AHI PPS – Transforming Communities

Patient Activation and Engagement: Transforming Communities

As part of the New York State Delivery System Reform Incentive Payment (DSRIP) program, an initiative to transform the health care delivery system, a network of community-based organizations, clinical providers, and public agencies comprising the AHI PPS (Performing Provider System), is building healthier communities in our region through patient activation and engagement.

Activation describes a person’s knowledge, skills, and confidence about managing their health and health care. Engagement refers to the methods and tools used to empower community members to take on a lead role in their care and overall wellness. Research has shown that people who are actively involved with managing their own health care tend to have better health outcomes. Engaged patients are healthier, more self-assured when facing health challenges, and are more satisfied with the care they receive.

But what does it really mean to be an activated and engaged health care consumer? Activation and engagement can take many forms, such as prioritizing scheduling an annual physical, or choosing to try the diet and exercise regimens suggested by your doctor. It can also mean becoming more informed about your medical conditions and options for treating them, learning how to use patient portals, or asking questions for clarity when talking with your doctor. Providers can encourage patients to be engaged in their care by promoting open communication and connecting them to helpful resources.

Collaboration and linkage to resources are key components of AHI PPS patient activation and engagement efforts. In addition to fostering better provider-patient interactions, PPS activities focus on improving access to care, promoting the benefits of primary and preventative care, and bringing together organizations from different sectors to address both a person’s medical needs and the social factors that may influence health. Housing instability, food insecurity, low income, and lack of transportation can all adversely impact individual and community health, while acting as barriers to successful patient activation and engagement.

Crystal Carter, Director of the Clinton County Office for the Aging, acts as a champion for patient activation and engagement initiatives within the AHI PPS service area. As a leader in an organization not traditionally associated with health care, Carter believes, “Participating in AHI PPS activities has helped us to understand how we fit into the health care process. For example, our clients might call our office seeking assistance with home delivered meals, housekeeping, shopping, and transportation. Many don’t realize that their health insurance may cover some of these services if they talk to their physician about their needs. We can help them make that connection so they are able to thrive in their homes and communities.”

The PAM® Survey

One tool being used by the AHI PPS to further promote dialogue between individuals, providers, and non-clinical PPS partners is the Patient Activation Measure (PAM®) survey. The PAM® survey assesses an individual’s comfort level with managing their health and wellness. PAM® survey results provide meaningful information with the potential for broad application.

Michael L. Countryman, Executive Director of The Family Counseling Center, noted that his staff has been using the PAM® survey since January 2016.  Based in Fulton County, The Family Counseling Center has implemented the survey in its domestic violence programs, care management and behavioral health departments, and forensic services programs.

“We survey everyone eligible who comes in contact with our agency,” said Countryman. He added, “This initiative is going to have a lasting impact. Tailored support allows us to be more effective when helping someone learn how to take better care of themselves. It shifts the paradigm, offering hope that we can affect change in other areas too, such as addressing generational poverty or fighting addiction.”

Coaching for Activation

Once an individual has taken the PAM® survey, their provider can use a web platform called Coaching for Activation (CFA®) to develop an approach to meet their needs based on insight provided by the person’s survey responses. Jessica Casey, RN, MSN, of Hudson Headwaters Health Network (HHHN) observed, “Once we understand a person’s activation level, the coaching foundation falls into place. It helps us provide the right support for each patient.” HHHN is a not-for-profit system of community health centers providing care to residents and visitors in the Adirondack/Lake George/Glens Falls region.

Casey oversees care managers at HHHN and oversees multiple locations where her staff is using the PAM® survey and CFA®. “Being able to customize care plans using Coaching for Activation helps us encourage informed decision-making and offer realistic, achievable solutions so our patients can be successful making the changes they want to make.”

Promoting increased patient activation and engagement is just one aspect of AHI PPS efforts to transform health care and build healthier communities. It is arguably one of the most important factors in achieving a more effective and impactful health care delivery system.

The AHI Community Engagement team, led by Community Engagement Manager Jessica Chanese, performs direct community outreach throughout the nine counties served by the AHI PPS (Clinton, Essex, Franklin, Fulton, Hamilton, Saratoga, St. Lawrence, Warren and Washington). Chanese stated, “Our goal is to unite and support organizations within the AHI PPS to improve care and services, while empowering health care consumers to act as integral members of an interdisciplinary health care team. Activated and engaged community members are the foundation for creating change and realizing a healthier future in Upstate New York.”

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