Engaging Consumers to Improve Health and Reduce Costs Judith Hibbard, DrPH Professor University of Oregon

Engaged Consumer What does it mean to be “activated” or “engaged?” Have knowledge, skill, confidence to manage health and health care In any population group, some people will be at the low, middle, and high end of this dimension. What does it really mean to be an activated engaged consumer and how to we make that happen in large population groups and within individuals?

Activation is developmental Having measurement, --- enormous opportunity to understand the process of becoming more engaged. Also understand what is going on with people at different points on this continuum. Low end. Poor problem solving, negative emotions, overwhelmed, discouraged, rather not think. May not see it as their job. High end. Have health goals, pro-active, information seekers, good problem solving skills. Think about the person at the low end… coming in for a visit. People who are not activated– giving them more information is not going to help. Source: J.Hibbard, University of Oregon

Activation Level is Predictive of Behaviors Research consistently finds that those who are more activated are: Engaged in more preventive behaviors Engaged in more healthy behaviors Engaged in more disease specific self-management behaviors Engaged in more health information seeking behaviors

Activation Level Linked with Most Behaviors Activation is about taking ownership and taking charge. Good news: activation is changeable– when gaining in activation, more than one behavior changes… Bad news: many of the behaviors… Source: US National sample 2004

Implications Experiencing success Many of the behaviors we are asking of people are only done by those in highest level of activation Persistence in asking – when don’t understand--in medical encounter Effectively use high deductible health plans Knowing about treatment guidelines Using quality information/ knowing where to find it When we focus on the more complex and difficult behaviors– we may discourage the least activated Start with behaviors more feasible for consumers to take on, increases individual’s opportunity to experience success. Help consumers by breaking behaviors down into smaller steps By not really knowing where people are– we are in effect throwing non-swimmers into the deep end of the pool and hoping for the best. What about people who are not activated, are we just discouraging them further? start with behaviors that are feasible– whether the clinical encounter– telephonic coaching– employer communications– -- the idea is to help or People gain a sense of competency: Experiencing success Physician support is important Encouragement Seeing others like them succeed.

Low activation signals problems (and opportunities) Study population – Age 50 to , At least one serious chronic condition 7

The Activation can predict utilization and health outcomes two years into the future for diabetics % change for a 1 point change in PAM Score Comparing a PAM Score of 70 (L4) vs. 50 (L2) P Hospitalization 1.7% decline 34% decreased likelihood of hospitalization .03 Good A1c control (HgA1c < 8%) 1.8% gain 40% greater likelihood of good glycemic control .01 A1c testing 3.4% gain 68% greater likelihood of testing LDL-c testing Robust measurement that predicts important outcomes… Carol Remmers. The Relationship Between the Patient Activation Measure, Future Health Outcomes, and Health Care Utilization Among Patients with Diabetes. Kaiser Care Management Institute, PhD Dissertation. Multivariate analysis which controlled for age group, gender, race, comorbidities and number of diabetes-related prescriptions.

What specific Interventions Have Been Shown to Increase Activation? Stanford CDSMP (peer support and problem solving) Worksite programs– Environmental Tailored coaching Clinician support Social Norms (modeling, messaging, opportunities to engage in behaviors) Opportunities or situations that make it easier to engage in behaviors and to experience success (which builds confidence) Environments that are supportive of self-management and healthy behaviors are correlated with higher levels of activation: Physician support for self management Employers that support healthy behaviors (both providing opportunities and setting norms) Families and neighborhoods that enable and encourage healthy behaviors

Tailored Coaching Study Intervention group coached based on level of activation. Control group was “usual care” coaching (DM company) Examined changes in claims data, clinical indicators, and activation levels 6 month Intervention period.

The intervention group demonstrated significant reductions in utilization Tailored coaching Usual coaching

Supporting Activation Means supporting people where they are Moving away from a generalized approach to a tailored or segmented approach. Doing so will likely increase the efficiency and efficacy of efforts.