maryanne lindeblad, bsn, mph medicaid purchasing administration state of washington october 6, 2010...
TRANSCRIPT
Increasing self management of chronic conditions through the
use of PAM and MI
MaryAnne Lindeblad, BSN, MPHMedicaid Purchasing Administration State of WashingtonOctober 6, 2010
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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 2
Chronic Care Management in Washington State
• 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
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Client Readiness is Key to Change
• 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
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Patient Activation Measure (PAM)
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
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Intervention Techniques
• 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
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Motivational Interviews (MI)
PAM Levels Stages of Change
Level 1: May not yet believe that the patient role is important
Precontemplation – not even thinking about making a change
Level 2: Lacks confidence and knowledge to take action
Contemplation - started thinking that making a change might be a good idea and is perhaps starting to make plans MaryAnne Lindeblad 7
Comparison of Readiness Levels
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Comparison of PAM Levels and Stages of Change, cont.PAM Stages of Change
Level 3: Beginning to take action
Preparation/Action - taking concrete steps which will lead to behavior change
Level 4: Has difficulty maintaining behaviors over time
Maintenance – maintains behavior change through continued effort
Comparison of PAM Levels and Stages of Change, cont
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PAM Stages of Change
Termination - no longer has to make great efforts to maintain change
Recycling/Relapsing - returns from any given stage to an earlier stage
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Impact of Intervention on Activation Level
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.
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Case Study 1Increased Activation with Coaching
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Distribution of PAM ResponsesWashington Medicaid
• 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.
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Case Study 2PAM Level 1 Client Success
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.
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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.
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Washington Experiences
National Academy of State Health PolicyNASHP, October 6, 2010
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Thank You