Health systems in the Albany area which includes ten counties conducted a training program last week for local health providers and community organizations on Patient Activation Measures (PAM) as part of their gearing up for the DSRIP Medicaid waiver implementation. This PAM program is viewed as one of the keys in efforts to improve health care and lower costs in the process by engaging patients and their caregivers. We have been saying how important it is to engage patients, families and caregivers in order to improve care and prevent re-admissions which is the overall goal of DSRIP. The PAM program provides a concrete program and structure to do that.
A 10 question survey is given and then each patient is assigned a score of 1-4 to indicate their level of engagement.
Those with a 1 score are the least engaged in their care and do not understand the need to play a role in their care. They do not understand treatment options and lack basic health care knowledge. They feel overwhelmed and believe others are responsible to manage their care.
Those scoring 2 are beginning efforts to improve their care but still have little experience or confidence to manage their care
Those scoring number 3 are active in trying to improve their care and have taken some steps to do so.
Those scoring number 4 are effectively managing their care and working closely with health professionals.
The overall goal of these measures is to provide coaching assistance to those scoring in the 1 and 2 categories to move them to 3 or 4 or show improvements where possible. The PAM survey is used to tailor health coaching to more accurately reflect the patient’s abilities to set realistic goals and achieve action steps that are defined, rather than take a generic approach that doesn’t recognize the differences in individual personalities and abilities. The coaching will focus on symptom understanding, medication adherence, diet and nutrition, physical activity, stress and coping and smoking cessation. Conditions that are targeted are: chronic heart failure, COPD, depression, diabetes, hypertension, schizophrenia and substance abuse and wellness disease prevention, and coronary artery disease.
The health systems in the Albany area intend to contract with community providers to conduct some of the surveys and perhaps assist in the coaching as well using community navigators. The navigators will be assigned to “hot spots” identified by the community needs assessment completed by the Healthy Capital District Initiative as locations where large numbers of uninsured and vulnerable populations either live or use the health care system.
The focus for the DSRIP projects is on Medicaid beneficiaries, however the PAM survey can be used with all patients.