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What is the Patient Activation Measure in Patient-Centered Care?

The patient activation measure (PAM) is a 100-point, quantifiable scale determining patient engagement in healthcare.

Patient activation is a key concept in the push for patient-centered care, but is often conflated with the notion of driving patient engagement. However, patient activation is its own quantifiable concept supported by the patient activation measure (PAM).

The PAM is used across the healthcare industry to determine the level at which a patient is activated in her own care. Below, breaks down the PAM, its origins, and how it is used today in the healthcare industry.

What is the PAM, how was it developed?

The PAM was created by a group of researchers in an effort to define patient activation. After noticing a gap in the literature, researchers Judith A. Hibbard, Jean Stockard, Eldon R. Mahoney, and Martin Tusler set out to create a first-of-its kind assessment for patient activation for any and all health and wellness behaviors:

There has been a lack of conceptual clarity regarding \u2018activation,\u2019 and thus a lack of adequate measurement. There are a number of existing methods for assessing different aspects of activation, such as health locus of control, self-efficacy in self-managing behaviors, and readiness to change health-related behaviors, but these measures tend to focus on the prediction of a single behavior. Moreover, there is no existing measure that includes the broad range of elements involved in activation, including the knowledge, skills, beliefs, and behaviors that a patient needs to manage a chronic illness.

Hibbard et al. created the PAM using a four-step process. First, the team looked at existing definitions for patient activation, breaking the term down into six different patient characteristics:

  • Ability to self-manage illness or problems
  • Ability to engage in activities that maintain functioning and reduce health declines
  • Ability to be involved in treatment and diagnostic choices
  • Ability to collaborate with providers
  • Ability to select providers and provider organizations based on performance or quality
  • Ability to navigate the health care system

From there, the team created 22 survey items within four levels of patient activation. Those levels include:

  • Believing the patient role in activation is important
  • Having the confidence and knowledge necessary to take action
  • Proactively taking action to maintain and improve one’s health
  • Staying the course even under stress

Each of the 22 items aligns under those four assessment categories. For example, under level one, patients are asked about the degree to which they agree that patients are in charge of their own wellness. Under level four, patients are asked about their confidence in managing wellness goals during tumultuous periods during their lives.

The researchers concluded their survey development by testing whether the measure was accurate and feasible.

“The consistency of performance of the measure is apparent in the reliability coefficients across subsamples,” the researchers wrote. “The high-reliability estimates indicate that the measure is appropriate for individual-level use, such as designing a care plan for an individual patient.”

The PAM can be used to assess a current patient’s activation levels, which in turn can drive improved outcomes, that same research team reported in Health Affairs. Some healthcare professionals will argue that there is also a cost benefit to patient activation, but per the Health Affairs study that assertion has yet to be proven.

The PAM can also help assess large-scale patient activation programs. Healthcare professionals can determine how effective the program was in improving patient activation by administering the PAM before and after an intervention.

Short-form PAM assessment reviews 13 measures

In 2005, the same group of researchers led by Hibbard created a short-form version of the PAM. The 13-item survey removed measures that would not have a significant impact on outcomes in an effort to reduce provider burden.

“A shorter version of the PAM would greatly enhance the feasibility of measuring activation in a clinical setting and would make survey administration much less burdensome and costly,” the research team said in a study recounting the short-form survey’s creation.

Referred to as the PAM-13, this survey still includes questions within each of the four patient activation levels. The 13 measures that remained at the end of the new survey’s development include but are not limited to:

  • When all is said and done, I am the person who is responsible for managing my health condition
  • I know what each of my prescribed medications do
  • I understand the nature and causes of my health condition(s)
  • I am confident I can figure out solutions when new situations or problems arise with my health condition

The PAM-13 is not a complete replacement for its long-form counterpart. The shorter survey yields a 92 percent accuracy rate when compared to the 22-item survey. However, the researchers argued that this is an excellent accuracy rate and an adequate platform upon which clinicians can base their patient engagement strategies.

Real-world accuracy of the PAM

Researchers have yet to conclusively determine how accurate the PAM is because it is a first-of-its kind quantifiable measure. Even so, the survey’s prevalence in peer-reviewed studies and clinical practice confirms its acceptance across the medical community.

Researchers have also looked at whether the survey has any limitations that might affect its accuracy. One such study observed that the PAM was developed using an 88 percent white patient sample, which may have created an implicit bias in the survey.

Another survey looked at the accuracy effects when PAM survey data points are missing. The 2014 study asserted that PAM surveys – and other patient-reported data – are often incomplete, leading to integrity issues.

When there is only one data point missing, the margin of error is not that large – about 2.5 percent, the researchers found. However, as the number of missing data points increases, as does the margin of error. When a short-form PAM survey is missing 12 of its 13 data points, it can be up to 44 percent inaccurate.

These findings emphasize the importance of having complete data sets, the researchers concluded. The team primarily suggested clinicians not use incomplete PAM surveys when developing patient engagement plans lest those strategies not work for the specific patient. Although, that solution may not be realistic in hospitals or practices that require all clinicians use a PAM.

More research should be done to facilitate complete patient-reported data and to develop adequate predictive statistics to supplement incomplete surveys.

How do healthcare orgs use the PAM?

Since its development, the PAM has been licensed by Insignia Health, meaning that healthcare organizations must purchase the survey rights to use it. The survey is for hospital and practice internal use and has no regulatory requirement attached to it.

Numerous medical researchers have leveraged the PAM to evaluate the efficacy of certain patient engagement strategies. Using the PAM on this wide scale enables healthcare researchers to develop best practices in patient engagement and patient activation.

The PAM can also be used on an individual patient level, helping doctors determine which specific strategies they will deploy with a singular patient. Industry experts from the American Medical Group Association (AMGA) recommend deploying the PAM during patient onboarding using either a paper survey or via the EHR. This allows providers to use the score from the onset when designing care management plans.

A 2015 best practices guide from the South Carolina Hospital Association (SCHA) explained that organizations should use PAM scores to determine the intensity of a patient engagement intervention.

“Health coaches were used to administer the PAM to new patients and coordinate appropriate behavioral health and self-management support in conjunction with primary care in an effort to improve patient and provider satisfaction and delegate tasks that do not require a physician’s skills and training,” SCHA wrote in the guide. “Based on their level of activation, patients were delegated to appropriate staff.”

Healthcare professionals can ultimately help support the goal for patient-centered healthcare by using the PAM. Patient engagement – and healthcare in general – is not one-size-fits-all. Therefore, it is important for providers to have data gleaned from surveys like the PAM to inform more individualized engagement activities.

“Use of the PAM with network participants can be an integral part of providing patient-centered care and connecting to effective healthcare,” SCHA wrote. “With knowledge of participants’ existing knowledge, skills, beliefs, and motivations, care can continue to be coordinated in the most appropriate, comprehensive manner.”

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