Increasing self management of chronic conditions through the use of PAM and MI

1. Increasing self management of chronic conditions through the use of PAM and MI MaryAnne Lindeblad, BSN, MPH Medicaid Purchasing Administration State of Washington October 6, 2010 MaryAnne Lindeblad

2. Chronic Care Management in Washington State High risk, high cost aged, blind and disabled adults with co-occurring disorders The most complex of the complex Payment is through a per member per month method with actuarially certified rates Program is classified as an Prepaid Ambulatory Health Program with CMS Currently using a 1937A Benchmark Benefit Authority MaryAnne Lindeblad

3. Client Readiness is Key to Change • Patient Activation Measure (PAM) is part of the assessment • http://www.insigniahealth.com • Stages of Change measured through modified Stanford Self-Efficacy tool http://patienteducation.stanford.edu/research/download.html MaryAnne Lindeblad

4. Patient Activation Measure (PAM) • Developed by Dr. Judith Hibbard at Oregon Health Sciences University • Insignia Health has proprietary rights • 13 questions about knowledge and confidence in self management • Administered at beginning of care management, at regular intervals and at “graduation” • 4 Levels of Activation MaryAnne Lindeblad

5. Intervention Techniques • Insignia Health designed “Coaching for Activation” for use by clients or clinicians in conjunction with PAM • Motivational Interviewing is used after Stages of Change are assessed • Both rely on client readiness for change and confidence in achieving goals MaryAnne Lindeblad

6. Motivational Interviews (MI) • First described by William H. Miller in 1983 as a technique to treat problem drinkers • Focused, directive counseling intended to elicit behavioral change that comes from client’s desire and confidence • Techniques - open questions, reflective listening, affirming and summarizing MaryAnne Lindeblad

7. Comparison of Readiness Levels MaryAnne Lindeblad

8. Comparison of PAM Levels and Stages of Change, cont. MaryAnne Lindeblad

9. Comparison of PAM Levels and Stages of Change, cont MaryAnne Lindeblad

10. Impact of Intervention on Activation Level MaryAnne Lindeblad

11. Case Study 1Increased Activation with Coaching • 45-year-old female with depression, fibromyalgia, GERD, severe and persistent nausea and vomiting plus pain identified as stress related to her daughter. • Action plan included specific action steps for stress management. • Activation scores moved from Level 2 to Level 3 as she felt more confident in her ability to manage her own health care. MaryAnne Lindeblad

12. Distribution of PAM ResponsesWashington Medicaid MaryAnne Lindeblad

13. Case Study 2PAM Level 1 Client Success • 55 year old male with morbid obesity, COPD and bilateral osteoarthritis of the knees with PAM Activation Level 1. • Agreed to participate in CCM in order to get gastric bypass and total knee replacement surgeries. • Client developed action plans related to goal for the knee and bypass surgery . • Lost 100 pounds, did not need gastric surgery and doing water aerobics. MaryAnne Lindeblad

14. Washington Experiences • Expect movement back and forth between stages and levels. Motivation and Activation are dynamic states. • Significant life events such as housing change, hospitalization of self or family/friends, new diagnosis, financial stress can stall or change a person’s ability to self manage. MaryAnne Lindeblad

15. Washington Experiences • Hierarchy of needs impact motivation. Threat of losing housing, not receiving check in time or not having enough food can take precedence over health action plan. • Depression affects person’s ability to self manage. Recommend screening. MaryAnne Lindeblad

16. Thank You Maryanne.lindeblad@dshs.wa.gov National Academy of State Health PolicyNASHP, October 6, 2010 MaryAnne Lindeblad