• Three coaching sessions focused on exercise, stress management,
diet and tobacco use
• At six-month follow up, significant improvement in health behaviors
addressed AND in health behaviors not addressed (Prochaska, et. al,
2008).
In chronic care management, we suggest that an increase in Patient
Activation be the overall target behavior addressed in the coaching
interaction. For example, in 2-3 sessions with a person with diabetes,
a focus on empowering the client to take action may prove to have a
ripple affect into multiple behaviors associated with managing their
disease.
Hypothesis:MI may facilitate an improvement in Patient Activation
which could explain why multiple risk factors changed
within a brief intervention.
References:
Self-management competencies differ significantly by
level of activation
About Health Management Services
The mission of Health Management Services (HMS) at Health Future
is to identify and disseminate best practice in health management and
chronic care. Located in Portland, Oregon, Health Management
Services was founded in 1997 at Oregon Health & Science University.
We provide-evidenced based employee interventions designed to
reduce health risks, manage chronic disease and increase productivity,
focusing on our MI-based health survey and health coaching.
Hibbard, J.H., Mahoney, E.R., Stockard, J., Tusler, M. Development and
Testing of a Short Form of the Patient Activation Measure. Health
Serv Res 2005:40(6): 1918-30.
Hibbard, J.H., Mahoney E., Stock R., Tusler M. Unpublished research shared by Judith H. Hibbard in personal communications.
November 9, 2009.
Hibbard, J.H., Stockard, J., Mahoney, E.R., Tusler, M. Development of the Patient Activation Measure (PAM): Conceptualizing and measuring
activation in patients and consumers. Health Serv Res 2004; 39(4):1105-1026.
Mosen D, Schmittdiel J, Hibbard JH, Sobel D, Remmers C, Bellows J. Is
Patient Activation Associated with Outcomes of Care for Adults with Chronic Conditions? J Ambul Care Manage 2007;30(1):21-29.
Prochaska, J.O., Butterworth, S., Redding, C.A., et al. Initial Efficacy of
MI, TTM Tailoring and HRI’s with Multiple Behaviors for Employee
Health Promotion. Prev Med 2008;46:226-31.