June 10, 2021
San Mateo County Health implements PAM and CFA with at-risk patients resulting in decreased emergency department visits and inpatient discharges
San Mateo County Health (SMCH) created the Bridges to Wellness Team (BWT) to serve clients considered to be highest utilizers of services and who have multiple comorbidities, such as complex medical conditions, mental health challenges, substance use disorders, multiple incarcerations, and experiencing homelessness insecurity. The team is composed of care navigators, supervising social workers, a nurse, nurse practitioners and a medical director who engage the clients and link them to the services based on need.
In early 2019, the BWT program implemented the Patient Activation Measure® (PAM®) survey to risk-stratify clients according to activation level, determine the needs of the population, and then tailor additional health coaching support to those with lower activation. The team also implemented use of Insignia Health’s Coaching for Activation® (CFA) program in late 2019. Initial results indicate that among those clients with improvements in PAM scores, average monthly emergency room visits and inpatient stays dropped by 18% and 52% respectively, confirming that PAM can be used as a tool to predict client behavior and health outcomes.