Patient Activation Measure Bebhinn Browne– Health Improvement Specialist (Long Term Conditions) Leeds City Council – Public Health PAMS Implementation 2018-20

Overview Personalised Care NHS Long Term Plan/Leeds Joint Health and Wellbeing Strategy Comprehensive Model of Personalised Care Patient Activation PAM Levels of Activation How PAM can be Used in Practice Tips for PAM Use PAM in Leeds

NHS Long Term Plan Boost ‘out-of-hospital’ care and dissolve the divide between primary and community services Redesign and reduce pressure on emergency hospital services People will get more control over their own health, and more personalised care when they need it Digitally-enabled primary and outpatient care will go mainstream across the NHS. Local NHS organisations will increasingly focus on population health and local partnerships with local authority-funded services, through new Integrated Care Systems (ICSs) everywhere A new NHS service model for the 21st century. This will be achieved through the following five major, practical, changes over the next five years:

Leeds Joint Health and Wellbeing Strategy Outcome 1. People will have longer and healthier lives. Outcome 4. People will be actively involved in their health and care. Priority 9 – Support self-care with more people managing their own conditions - Support self-care with more people managing their own conditions by supporting people to maintain independence and wellbeing within local communities for as long as possible. People need to be more involved in decision making and their own care planning by setting goals, monitoring symptoms and solving problems

15 million people live with long-term conditions (LTCs).

Structure and Governance

Personalised Care Shared Decision Making Personalised care and Support Planning Enabling Choice Social prescribing / Community Based Support Supported Self-management Personal Health Budgets Supported self-management and patient activation is one of six key components. By making patient activation central to the Self-Care Support programme, NHS England is sending a clear signal to the wider health and care system about the importance of supporting people to develop the knowledge, skills and confidence to manage their own health.

Patient Activation According to the King’s Fund (2014) ‘patient activation’ is the knowledge, skills and confidence a person has in managing their own health and health care. Levels of activation are dynamic and may change over time.

Patient Activation Highly activated individuals understand their role in the care process and tend to have better health outcomes. Those with low levels of activation are less likely to play an active role in staying healthy. - Highly activated individuals are more likely to engage in positive health behaviours and manage their conditions more effectively. - Those who have low levels of activation are less good at seeking help when they need it, following advice given to them by health professionals and in general are poorer at managing their health. - Levels of activation are transient, people can be more or less activated at different points in time i.e. a life crisis may result in someone being less activated than normal. Evidence suggests that patient activation can be increased by offering support and providing opportunities to develop knowledge and skills both condition specific and about health in general.

What is PAMs The Patient Activation Measure (PAM) is a tool to support self-Management Enables the tailoring of strategies to meet the needs of the individual. Created in USA 10 years ago and validated in the U.K (Hibbard, 2014) Assesses the individuals current level of activation The level of activation is a good indicator of a person’s ability to self-care and can provide support - Understanding and responding appropriately to an individual’s level of activation is a key skill for clinicians and a key priority in realising the national aspiration for person-centred and personalised care in the NHS. It can also help commissioners to make available the kind of interventions needed.

Patient Activation Measure We would like to learn more about how you view your health so we can better tailor our in brief survey. Please answer these 13 statements with what’s most true for you. I understand my health problems and what causes them. Disagree strongly disagree Agree Agree strongly N/A I am confident that I can follow through on medical treatments I may need to do at home. I know what treatments are available for my health problems.   I have been able to maintain (keep up with) lifestyle changes, like eating right or exercising. I know how to prevent problems with my health. I am confident I can figure out solutions when new problems arise with my health. I have been able to maintain (keep up with) lifestyle changes, like eating right or exercising, even during times of stress. I am the person who is responsible for taking care of my health Disagree strongly disagree Agree Agree strongly N/A Taking an active role in my own health care is the most important thing that affects my health I am confident I can prevent or reduce problems associated with my health I know what each of my prescribed medications do. I am confident that I can tell whether I need to go to the doctor or whether I can take care of a health problem myself. I am confident that I can tell a doctor or nurse concerns I have even when he/ she does not ask. I am confident that I can follow through on medical treatments I may need to do at home.

Levels of Activation - Highly activated patients likely to adopt healthy behaviours, to have better clinical outcomes and lower rates of hospitalisation - Low activation levels suggest patients more likely to attend A&E, be hospitalised, increased cost - Intervening to increase activation can improve a patient’s engagement and health outcomes and enables patients to manage their health - Improvements in patient activation scores have been seen for up 18 months following intervention

How Can PAMS be used in Practice Tailoring tool –Encourages the provision of proactive system support for people with long-term conditions to develop the skills, knowledge and confidence to manage health and keep well at home. Tailoring tool – Measuring patient activation gives healthcare professionals a starting point to meet the people ‘where they are’, helping them to tailor their approaches to the individuals more appropriately to support them on their ‘journey of activation’. Using the PAM in this way as a tailoring tool encourages the provision of proactive system support for people with long-term conditions to develop the skills, knowledge and confidence to manage health and keep well at home. For example, one GP practice in Sheffield has redesigned their diabetes review process through offering longer appointments using the PAM to tailor discussion according the individual’s level of activation. Tailoring tool and outcome measure – As a quantifiable measure, PAM can be used at scale and to assess whether the services/interventions are providing effective and tailored support to people’s needs. Aggregate/cohort PAM scores can be used to evaluate commissioned programmes to understand if they increased people’s activation, or if any changes are required to the types of services required in the local area according to people’s needs. It can be used to compare outcomes from different programmes.

This guides the conversation Conversation tool Use PAMs as an opportunity to understand the member’s viewpoint Identify key area of focus and perceived barriers. The PAMs It can help to shape the agenda for the consultation, including exploring patient expectations and motivations and options for supporting the patient to increase their levels of knowledge, skills and confidence. The first “agree” statement is a good place to start the coaching conversation. The patient has some confidence in the subject but may still have some growth needed. Using #4 as an example: I see you responded “agree” that you know what each of your prescribed medications do – let’s talk about each of them … You may find areas you can help educate. This guides the conversation

Coaching for Different Levels

How can measuring patient activation help clinicians? Tailor approach to individuals appropriately. Assess a person’s ability to take on self-management health tasks. It can help to shape the agenda for the consultation. Explore patient expectations and motivations to increase their levels of knowledge, skills and confidence. Identify interventions and options that are appropriate and realistic for individuals. Identify where a carer’s help may be valuable Monitor a person’s progress Objective feedback to both clinician and patient on goals relating to self-management. Understanding a person’s level of activation can help clinicians to identify interventions and options that are appropriate and realistic for individuals. It can also help identify where a carer’s help may be valuable, for example in supporting a person to understand and take their medicines. It can help clinicians to monitor a person’s progress, such as where a care plan has been agreed. Measuring a patient’s activation at different stages in the plan provides objective feedback to both clinician and patient on goals relating to self-management. All of these support clinicians to develop a more person-centred approach in their interactions with patients.

Top Tips for implementing PAMs Administer PAM as close to the initial interaction as possible Getting a PAM score right away builds rapport Use the responses to drive the conversation Re-administration recommended timing of 3 to 4 months following initial PAM administration A minimum of 2 x annually to show a noticeable difference in patient’s knowledge, skills, and confidence Administer PAM as the very first assessment in the initial interaction Getting a PAM score right away builds rapport because your interactions meet the patient where he/she is at Use the responses to drive the conversation Can be used as a way of evaluating if a person has improved in the self management Getting a pre and post score of PAM will give you an evidenced based score of an improvement in self management Complete with Patient It is imperative that this tool is administrated with a patient.

Primary Care/ Directed Enhanced Service The contract aims to ensure general practice plays a leading role in every Primary Care Network which will include bigger teams of health professionals working together in local communities. PAM to be used as part of the DES in primary care.

PAMS Implementation plan 18-20 Future of PAMs in Leeds 2019-2021 City wide Primary Care City Wide PAMS Task and finish Group Better conversations work stream Reporting systems Continue to encourage and assist usage in LTC reviews. Using in pre-diabetes group interventions. Secondary Care Leeds Community Healthcare Patients under: The Self-care neighbourhood team service assessing The Cardiac and pulmonary rehabilitation team. Weight management service. Virtual respiratory ward Measuring to impact of the Live Well Leeds Project. OT Pilot project in Pudsey NT. Leeds Teaching Hospital Trust – Living with Cancer and Beyond Care Review as part of the Health needs assessment which happens at diagnoses and after treatment. Head and Neck team at entry and then again 3-6 months to encourage a more tailored holistic approach towards their care which may result in m ore referrals to life style interventions (one you Leeds). Third Sector/ Social Prescribing Used in any LTC support To measure the success of an intervention/project to report back to commissioners/funding bodies. PAMS Implementation plan 18-20

Interested in Implementing PAMs within your organisation Interested in Implementing PAMs within your organisation? - please contact Bebhinn.Browne@leeds.gov.uk