Reduce Readmissions by Activating Patients to Do 'Self-Care'

Tinker Ready , April 10, 2014

Patients take the test while in the hospital and their score helps the discharge team tailor follow-up instructions and care. "For high-activated patients, they may follow up with a phone call," Hibbard said. "For low-activated patients, they may go to the home."

A study of 695 patients published in February looked at the relationship between PAM scores and 30-day readmission rates at Boston University Medical Center. The result: Patients rated "low" on the activation scale were twice as likely to be readmitted within 30 days as those who earned high PAM scores.

Small Data Leads to Larger Efforts
While the answers to all 13 questions probably qualify as small data, some hospitals are using it as a starting point from which larger self-care initiatives are being launched. At, the website of the Office of the National Coordinator, a featured "success story" describes such a program at the Mountain States Health Alliance in Johnson City, TN. 

The EHR system there monitors records for cues, such as symptoms of blood infection, and then contacts providers. The story notes that once the system flags a case that is likely to result in a readmission, providers and hospital staff can take steps such as 'reminding patients about preventive care, prescribing medicine, or deploying case managers to help patients navigate treatment plans." Hospitals nationwide are trying some version of this approach.

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