Patient Activation and Motivational Interviewing Presented by: Susan Butterworth, PhD, MS Associate Professor Oregon Health & Science University President, Q-Consult

Objectives Introduce construct of patient activation and Patient Activation Measure Present theory of the relationship between patient activation and MI Explore value of patient activation scores in MI- based intervention

Give a man a fish and you feed him for a day. Teach a man to fish and you feed him for a lifetime. - Chinese Proverb Knowledge/Skills ACTIVATION EmpowermentConfidence Patient Activation Judy Hibbard, PhD

Why is activating the patient so important?  Healthcare resources are scarce; it is increasingly important for people to take an active role in managing their care  Lifestyle management is the key to prevention and treatment of chronic conditions  Activation can be influenced in a brief intervention and, in turn, influences the person across all risk factors  Patient activation is correlated with multiple outcomes

Activation is related to many outcomes

Patient Activation Measure PAM 13 Low Literacy PAM

Activation is Developmental

Addiction Diabetes 1 Asthma Diabetes 2 CAD Chronic Pain COPD Heart Failure Mental Health ~10,000 survey participants: No association between having chronic condition and low PAM scores. HRA Research Implications: Healthcare industry may want to re- examine how they identify people for intensive interventions

Patient Activation and MI: How can multiple behaviors be changed even when all the behaviors for each participant are not being treated? Motivation Ambivalence Self- efficacy Health Coach MI

Patient Activation and MI: Focusing on patient activation as overarching targeted behavior Patient Activation Managing fluids Taking meds Asking Dr questions Under- standing disease Improving self-efficacy

Study #1: MI-based Health Coaching as Chronic Care Intervention Quasi-experimental design over 8 month period Employees at large medical university Chronically ill group enrolled in health coaching Staff extensively trained in MI; little training in patient activation Outcome measures ▫ Perceived global health ▫ Self-efficacy for managing chronic illness ▫ Patient Activation ▫ Stage of change for most important behavioral risk ▫ Lifestyle management

MI-based Health Coaching Intervention

Outcome for Patient Activation * p = 0.02 ** IPTW adjusted

Outcomes As compared to control group, treatment group also had significant improvement in: ▫ Perceived global health ▫ Self-efficacy for managing chronic illness ▫ Stage of change for most important behavioral risk ▫ Lifestyle management

Tailored Coaching Study Disease management organization Minimal training for all staff in MI Extensive training in tailoring coaching based on patient activation level for staff in treatment arm Intervention group coached on activation level. Control group received ‘usual care’ coaching Outcome measures: claims data, clinical indicators and activation levels 6 month intervention period

Outcome for Patient Activation

Outcomes Those who received coaching with the PAM: ▫ 33% decline in hospital admissions compared to the control group, which remained flat ▫ 22% decline in emergency room visits compared with an increase of 20% in the control group. ▫ Significant improvements in diastolic blood pressure and LDL cholesterol levels relative to control group ▫ Significantly increased adherence to recommended immunization and drug regimens

What does a PAM score tell us? May be overwhelmed or depressed May need to take smaller steps and have more contact May not understand disease or how treatments work May not have confidence about managing condition Menu of options, empathetic reflections, empowering affirmations may be helpful Low Patient Activation Score May have high level of knowledge or understanding May resent someone telling him/her what to do May have strong opinions about treatment options and have researched issues on their own May be used to success and feel frustrated E-P-E, supporting autonomy, putting pt in driver’s seat may be helpful High Patient Activation Score

Case #1 Maria Gonsalves has had diabetes for 20 years and has just been diagnosed with Congestive Heart Failure. Her patient activation score is low. She seems preoccupied when you try to talk to her and close to tears. What is your approach with her? What is your goal for the first couple of sessions? In your small group, role play at least 2 different approaches that you could use. Which approach can you use that will help address/improve patient activation?

Case #2 William Bickle has been going to your clinic for 5 years. He has a reputation as being difficult. You are newly assigned to him as care manager. His labs have generally been good but you notice that they have recently been out of range in a number of areas. His patient activation score is high. What is your approach with him? What is your goal for the first couple of sessions? In your small group, role play at least 2 different approaches that you could use. What approach could you use that will support his patient activation?

Case #3 Rose Ann Yardley has been a patient of yours for a while and you have good rapport. She has low patient activation and you have noticed that she is not proactive about her health, depending on you and the doctor to tell her what to do. She also listens to patients in dialysis give advice and sometimes gets confused. You have approached her about moving from a catheter to a fistula but another patient has told her a horror story about how his didn’t work out. In an initial brief discussion, she told you that she doesn’t want to change her catheter and why. This is your second session with her. What is your approach with her? In your small group, role play at least 2 different approaches that you could use. What approach could you use that will address/improve her patient activation?

In Summary Patient activation may be an important underlying mechanism of MI It may be helpful to provide training to healthcare providers/coaches in patient activation in addition to MI Patient activation scores can be used to: ▫ Identify patients at risk; ▫ Provide additional risk factor information to healthcare staff; ▫ Guide health coaching approach; ▫ Measure outcomes of an MI-based intervention.

Resources For more information on PAM, go to For list of citations regarding patient activation, me at