Getting Patients to Take Charge of Their Health

One afternoon, I heard a colleague let out an exasperated groan in front of the hospital computers. His patient had been admitted. Again.

Overweight for much of his youth, the patient developed diabetes in his early 30s, then high blood pressure a few years later. By the time he was in his 40s, he had become so debilitated by a heart attack, congestive heart failure, peripheral vascular disease, arthritic joint pains and his ever-increasing weight that he could no longer work.

He was in his 50s now, and, his forays outside his home were limited to doctors’ offices or the hospital, where he would show up with out-of-control blood sugars, chest pains, an infection attacking his legs or feet or, as it was this time, shortness of breath.

Lars Klove for The New York Times Dr. Pauline Chen

My colleague stood up, bracing himself. “I hate to say it, but I feel like he’s done this to himself,” he said. He said the patient seemed to ignore all medical advice and had no interest in learning about his diseases. “If he were even a little bit interested in his own care, he wouldn’t be where he is.”

Many other observers, including myself, might have jumped to the same conclusion.

It’s easy to do what my colleague did and hold patients responsible for their own health. By taking an active role in their care, patients could be healthier, clinicians would feel more gratified, and even health care costs would decrease, as there would presumably be less need for additional services outside the doctor’s office.

But like everything in medicine, carrying out this “cure” takes work, as an interesting collaboration between researchers and a nonprofit health care system is revealing.

For almost two years, Fairview Health Services, with more than 40 primary-care clinics in the Minneapolis area, has been giving patients a survey developed by researchers at the University of Oregon in Eugene to measure how actively involved they are in their heath care. Known as the Patient Activation Measure, the survey includes just 13 questions and takes only a few minutes to complete, with patients responding to statements like, “I know what my prescribed medications do,” “I am confident I can tell my health care provider concerns I have even when he or she does not ask,” “and “I am confident that I can maintain lifestyle changes like diet and exercise even during times of stress.” Patients are then placed into one of four categories depending on how likely they are to understand their health care issues and how much confidence and skill they have to take care of themselves.

Not long ago, the researchers examined the survey results of over 25,000 Fairview Health patients and compared those results with various objective measures of wellness like blood pressure, body mass index, blood sugar and cholesterol levels, emergency department use and hospitalizations.

Although not all the differences were dramatic, patients who were more involved in their health were less likely to smoke, be obese, get hospitalized or go to the emergency room than those who were less engaged. And while more affluent patients tended to be healthier than those who were poorer, patients who were more active in their own care tended to be in better health than their socioeconomic peers, regardless of income.

With these findings in hand, Fairview Health has been trying to find ways to use patients’ activation survey results and encourage their participation. Recently, the health care system tried offering a two-day seminar for clinicians on techniques to motivate patients. Instead of simply offering generic advice, lectures, laboratory tests or prescriptions, the clinicians learned to encourage and respect individual patients’ involvement levels by allowing them to come up with their own solutions to wellness issues, an approach that showed some promise. But it also posed challenges. For at least a few patients, for example, the most effective personal strategy for remembering to take a pill first thing in the morning meant placing the medication next to a pack of cigarettes.

In another Fairview Health initiative, hospital teams have tried using the results of the surveys to plan patient support after hospital discharge. If a patient was hospitalized for complications of diabetes, for example, and showed low “activation” levels on her survey because she had difficulty regularly monitoring her blood sugar levels at home, the hospital might schedule more frequent home visits and telephone calls by visiting nurses. The patient would also get a timely follow-up appointment in the doctor’s office.

While it’s still too early to know if these initiatives and others are actually encouraging patients and having an impact on their health, both the clinicians and the researchers remain committed to continuing their work in this area. Fairview Health plans to continue administering the activation survey to patients and expand its motivational seminar program, and the University of Oregon researchers hope to further explore how clinicians can best encourage patients.

Referring to the current health care system, Valerie Overton, an advance practice nurse and vice president of quality and innovation at Fairview, said, “There comes a time when we have to realize that there’s not much more to squeeze out of this old turnip.

“Patient engagement is a way to get us to the next level of quality of care, but it’s not an easy journey.”