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Five strategies used by primary care clinicians in supporting patient activation

Although primary care physicians encourage behavioral changes in their patients in different ways, there are five strategies reported among clinicians that show great promise, according to data published in the Annals of Family Medicine.

The researchers noted that there is evidence suggesting a relationship between health outcomes and patient activation, defined by the researchers as “having the knowledge, confidence and skills to take care of one’s health and health care.” However, there are limited data on the physician’s role in supporting such behavior.

“Research to date has not examined whether clinicians’ behaviors influence patients’ level of activation, however,” Jessica Greene, PhD, of the George Washington University School of Nursing, in Washington, D.C., and colleagues wrote. “That is, although some of these behaviors may be intended to engage patients in their own care, for example, the sharing of the medical record or asking patients to state preferences, it is unclear which if any of these behaviors result in an overall increased capacity for patients to self-manage (or to become more activated).

To identify these strategies, the researchers conducted a mixed methods study, in collaboration with Fairview Health Services. After aggregating data on the change in patient activation measure score for 7,144 primary care patients, they interviewed the 10 clinicians whose patients’ score increases were among the highest, and another 10 whose patients’ score increases were among the lowest.

According to the researchers, the five strategies used by clinicians with high patient activation are:

Emphasizing patient ownership

Clinicians should think of themselves more as a coach, and stress that it is the patient who is in charge of their own health. The researchers quoted a physician, describing a common conversation with patients: “I’m here to coach you, not to make you better — you make yourself better. I can’t do that for you.”

Partnering with patients

The researchers found that top performers worked with patients to set goals, strategize and problem solve. Some clinicians reported that such partnerships helped them learn more about what behavioral changes are feasible for their patients. “I do know them, but I don’t know their lives at all outside the clinic,” one family practitioner interviewed said.

Identifying small steps

Clinicians and patients should agree on small, realistic steps toward healthier behaviors. This helps to avoid overwhelming patients, and to set them up to succeed, enabling them to take larger steps in the future. One of the interviewed clinicians said, “If they say, ‘I can’t do anything to make my life better,’ [I’ll say], ‘Let’s think of something you can do.’”

Scheduling frequent follow-up visits to cheer success, problem solve, or both

According to the researchers, top performing clinicians said it was important for patients to understand that “the door is always open.” One clinician included in the study said, “I ask them, ‘Why aren’t we successful? What’s the problem? What are you finding is keeping you holding you back?’”

Showing care or concern for patients

Half of the top performing clinicians reported often telling patients how much they cared about them, as a way of supporting behavior change. “Most of my patients know I am very up front and honest,” a family practitioner told the researchers. “Particularly my female patients, they joke with me and say, ‘Not many men can tell me I’m fat and then see me again.’ … I tell them it’s because I care about them and want them to be healthy.”

In addition, the researchers found that most clinicians, regardless of group, stated they had developed their own way of encouraging behavior changes in patients. Clinicians whose patients showed high activation score increases reported spending more time counseling and educating patients.

“Supporting patient self-management represents a paradigm shift for many clinicians,” Greene and colleagues wrote. “As we see from the results of this study, some clinicians embrace strategies for patient engagement with more enthusiasm than others. From a policy perspective, it is critical that all primary care clinicians support patient self-management and activation.” – by Jason Laday

Disclosure: Researcher Judith Hibbard, DrPH, of the ISE Health Policy Group at the University of Oregon, reports being a consultant to, and equity stakeholder in, Insignia Health. The other researchers report no relevant financial disclosures.