Shanoor Seervai, MPP, Person-Centered Care Research Manager at Phreesia, sat down with two experts to discuss why engaging patients in their care and supporting them to self-manage their health is key to improving outcomes and reducing costs.  

Dr. Abi Sundaramoorthy, MD, MBA, is a practicing physician with over 10 years of experience promoting high value care for hospital systems, as well as private companies. She is Chief Medical Officer at Wellinks, a digital healthcare company that offers an integrated, virtual, chronic obstructive pulmonary disease (COPD) management solution for patients. 

Dr. Christina Suh, MD, MPH, is a general pediatrician with over 15 years of experience delivering primary care to low-income children in Aurora, Colorado. She is a Director of Clinical Content at Phreesia. 

See below for a lightly edited summary of that discussion. 

Seervai: Can you tell us a little about what Wellinks does? 

Dr. Sundaramoorthy: We are a technology-enabled care delivery organization for patients with underlying COPD and cardiopulmonary conditions. We excel in partnering with Medicare Advantage plans and value-based providers to manage COPD and chronic conditions through a very specialized approach. Our model integrates virtual pulmonary rehab and tailored clinical coaching, enhancing self-management and overall wellbeing for patients. 

Seervai: Could you explain what patient activation is and why it’s so important to engage patients in their care? 

Dr. Suh: I think of patient activation as the best kept secret we have. Patient activation is defined as an individual’s knowledge, skills and confidence to manage their own health and care. It’s been in use for over 20 years and has been very well-studied across disease conditions and specialties. When you can engage a patient and help them be more activated, you can help them reach better clinical and health outcomes. Patient activation is also associated with decreased ED utilization, hospitalization and re-admission. Patients who are more activated are also found to be more satisfied with their care. 

Seervai: Tell us what the value of patient activation and the Patient Activation Measure (PAM) is to providers. 

Dr. Suh: The PAM gives the care team information and insight into where the patient is in terms of their activation. Think of it as a spectrum of activation, with individuals who are on the lower activated end as being more passive recipients of their care. These are individuals who aren’t asking questions; they get overwhelmed, frustrated and disengage very easily.  

On the flip side, highly activated individuals are more proactive in their care. When I think back to families that I took care of, I often think about these more activated individuals as kind of “gold star families,” the ones who came for their follow-up visits, and whatever treatment plan we established, they went home and did it.  

By knowing where a patient is in terms of activation, it helps the care team and provider understand—how do I support this patient best?  

Shanoor: Dr. Sundaramoorthy, from your perspective, why is patient activation so important to the work you do at Wellinks? 

Dr. Sundaramoorthy: Wellinks’ philosophy is founded on the fact that behavior change produces results, whether those results are related to quality or reducing cost and utilization. Patient activation takes that philosophy to the next level and makes it measurable in terms of how to bring about behavior change. Health coaching has traditionally gotten a reputation for being sort of conversational, with a lot of variation. We wanted to make sure that there was standardization of that process, and that the process was validated through years of research. PAM has been validated time and time again over several years, and it’s measurable. Once we see behavior change in a patient, we can measure that through the PAM and say, ‘there’s a cause-and-effect relationship,’ not just that they’re correlated with each other.  

Seervai: What makes patient activation and care management for COPD patients particularly important? 

Dr. Sundaramoorthy: When you think of the healthcare landscape right now, we have a tremendous amount of our population that is completely unmanaged. I like to use the analogy of when you have a bleeding vessel, you first start by stopping the bleeding, and then you go back and fix the vessel. You can think of healthcare right now as a rapidly bleeding vessel. 

Even though we want to make sure everybody is getting their preventive care, the way we’re dealing with it right now is stopping the bleeding. But, as we see patients deteriorating, how can we get to them at the beginning of that deterioration process and perhaps divert them away from the emergency room or hospitalization to a more appropriate site of care?  

Certain disease processes lend themselves better to that kind of redirection. COPD is a great example. Number one, the deterioration has a symptom associated with it—breathing. So, you get very early symptoms that you are going to deteriorate. Number two is that disease process needs to lend itself to de-escalation. When you use the right inhaler or steroid pack, you can de-escalate that process.  

Seervai: Are there lessons that we can draw from the COPD space to other medical conditions which are also complicated and costly to treat? 

Dr. Sundaramoorthy: If you have an activated patient, we can start the management process early on, before a patient starts deteriorating, making sure that they’re on the right meds or eating the right types of foods. We never need to get to that clinical deterioration: you can see that in chronic kidney disease (CKD), hypertension, diabetes and obesity.  

The key to the healthcare problem is this: We can engage the payers, we can engage the providers, but, if you don’t have an engaged and activated patient, we can’t get ahead of the problem. 

Dr. Suh: What we also know from the research is that activation can predict which patients are going to go on to develop a new chronic condition. It can predict which patients are going to worsen in a chronic condition. The fact that activation is predictive is a strength of this measure because in a value-based care kind of arrangement, one of the fundamental concepts is risk stratification—looking at those patients who are going to be those high-risk patients, who are high utilizers and high cost.  

Seervai: At Wellinks, how would your approach differ with a higher activated COPD patient versus a lower activated COPD patient? 

Dr. Sundaramoorthy: A very common intervention used in the COPD world is a COPD action plan–how do you identify your symptoms and which categories do they fall under? And then, what is a specific intervention and how can you appropriately use that intervention to de-escalate yourself if you feel like there’s an impending exacerbation?  

In a higher activated patient, I can defer to that COPD action plan. You don’t even need a health coach. Patients can put their symptoms into our app, and it’ll tell them the intervention needed. I can trust that this patient is going to act on that and likely de-escalate themselves. Maybe they need to have an appointment within the next few days with their physician. The physician may alter medications, but this patient never has to go to the emergency room or get hospitalized.  

With a lower activated patient, even though they have the app and a COPD action plan at home, they’re likely going to reach out to one of our coaches and we are going to walk them through one-on-one what to do to de-escalate themselves or go to the right site of care. 

Same situation, but two very different types of patients based on their activation. PAM tells us how to allocate resources toward that. You can see the higher activated patient needed a lower touch resource, which is oftentimes less costly. The lower activated patient needed a much more intense touch from an actual human resource, which can be much more costly to the healthcare system. 

Seervai: It’s also costly in terms of saving lives and the intensive care that a patient needs. What are the results you’re seeing in terms of health outcomes or hospital admissions, for example? 

Dr. Sundaramoorthy: Studies show that a one level increase in PAM amounts to approximately an 8% reduction in downstream costs. At Wellinks, we’ve seen a seven-point improvement in PAM over the course of 12 months in the patients we care for, on average. In many of the cohorts we’ve been studying and following the PAM process on, we’ve seen an all-cause re-admission rate reduction of about 23% and specifically a COPD readmission reduction rate of 100%.  

Seervai: Numbers are important, but healthcare is ultimately about improving the lives of patients who are living with health conditions that can be life-threatening. Do you have any stories about patients whose life changed because of patient activation? 

Dr. Sundaramoorthy: We had a patient who had six hospitalizations in the past two years when we first engaged her into the Wellinks program. She had a lot of difficulty with motivation, understanding the disease process, etc. Her last hospitalization was so severe that she was ventilated and admitted into the ICU for six days. Upon discharge, she ended up joining the Wellinks program. We did a lot of work with her in terms of the interventions that are specific to COPD, but also focusing on getting her motivated, getting her activated through PAM goal setting. We saw a change in PAM score of greater than 29 points. She also quit tobacco use and joined our group coaching classes.  

Today, she has gone 14 months without any hospital admissions. We’re very proud of that story. We have a very satisfied patient, and a very satisfied physician because they feel like the patient listened to the instructions they’d given, and that’s changed her quality of life. 

Seervai: More broadly, where does patient activation fit into value-based care (VBC) and how CMS is looking at integrating patient-reported outcome measures into more of its programs? 

Dr. Suh: We have heard from CMS that they are very interested in amplifying the patient voice in more of their programs, including quality and VBC programs. Therefore, CMS is starting to bring in patient-reported outcome measures like the PAM into more of their models and payment programs. For example, for several years, the PAM has been a part of the Kidney Care Choices Model, which is a CMMI innovation payment model in the CKD management space.  

PAM has now been named a quality measure for the Merit-based Incentive Payment System (MIPS) program for this year. We’re starting to see CMS taking very concrete steps in bringing patient-reported outcome measures like PAM into these programs. Everyone can expect to see more of this and perhaps see PAM show up in more models and in more programs through CMS. 

At the core of it, patient activation can help a provider deliver care that is patient centered and shift their care delivery away from a one size fits all model. Understanding activation at an overall population level can help an organization determine which patients they should focus resources on first.