‘Patient activation’ describes people’s knowledge, skills and confidence to manage their own health. Scores are closely linked to clinical outcomes, the costs of healthcare and patient experience. NHS England purchased Patient Activation Measure (PAM) licences to be used in Vanguard sites across the county to measure patient activation. Cornwall (NHS Kernow CCG) partnered with NHS South West Cardiovascular Clinical Network and Cornwall & Isles of Scilly Local Pharmaceutical Committee (LPC) to pilot a PAM service in community pharmacies in Cornwall for patients with type 2 diabetes mellitus (T2DM).It used PAM scoring and goal setting, combined with motivational interviewing in pharmacies, for individuals with T2DM, to understand how this might help them self-manage their condition. A total of315 patients were recruited to the service: 234 completed the full intervention; 29 formally withdrew, and the remainder were lost to follow up.Of those who completed the service, 98% either achieved (72%) or partially achieved (26%) their goals. PAM scores increased in 77% of patients by a mean of 8.64 points.
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Patient activation is a new area for the NHS so studies tailoring services for patients based on their PAM level, or aiming to increase PAM scores, inform the development of future services. The Pharmaceutical Services Negotiating Committee (PSNC) released a briefing paper in October 2016 highlighting the concept and its relevance to community pharmacy. In October 2016 a Pharmacy Integration Fund was announced by NHS England to support efficiency savings and reduce pressures elsewhere in the NHS. National pharmacy bodies want to increase community pharmacist involvement in managing long-term conditions, supporting healthier lifestyles and optimising medication use. Patients prescribed new medication for T2DM at diagnosis or flagged for the ‘new medicines service’ in the pharmacy mean pharmacists can identify those who would benefit from more support. Demand for structured education services in Cornwall means there is a time lag between diagnosis and being offered a place. Patients want more support when first diagnosed so pharmacists were encouraged to focus on this group.
Invitations to take part in ‘an exciting new service’ were sent to every pharmacy in Cornwall. All pharmacists were required to attend the training event which launched the service and fulfil training requirements. A total of 20 pharmacies were selected and asked to recruit up to 25 patients who could identify a suitable goal. The pharmacists recorded and uploaded data to PharmOutcomes. At the initial consultation, the pharmacist obtained consent from the patient and undertook a PAM assessment, providing a baseline score and activation level. Then they spoke with the patients about their diabetes and general health, helped them identify a goal and coached them to achieve it. Written information was provided where needed. The PAM is a proprietary tool developed by Insignia Health. It is the most commonly-used measure of activation and comprises a series of statements about beliefs, confidence in the management of health-related tasks and self-assessed knowledge. The answers generate a score of between 0 and 100 and an activation level of 1-4. Pharmacists entered questionnaire results into PharmOutcomes, generating instant results and enabling them to tailor their interventions. Following the initial consultation there were at least four consultations at two-to-three-week intervals, usually via telephone, to check progress and provide further support. A final face-to-face consultation took place three months after the first in which progress was discussed and the patients were asked if they had achieved their goal. The PAM assessment was repeated and participants were offered an evaluation questionnaire. A record of every interaction was made on PharmOutcomes and the anonymised data were used for evaluation.
Effectiveness was measured by comparing baseline to endpoint PAM scores, asking patients about their ability to achieve goals and analysing data for other benefits patients may have gained as a result of taking part. A total of 77% of patients saw their PAM score increase between baseline and final assessment, 9% saw no overall change and 14% saw a decline. This represents a percentage increase of 15.1%, which is potentially higher than the average reported by such interventions using PAM.The final assessment saw a significant reduction in those participants at levels 1 and 2 and significant increases in those at levels 3 and 4, with 44% of participants rising at least one activation level. Increased patient activation results in better health, reductions in hospital admissions, better access to routine screening and monitoring, plus improvements in test results, including HbA1c.Those with higher scores are more likely to self-manage and achieve further goals.The majority of patients set goals relating to lifestyle. At the final consultation, 72% said they had achieved their goals, 26% had partially achieved their goals and 2% had not.Pharmacists recorded making wide-ranging interventions and referrals to optimise their patients’ care, including ‘flu’ vaccinations, alcohol intervention and brief advice, referrals into the ‘hot foot’ and retinal screening pathways, plus medicines optimisation.
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The results have been presented at local and national level. The LPC in Devon is applying for funding to develop a similar service in pharmacies. Cornwall LPC and NHS Kernow CCG are considering including it in formal diabetes pathways. NHS Kernow CCG commissioned 100 further interventions in 2018-19 but further funding is unclear. The independent evaluation strongly supported the benefits the service provided to patients in managing their diabetes and increasing confidence to self-manage. It also supported the pharmacists’ role in supporting patients with T2DM. Direct analysis of the impact on healthcare utilisation and services was outside the scope of the evaluation. NHS Kernow CCG has also funded a similar service for 100 patients with type 1 diabetes, to reduce admissions due to diabetic ketoacidosis.
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