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4 Main Barriers Diminishing Patient Activation Efforts

Driving meaningful patient-provider communication and addressing patient social determinants of health needs are key to patient activation.

As the medical field pushes value-based care efforts, the concept of patient activation has become more critical. After all, it’s an activated patient who is able to fend off or manage illness in between clinic visits.

And in doing so, she is able to keep healthcare costs low and her clinical outcomes good.

Patient activation as healthcare providers know it today was defined in 2004 by a group of researchers identifying a gap in the literature about patient activation. Because there was no uniform reference to characterize patient activation, it became hard for clinicians to measure activation and therefore intervene.

Through an extensive literature review, Judith A. Hibbard, Jean Stockard, Eldon R. Mahoney, and Martin Tusler, distilled patient activation down to six central concepts:

  • 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 researchers developed the patient activation measure, a 22-item survey set to assess the extent to which a patient is believes in, is prepared for, and has the self-efficacy to manage her own care. Hibbard et al. used its definition of patient activation to create four central survey question categories:

  • 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

The survey has been proven to enhance patient engagement efforts on both an individual and population-based scale, the researchers found. Some professionals have posited there may be a direct cost benefit to the PAM, although no data has been able to back that up.

Nevertheless, patient activation is a critical part of patient self-management. Health and wellness happens outside the four walls of the hospital or clinic and without the in-person support of a provider.

Understanding the extent to which a patient is able to accomplish chronic disease management will help providers understand how best to design care plans for patients to yield optimal outcomes.

But clinicians know they can’t simply snap their fingers and a patient will become activated in care. Driving patient activation in care is challenging work that can come with several roadblocks along the way.

Language, communication barriers

Without clear communication, it’s impossible for a clinician to either assess patient activation or make headway in promoting it. But human interaction is not black and white, and challenges get in the way of a productive office visit.

Perhaps most obviously, language barriers get in the way of a meaningful patient-provider conversation. When a clinician primarily speaks English and the patient has only limited English language proficiency, it can be hard to get to the meat of a self-management protocol.

Most medical providers are working away from using family members as interpreters during the clinical encounter. Family members can sometimes misinterpret medical jargon, or unconsciously water down advice or diagnosis to temper the blow of unexpected news for their loved one.

Instead, organizations are trying to hire human interpreters in the medical facility and lean on digital interpreters when humans are not available.

The clinician leading the discussion who utilizes some sort of interpreter should not underestimate the power of body language. Studies have shown patients with limited English language proficiency were able to pick up on tone and non-verbal cues.

Communication barriers can go beyond language barriers, as most providers know. Clinicians working to boost patient activation need to speak to their patients with empathy and zero in on the lifestyle factors that truly matter to the patient.

Motivational interviewing will be essential to meeting that goal. Through motivational interviewing, clinicians can determine what kind of wellness goal a patient would like to set, which increases the odds the patient will stick to a treatment plan.

A patient’s wellness goal is rarely about a number or health metric. Instead, many patient goals surround spending more time with their loved ones, being able to play with their grandchildren, or seeing a beloved family member walk down the wedding aisle.

Leveraging those personal life style goals will humanize self-management efforts and demonstrate to the patient that it is partly their responsibility to improve their health and wellness.

Low patient health literacy

Similar to language and communication barriers, low patient health literacy can get in the way of efforts to improve patient activation. Health literacy refers to a patient’s ability to use, obtain, and process certain health information.

A patient with high health literacy is able to understand the complex medical concepts her provider may communicate, and she can offer up her own understanding of her diagnosis.

There’s a strong link between health literacy and patient activation. A patient who is highly activated — and by definition is motivated to take control of her health, understands the steps to doing so, and has the ability to obtain resources needed for chronic care management — likely has high health literacy.

Conversely, a patient with low health literacy may recognize the importance of her taking control of her own health, but would be unable to take the steps to do so.

Fundamentally, framing patient activation efforts in a patient’s health literacy level may not necessarily raise a patient’s health literacy level; instead, clinicians need to deliver care and patient education that meets a patient’s health literacy level. In other words, providers need to meet patients where they are.

A good rule of thumb is to deliver all patient education at about a fifth grade reading level, but in some cases a provider may need to further simplify her health messaging. Using a patient health literacy assessment, which can take only a matter of minutes, would be a good addition to the PAM. Using these assessments in tandem will give providers a better idea of the best step forward in patient activation.

Constrained patient resources, social determinants of health

With the medical industry in large agreement that most health and wellness happens outside the clinic, it’s important providers be sure a patient’s social circumstance aligns with the health goals laid out for them.

In other words, providers need to make sure a patient’s social determinants of health will not get in the way of the self-management plan.

The social determinants of health are the social factors that keep patients from obtaining health or wellness. A patient who is food insecure, for example, will have trouble keeping up with a medication regimen that requires her to take pills on a full stomach, for example.

A patient experiencing one or more social determinants of health may have trouble becoming activated in care because her social circumstances bar her from the activities outlined in her care management program. In some cases, she may see care management as futile and give up.

More healthcare organizations are setting up programs to address the social determinants of health. Large health institutions with a lot of capital are investing in large-scale projects, like building up affordable housing.

For smaller organizations, community health partnerships are giving patients a place to go when a provider screens for social determinants of health. For example, a community health partnership between a hospital and a food bank may help that food insecure patient take her pills on a full stomach.

In the cases providers do not have the community health resources to address social determinants of health, it is beneficial to cater care plans according to a patient’s needs or limitations. Being cognizant about a patient’s social circumstances allows a provider to drive patient activation in a more realistic way with a little more empathy.

Lapse in cultural competency, patient trust

Ultimately, patient activation will be out of reach if a provider cannot engender trust between herself and her patient. Patients who are innately mistrustful of the medical establishment will have a hard time obtaining that first layer of patient activation: acknowledging the importance of a patient’s role in healthcare.

A lot of patient trust issues stem from limited cultural competency and the history some marginalized populations, like Black and Hispanic people, have with healthcare. Bridging this gap is a daunting task, but it will be important to begin tackling it with cultural competence training.

Organizations that value cultural competence usually have the following things in common:

  • Clear efforts to understand community needs
  • A broad definition of culture
  • Acknowledgement of language interpretation needs
  • Continued learning among organizational leaders
  • Cultural competency training for staff members and clinicians
  • Cultural competency ingrained in organizational policies

Cultural competence does not mean all providers will know all preferences of all cultures; instead, it shows an openness and willingness to learn and pick up on cues from patients. Organizations working to improve cultural competence should first look at the needs of their communities and embed those needs into training and the hospital or clinic mission.

Organizational leadership may then begin training staff, outlining the changing demographics in the US and the risks associated with low cultural competence.

When providers are able to do deliver culturally competent care, they can build more trust with their patient. In turn, the patient may begin to recognize her own role in her healthcare, be open to working alongside her clinicians, and activated to bring her health home with her.

At the end of the day, that’s exactly what patient activation is. Providers working to improve patient activation must help patients see their own role in their health, provide them with the tools to manage health, and continuously engage them in collaborative care.

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