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Patient Engagement Along the Continuum of Care: Case Studies and Best Practices

November 13, 2018

Patient engagement generally describes patient involvement in their own healthcare. The concept of patient engagement is not new; for example, diabetes educators have been talking about “shared decision making” since the early 1990s.1 It is still a current hot topic among policymakers, though, and is a key component of meaningful use legislation, the Affordable Care Act, and the U.S. Department of Health and Human Services’ National Strategy for Quality Improvement in Health Care. Additionally, increasing patient engagement can benefit you and your patients. Engaged patients are more likely to have better outcomes and greater satisfaction with their healthcare experience and are also less likely to file malpractice lawsuits.2

Patient Activation

One aspect of patient engagement is “patient activation.” Patient activation is defined as “an individual’s knowledge, skill and confidence for managing their health and healthcare.”3 The most commonly used measure of patient activation is the Patient Activation Measure (PAM).2

The PAM is a 13-question survey that patients complete themselves. Once scored, the patient is categorized into one of four activation levels, which represents the patient’s concept of their ability and desire to manage their health and healthcare.4 The PAM has been validated in outpatient clinics and hospitals, and in healthy patients, patients with chronic disease, and mental health disorders. One of the most important attributes of the PAM is its established relationship to patient outcomes — patients with high PAM scores are more likely to have positive healthcare outcomes.2

Up to 40 percent of patients may have low activation levels, which does not necessarily correlate with income level, education, or access to care.2 Low activation patients are likely to feel overwhelmed with managing their health, to have low confidence in their ability to positively impact their health, and to misunderstand their role in the healthcare process. Low activation patients are far more likely to have unmet medical needs compared to patients with high activation levels, who are more likely to make healthy lifestyle choices, use the healthcare system appropriately, successfully manage chronic disease self-care, and educate themselves about their health.2

Although patients present to healthcare encounters with various levels of activation, studies have shown that optimal communication and collaboration — using targeted interventions — can significantly increase activation levels and thus improve health outcomes.4,5,6,7

Confirm Comprehension with the Teach-Back Method

Patient Portals and Patient Engagement

Patient portals can increase patient engagement, but only if patients use them. Patients who are otherwise engaged in their healthcare may have limited computer skills. Offering patient portal training sessions to show patients how to get online and retrieve information from the portal is an excellent way to reach patients who may be struggling with the technical aspects of engaging through a portal. Teaching your patients how to use your portal is also a good way for you to learn about its user-friendliness. If using your portal frustrates you or your staff, you need to make some usability changes.

The U.S. Department of Health & Human Services Agency for Healthcare Research and Quality (AHRQ) provides a Portal Feedback Form and a variety of other patient portal tools in its Health Literacy Universal Precautions Toolkit, 2nd Edition. A patient portal is a great way to save time and engage patients, but it’s important to remember that it is a supplement to, not a substitute for, discussions with patients.

Research shows that patients comprehend around half of the information they are provided during the informed consent process.8 The teach-back method is a way to determine if your education efforts have been successful during the informed consent process and other patient encounters, such as discharge from the hospital and everyday office visits.

When using the teach-back method to assess patient understanding, avoid quizzing the patient (e.g., “Do you understand?” or “Do you have any questions?”). Instead, ask open-ended questions that cannot be answered with yes/no answers, which are more likely to prompt meaningful responses. For example, during the informed consent process for hernia repair, to assess whether the patient understands their options, a surgeon could ask, “We talked about three treatment options today: watchful waiting, an open hernia repair, and an arthroscopic operation. I want to make sure I explained each option clearly. Would you please tell me how you would explain watchful waiting to a family member?”9

If the patient cannot repeat back the nature, risks, benefits or alternatives associated with an anticipated procedure, or cannot tell you how they will take medications or change dressings following discharge, try alternative education methods. For example, simple drawings, models, and demonstrations of the desirable behavior (such as showing the patient how to empty a Foley catheter urine bag) may help a struggling patient understand how to comply with treatment recommendations.

Numerous teach-back resources are available online; for example, the Always Use Teach-Back! Toolkit describes principles of plain language, teach-back, coaching, and system changes necessary to promote consistent use of teach-back and includes videos of clinicians using teach-back.


Discovering and integrating patient preferences and encouraging patient involvement in treatment decision-making has many benefits, including better healthcare outcomes and higher patient satisfaction. Although patients are rightfully expected to take some responsibility for their own health, those who are the least likely to do so are the most likely to be dissatisfied with their healthcare experiences and are more likely to file lawsuits.3

The closed claim case studies linked below focus on three points along the continuum of care during which patient engagement can make a major difference in patient safety and liability risk: informed consent, hospital discharge and chronic disease management. Incorporating into your practice the risk management strategies in these case studies can increase patient engagement and reduce the risk of patient injury, increase patient satisfaction, and lower malpractice risk.

More Information About Patient Engagement Along the Continuum of Care

This content from Claims Rx


1. Funnell MM, Anderson RM. “Patient Empowerment: A Look Back, A Look Ahead.” Diabetes Educ. 2003; 29(3):454-458. (resource not available online)

2. Hibbard J, Gilburt H. “Supporting People to Manage their Health: An Introduction to Patient Activation.” The King’s Fund. May 2014. (accessed 9/18/2018)

3. Julia James. “Health Policy Brief: Patient Engagement.” Health Affairs. February 14, 2013. (accessed 9/18/2018)

4. Hibbard JH, Mahoney ER, Stockard J, Tusler M. “Development and Testing of a Short Form of the Patient Activation Measure.” Health Serv Res. 2005;40(6) part 1:1918–30. (resource not available online)

5. Alegría M, Sribney W, Perez D, Laderman M, Keefe K. “The Role of Patient Activation on Patient–Provider Communication and Quality of Care for US and Foreign Born Latino Patients.” Journal of General Internal Medicine. 2009;24(Suppl 3):534-541. (accessed 9/18/2018)

6. Hibbard JH, Mahoney ER, Stock R, et al. “Do increases in Patient Activation Result in Improved Self-Management Behaviors?Health Serv Res. 2007;42(4):1443–63. (accessed 9/18/2018)

7. Joint Commission. “Transitions of Care: Engaging Patients and Families.” Quick Safety. 2015 Nov; Issue 8. (accessed 9/18/2018)

8. Schillinger D, et al. “Closing the Loop: Physician Communication with Diabetic Patients who Have Low Health Literacy.” Archives of Internal Medicine. 2003;163(1):83-90. (accessed 9/18/2018)

9. Agency for Healthcare Research and Quality (AHRQ). “The SHARE Approach—Using the Teach-Back Technique: A Reference Guide for Health Care Providers.” July 2014. (accessed 9/18/2018)

Linked Sources

American Recovery and Reinvestment Act of 2009. (accessed 9/18/2018)

Patient Protection and Affordable Care Act. (accessed 9/18/2018)

Agency for Healthcare Research and Quality (AHRQ):

Filed under: Patient Relationship, Patient Communication, Article, Physician



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