Hospitals, health care systems, and health care plans are rapidly moving from a symmetrical health care model to an asymmetrical health care continuum. Community, ambulatory, and hospital health care providers have put their collective ideas and projects into practice. They share a common aim of engaging patients and their partners to improve health and treat chronic disease. It is through the dissemination of their research and evaluative projects that like-minded caregivers begin to discuss their work. They share their ideas on how to prevent unnecessary hospital admissions and improve the patient experience.
There is a heightened awareness among case managers that once the patient identifies a goal and the case manager identifies health-related action steps to reach the goal, the work has just begun. Health care systems recognize the need to enhance and assist their patients' transition from hospital to home, both while in the hospital and after discharge. Patients do not respond to uniform teaching styles and require disease education tailored to their specific needs.
“Patient activation” is a term used to describe the knowledge, skills, confidence, and resources patients possess to manage their disease state in an active and informed manner. This patient-centered approach meets patients at their personal level of readiness to learn and accomplish the health-related goals. Patients with the highest level of activation display interest and involvement and actively decide their best course of action. A high patient activation level is associated with decreased health care costs (Hibbard, Greene, & Overton, 2013; Hibbard, Stockard, Mahoney, & Tusler, 2007).
Case managers have long understood the value of patient-centered care. It is central to the Case Management Society of America (CMSA) Standards of Practice for Case Management. However, as with all initiatives, case managers need the education and tools to engage patients as a partner to prevent further health deterioration and to improve their well-being. Case managers will benefit from learning about the patient activation concepts and about the tools needed for implementation.
The relationship-based care model informs case managers that a relationship occurs every time a case manager makes a connection with the patient. Case managers, through the intentional presence with their patients, create an atmosphere of mindfulness and a human-to-human connection (Manthey, 2012). Case managers meet their patients at their level, aware of the importance of patient activation. Utilizing this strategy to prepare patients for an active role in their care demonstrates that meaningful relationships are at the heart of case managers' purpose. This approach enables the patient and the case manager to perform important work together to achieve shared goals. The case manager's willingness to individualize each patient's care plan validates his or her commitment to that particular patient.
Patient-centered care must also be patient-directed care for patients to be fully engaged. This is more than a subtle difference in direction and focus. Patients benefit from an education plan tailored to their current level of understanding and their acceptance of their medical condition. Dr. Hibbard and her colleagues found that activated patients play an important role in managing their own health. They accomplish this through collaborating with their providers and maintaining their health. (Hibbard et al., 2007). Case managers achieve this process by embracing the patient relationship and viewing both the patient-centered plan and patient education from patients' perspective.
It is the case managers who can coach and lead patients toward a higher level of learning and subsequent confidence in their ability to self-manage disease. To achieve success in this endeavor, case managers, working across the continuum of care, require the tools to plan, intervene, and evaluate their work with individuals as well as populations.
The CMSA recognized this need and developed the Integrated Case Management (ICM) training program, a tool for case managers to identify intrinsic risks as well as strengths of vulnerable patients. Inherent in the CMSA ICM program is the necessity of patient engagement in their plan of care. The ICM program examines the four domains of health: Physical, Psychological, Social, and Health System. The risks and strengths of individual patients are identified within each domain and further detailed as to history, status, and future risk of vulnerability and peril (Fraser, Perez, & Latour, 2018). Case managers who are well versed in the ICM model are able to tap into patients' own abilities and strengths to achieve their goals.
The Patient Activation Assessment (PAA) and the Patient Activation Measurement (PAM) are two tools developed by Eric Coleman and Judith Hibbard, respectively, to allow case managers to measure their patients' activation levels and provide guidance on effective interventions to improve the patient activation level.
Dr. Coleman's Four Pillars provide the framework for the PAA. They include: (a) medication self-management, (b) dynamic patient-centered record, (c) follow-up appointment, and (d) red flags. The case manager can embed the fundamentals for any chronic condition in the four pillars. Patients score points based on their ability to meet the criteria of each level of the pillar (Coleman, 2018). The PAA provides case managers with a method for tracking patients' progress in patient activation and provides quantitative data on the value of the patient teaching intervention.
The patient's Personal Health Record is a patient tool that provides a log or diary of data such as blood pressure, blood glucose, or weight, measurements (Coleman, 2018). The patient can also record medical, therapy, or any other health-related appointments.
The PAM is a licensed quantitative tool. It is a 13-question instrument developed to measure a patient's knowledge, skill, and confidence for self-management. The PAM measures each patient's developmental progress in these areas. The instrument provides a baseline activation level and may be used while the case manager is coaching the patient to determine the patient's progress in taking an active part in the management of his or her disease (Hibbard et al., 2007). The case manager may measure patient activation prior to a coaching experience and after the coaching experience.
The case manager with the interprofessional team continues to learn from pioneer patient advocates such as Ernest Avery Codman and Avedis Donabedian that clear communication by practitioners creates the learning link to patients and improves the efficacy of the health care organization (Delbanco & Gerteis, 2018; Parker & Albrecht, 2012). The benefit is an increased patient or caregiver confidence level in managing their condition, in understanding their medication regimen, and in communicating with the health care team (Coleman et al., 2004; Ford, Hope, & Schofield, 2003; Jack et al., 2009).
The literature is rich with evidence for providing patients' education, guidance, and coaching at their level of patient activation to achieve an optimal transition across the continuum of care. Case managers work across this continuum, and the degree of patient activation tools implemented will vary. The case manager may not determine a patient's activation level in a particular setting. However, knowledge of the activation level and a patient's response to a teaching intervention is important. The case manager with the interprofessional team can decide which intervention provides the most impact for his or her patient population in the most effective manner.
Mary McLaughlin Davis, DNP, ACNS-BC, NEA-BC, CCM
Coleman E. A., Smith J. D., Frank J. C., Min S. J., Parry C., Kramer A. M. (2004). Preparing patients and caregivers to participate in care delivered across settings: The care transitions intervention. Journal of the American Geriatrics Society, 52(11), 1817–1825.
Ford S., Hope T., Schofield T. (2003). What are the ingredients for a successful evidence-based patient choice consultation? A qualitative study. Social Science and Medicine, 56, 589–602.
Fraser K., Perez R., Latour C. (Eds.). (2018). CMSA's integrated case management: A manual for case managers by case managers. New York, NY: Springer Publishing Company.
Hibbard J., Greene J., Overton V. (2013). Patients with lower activation associated with higher costs; Delivery systems should know their patients' “scores.” Health Affairs, 32(2), 216–221.
Hibbard J., Stockard R., Mahoney E., Tusler M. (2007). Self-management and health care utilization: Do increases in patient activation result in improved self-management behaviors? Health Services Research, 42(4), 1443–1463. doi:10.1111/j.1475-6773.2006.00669.x
Jack B. W., Chetty V. K., Anthony D., Greenwald J. L., Sanchez G. M., Johnson A. E., Culpepper L. (2009). A reengineered hospital discharge program to decrease rehospitalization: A randomized trial. Annals of Internal Medicine, 150(3), 178–187.
Manthey M. (2012, May 1). Lecture on relationship based care. Unpublished manuscript, Cleveland Clinic, Cleveland OH.
Parker D., Albrecht H. (2012). Barriers to care and service needs among chronically homeless persons. Professional Case Management, 17(6), 278–284.