CMS requires kidney care providers to promote patient activation, self-management
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While patient activation is “a fairly new term in the kidney space,” a speaker argued it is now necessary for nephrology nurses to understand and improve activation and self-management for patients with kidney disease.
This necessity comes with the inclusion of patient activation by CMS as a quality metric in the Kidney Care Choices model, according to Paul N. Bennett, PhD, MHSM, RN, BN, GCertSc, director of medical and clinical affairs at Satellite Healthcare and an associate professor at the University of South Australia, Adelaide.
Patient activation
“The idea of patient activation and self-management is to ensure that people are independent and that they do things for themselves,” Bennett told the audience at the virtual American Nephrology Nurses Association National Symposium. “However, the reality is that we provide good services — dialysis services, home care services, chronic kidney disease services — and many people come into a dialysis clinic, wash their hands, put their arm out and they let us do everything.
Although that’s the way the system is, it’s not the best way to encourage self-management, to increase home dialysis rates and to ensure people are empowered in their care. And it’s been forced upon us because recently the CMS has imposed on some of the programs a patient activation measure that we’ll have to follow. We don’t have a choice in understanding patient activation.”
In his definition of patient activation, Bennett began by describing the broader idea of empowerment, which he said is about patients gaining greater control over decisions and actions that affect their health. An important aspect of empowerment, he noted, is engagement; patient activation can be placed in the subset region of engagement.
“It is specifically the knowledge, skills and confidence a person has in managing their health care,” Bennett said. “Patient activation is an antecedent or precursor to ensuring people are self-managing. If you don’t have the knowledge, skills and confidence, you’re not going to be able to self-manage.”
Bennett said that although studies are lacking regarding exactly what steps the health care community can take to improve patient activation, research suggests it is possible to alter patient activation levels, notably in the first 3 or 4 months of dialysis initiation.
He cited a study for which patients on either in-center or home dialysis were surveyed a few weeks after treatment initiation and again 4 months later. Researchers found a significant change in patient activation scores (or patient activation measure, PAM), with half of all participants moving from one activation stage to another (some moving through multiple stages). Some patients became more activated, while others became less activated.
“This is fascinating because it means that something is happening over the first 3 months of dialysis where some people are becoming disempowered, disengaged and unable to self-manage, while other people are becoming more engaged and more empowered to self-manage,” Bennett said. “So, there’s clearly things that we can do during the first 3 months of dialysis that will potentially decrease this drop in activation.”
Role of the nephrology nurse
Bennett emphasized the centrality of the nephrology nurse in increasing patient activation and self-management ability, contending that patients are more likely to be receptive to nurses they see for dialysis treatments regularly than other health care providers they might only see every few months.
“[The dialysis clinic] is where they get their truth,” he said. “They get their truth from the nurses and the patient care technicians, or the culture [within the clinic]. That’s why it’s vitally important that the culture embraces this.”
Despite not having the evidence to inform specific programs to improve patient activation, Bennett said nephrology nurses can still work toward this goal by measuring activation levels to identify self-management needs (determining where a patient performs well or where the patient lacks skills, knowledge or confidence) and engaging with patients and families to provide support, as well as collaborating with social workers, renal dieticians and nephrologists.
“Clearly, as nurses, we’re busy people; we have our work cut out for us just to keep patients safe,” Bennett concluded. “But imagine if we could improve patients’ self-management, get them on home dialysis, improve their care and improve their quality of life.”
To explore this area further, Bennett said a study is being conducted in Australia. The study is examining the effectiveness of interventions tailored to baseline activation level; these tailored interventions or self-management programs, according to Bennett, have already demonstrated efficacy for patients with heart failure.
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Bennett PN. Patient activation and self-management for people with CKD and ESRD. Presented at: American Nephrology Nurses Association National Symposium (virtual meeting); May 2-5, 2021.
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