Why Patient Activation is Key to Successfully Address Health-Related Social Needs

An important trend in healthcare is that a growing number of organizations are screening patients to better understand how to address social drivers of health (SDOH). We know that non-medical factors – like nutrition needs, transportation, education, or housing – have a direct impact on a patients’ overall health. Screening for SDOH creates a holistic picture of the patient and their unique circumstances and addressing them ultimately improves health outcomes.

But in practice, once healthcare providers have these data and understand their patients’ unmet social needs, few have the resources to address them—which is frustrating for both patients and their providers.

Even in cases where social needs programs are successfully implemented, they often do not lead to the most efficient allocation of resources. Take, for example, this large-scale study of a social needs case management program in Contra Costa County in California.

Medicaid patients at elevated risk for healthcare use (those in the top 15%) were offered 12 months of social needs case management, with more intensive services targeted to people with higher demonstrated needs. Although emergency department and hospital admissions fell, savings from reduced healthcare use did not cover the program's cost. In other words, even in the best-case scenario – decreased hospital use and potentially improved health – an effective social needs intervention likely does not reduce healthcare costs.

When the study results were published in the Annals of Internal Medicine, the authors wrote: “More work is needed to identify ways to increase patient uptake and define characteristics of successful programs.” The authors note that a key limitation of the study was that only 40% of the target group participated in the intervention, so we do not know how those who did not participate may have responded to the intervention.

Our experience tells us that patients with a high level of social needs range from highly engaged to unengaged, like every patient population.

This begs the questions: Does low engagement impede even participation in social needs programs that reduce utilization and costs? What if intensive resources inadvertently go to patients with high social needs who are more engaged, and therefore may not need the most support?

I’ve been grappling with the work of how to use data on patients’ social needs to improve outcomes and address other challenges like costs and staff burnout as a member of the National Quality Forum (NQF) Leadership Consortium. Our report, released last month, makes ten recommendations to help healthcare organizations address social needs by partnering with community services to connect patients with needed resources.

I’m realizing that what makes a successful program is not only connecting patients with resources, but specifically targeting intensive resources to the patients who need them most—those with both high social needs and low engagement.

Take the case of HealthLinc, a federally qualified health center (FQHC) in Northern Indiana serving over 40,000 patients, more than half on Medicaid. HealthLinc partnered with Phreesia to address social needs. We screened patients using the Protocol for Responding to & Assessing Patients’ Assets, Risks & Experiences (PRAPARE), and then assessed patients’ knowledge, confidence and skills to manage their own health using the Patient Activation Measure® (PAM®).

The PAM is a 100-point survey that sorts patients into four levels and tells us whether a patient is overwhelmed and discouraged in managing their care (Level 1) or goal-oriented and proactive (Level 4). Once HealthLinc determined if a patient screened positive for any social need, they used the PAM to decide what kind of support and resources each patient needed to help them manage their health.

Lower-activated patients – those who scored lower on the PAM – required more support, like direct outreach from a community health worker (CHW), in addition to digital outreach, while higher-activated patients received digital outreach only.

Did this work? Within just five months, HealthLinc’s CHWs saw a 43% reduction in time spent on direct patient intervention, meaning they eliminated unnecessary interventions and focused their efforts on those who needed the most CHW support and providing screenings to more people.

They also reported more substantive conversations with patients, indicating that segmenting patients by PAM level improves the quality of social-needs support CHWs can provide. This segmentation approach is key to scaling SDOH programs and may be a factor in making programs more cost-effective.

My hunch is that the Contra Costa case management program could have benefitted from a similar segmenting approach. The program was designed to target those at elevated risk for hospital use – a critical first step – but it did not stratify them by PAM level. If the intervention had also deployed PAM, they would have likely learned that some of the top users are higher-activated patients and do not need intensive services; those who are lower activated possibly needed even more intensive support.

The program could have been more successful if the interventions were more targeted. At least that’s what HealthLinc learned: Instead of giving intensive support to every patient with a social need, they used the limited resource of CHW time more efficiently when they focused on the patients who were least activated and needed the most support.

We need to continue to try new approaches to address social needs, and I believe the most successful ones will use tools like the PAM to target resources effectively and have the greatest impact. Read all the NQF Leadership Consortium’s recommendations, and learn about other new or existing projects to address SDOH, in the full report.