Research shows that one of the major contributors for an extended stay in a long-term care facility is lack of knowledge regarding goals for rehabilitation after being discharged from an acute care facility. It is important to determine patients’ levels of engagement because individuals who are actively involved in discharge planning and rehabilitation goals are able to manage their ongoing care more effectively, which results in increased quality of life. The data was collected using a survey method and the instrument used was the Patient Activation Measure or PAM which is a highly accurate and reliable tool. The 22 question survey was used to determine the level of patient activation among patients who are currently receiving rehabilitation services at a rehabilitation or long-term care facility. Determining the level of engagement in patients receiving rehabilitation services will provide health care providers insight into the how willing patients are to be engaged in their own care. A total of 11 surveys were completed by patients varying age, gender, and length of stay. Each patient was currently receiving rehabilitation services at National Healthcare Corporation of Johnson City or John M. Reed Health and Rehabilitation Facility in Limestone.

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The objectives of this study were to assess patient activation levels, to assess association between sociodemographic characteristics and patient activation, to assess association between health status characteristics and patient activation, and to assess association between patient activation and medication adherence among Medicare beneficiaries with type 2 diabetes. A retrospective cohort study was conducted using data from the 2009 through 2013 Medicare Current Beneficiary Survey (MCBS). Patient activation was measured with the Patient Activation Supplement in the MCBS and was categorized as low, moderate, and high levels based on activation scores. Medication adherence was assessed with proportion of days covered (PDC) using Medicare Part D administrative records from the MCBS within a period of six months after measurement of patient activation. The sample included Medicare beneficiaries who completed the MCBS Patient Activation questionnaire, who were diagnosed with type 2 diabetes, and who were 18 or older. Beneficiaries were excluded if they responded “Not ascertained,” “Not Applicable,” “Don’t know” or “Refused” to more than 50 percent of the Patient Activation questions, did not have continuous Medicare Part A and Part D coverage throughout the assessment period, had less than two Medicare Part D claims for an antidiabetic medication throughout the assessment period, used insulin during the assessment period, resided in long-term care facilities, or had Alzheimer’s disease, dementia, mental retardation or mental disorder. All analyses were conducted in SAS 9.4 for Unix environment. An <i>a priori</i> alpha level of 0.05 was used to determine significance. Bivariate and multivariable weighted ordinal logistic regression were applied for assessing associations. A total of 571 individuals met sample selection criteria. The mean age was 72.4 years. Of the 571 persons in the sample, 27.5 percent were at low activation level, 38.7 percent were at moderate activation level, and 33.7 percent were at high activation level. Approximately three-fourths of the sample persons were adherent to antidiabetic medications. Low activation was more likely to be found in males, less educated patients, and patients without arrhythmia. Ex-smokers as compared to non-smokers and overweight patients as compared to those with healthy weight were less likely to report low activation. In multivariable logistic analysis adjusting for race, gender, osteoporosis, Charlson Comorbidity Index score, and number of prescribed medications, patient activation level was not significantly associated with medication adherence. Non-Whites and patients with a Charlson Comorbidity Index score of 1 as compared to those with a score of 0 were more likely to be non-adherent. A lower number of prescribed medications was associated with higher odds of non-adherence.

Purpose: The systematic review explored whether self-management interventions improve patient activation in long-term conditions, and if any improvements are greater than the amount of change experienced by patients in usual care or active control conditions. It also aimed to determine if positive effects on activation are maintained at follow-up. The empirical study sought to explore relationships between patient activation, psychological factors (depression and valued living), perceived clinician empathy, perceived symptom severity, self-management and demographic variables. It also examined whether depression, valued living and perceived clinician empathy are unique predictors of activation, and if activation is a unique predictor of self-management for MS, when relevant confounding variables are controlled for. Methods: For the systematic review, a comprehensive search of multiple electronic databases was conducted to identify intervention research reporting on patient activation outcomes, as measured by the short-form Patient Activation Measure (PAM-13), in people with long-term conditions. For the empirical study, a cross-sectional survey of 118 people with MS explored patient activation, MS symptom severity, valued living, depression, perceived clinician empathy, self-management for MS and demographic factors. Correlation and hierarchical regression analyses were employed to explore relationships between variables. Results: Twenty-five studies were eligible for inclusion in the systematic review, reporting a wide range of long-term conditions. Twenty-one studies (10 RCTs; 1 non-randomised study; and 10 uncontrolled studies) found an improvement in patient activation at post-intervention. Nine studies reported a significantly greater improvement in activation in self-management conditions compared with usual care or an active control at post-intervention. In six out of eight studies, gains in patient activation were maintained in the intervention group at follow-up. However, in four of these six studies, patient activation in the control group also improved over time. Findings from the empirical study suggested that only valued living was a significant predictor of patient activation after controlling for demographic variables and MS symptom severity. Neither depression nor perceived clinician empathy significantly predicted activation. After controlling for valued living, depression and perceived clinician empathy, patient activation independently predicted 5.5% of variance in self-management for MS. Both activation and perceived clinician empathy were significant predictors of self-management for MS. Conclusions: Self-management interventions improve patient activation in long-term conditions compared with usual care or active control. Patient activation gains appear to be maintained longer-term; however, the impact of self-management interventions on activation is unclear due to increases in activation in control groups over time. Valued living is associated with patient activation in MS, while patient activation and perceived clinician empathy are associated with MS self-management. Self-management interventions targeting valued living and the patient-clinician relationship may be effective for addressing low levels of activation in some patients with MS.

The thesis that this dissertation aims to defend is: Certain self-management behaviours in End Stage Renal Disease are predicted by self-efficacy, patient activation, and psychological distress, and in turn predict clinical status. However, self-management is often oversimplified and poorly operationalised, in both the literature and in clinical practice, to adherence and 'good/bad' distinctions that may impede future investigations and interventions. End Stage Renal Disease (ESRD) is a chronic condition associated with significant morbidity and increased risk of death. It is commonly treated with haemodialysis, a life sustaining treatment that last approximately four hours, repeated in a healthcare centre or at home, at least three times a week. ESRD also necessitates adherence to a complex set of dietary and fluid intake guidelines, in addition to a complex medication regimen, if the person is to avoid a further increase in the risk of severe symptoms and death. Chronic illness self-management is more than just adherence to prescribed medical treatments however, and requires an individual to preserve their emotional wellbeing, maintain social support networks, and continue to function in a variety of social roles and situations. While this has long been recognised in the theoretical literature about self-management, these concepts are often not well translated into clinical practice or empirical investigations of self-management behaviour in ESRD. When operationalising self-management, some investigations treat the 'behaviour' element of self-management as being limited to dialysis, medication, and fluid adherence, or are ignored in favour of psychological correlates such as self-efficacy. A frequent criticism of the self-management literature is that self-efficacy is often treated as an outcome, rather than a psychological component of changes in behaviour, wellbeing, or clinical outcomes. The investigations presented in this dissertation seek to investigate self-management in terms of specific behaviours that go beyond adherence. In doing so, they explore two different types of self-management behaviour, here termed 'cooperative' and 'defensive' self-management. These behaviours can then be examined in relation to adherence and self-efficacy, as well as other theoretically related factors including patient activation, psychological distress, and illness perceptions. The first three chapters set out the background to the empirical investigations reported in this dissertation. Chapter one covers the background on ESRD and its treatment. Chapter two describes the current state of the conceptual and empirical literature concerning self-management. Chapter three combines a narrative review of empirical investigations into self-management in ESRD, and a review of publically available resources concerning self-management in ESRD. Chapter four describes the methods used in the following empirical chapters. Chapters five, six, seven and eight report original empirical investigations on self-management in ESRD. Chapter nine is a discussion of the combined findings, and their implications in the wider clinical and academic context. Chapter 5 presents the results of a series of focus groups conducted with people on in-centre haemodialysis for ESRD, and the healthcare professionals involved in their care. These explored what each group understood by 'self-management', the behaviours and tasks that were important, and the practical, social, and emotional facilitators and barriers. A series of interviews conducted with patients eighteen months later revisited these concepts, focusing on motivations for engaging in self-management behaviours. The combined findings revealed that patient and HCP concepts around self-management overlap, but have a different focus, with HCPs seeing self-management as being about adherence, and patients seeing it as a complex balancing act to maintain their health, emotional wellbeing, and social roles. HCPs identified some patients as 'good' and others as 'bad'. Chapter 6 presents the results of a cross-sectional investigation of self-management behaviour and theoretically related psychological factors, including self-efficacy and psychological distress. Self-management was operationalised using an available scale that covered a variety of the behaviours patients and HCPs identified as important in chapter 5, which included both 'cooperative' and 'defensive' subscales. Self-efficacy, patient activation, and psychological distress were related to 'defensive' behaviours, with higher levels of psychological distress being related to the performance of more defensive behaviours. Higher self-efficacy was related to less frequent performance of defensive behaviours. A novel finding was that psychological distress mediated the relationship between self-efficacy and self-management behaviours. The implication that some proactive self-management behaviours may be associated with poorer emotional wellbeing is discussed. Chapter 7 presents the results of an 18 month longitudinal study of self-management behaviour and clinical markers of adherence. It also reports a survival analysis in the same cohort followed up to 30 months. Higher frequency of cooperative self-management behaviours were associated with lower levels of adherence as indicated by clinical markers. This may be due to the dialysis units in which the study took place, and may in fact reflect how self-management support was conducted in the units at the time of the study. Higher self-efficacy was found to be associated with lower mortality over 30 months after controlling for factors such as age and residual kidney function, an original and potentially important finding. The findings in chapters 6 and 7 raised additional questions about how self-management behaviours are measured and what those measurements indicate. To further investigate, and lay the groundwork for a new scale and general guidelines on the operationalisation of self-management in ESRD, a series of cognitive interviews were conducted. These are reported in chapter 8. They were conducted with people on home haemodialysis, a population whose engagement in a whole range of self-management behaviours is likely to be high. The role of social and emotional factors in the scale and behaviours discussed was also explored. The chapter concludes with a series of suggestions for measuring self-management behaviour in ESRD. This dissertation will explore the concept of self-management for people on haemodialysis, the behaviours involved, and their relationship with psychosocial and clinical status.

<div><div><div><p>Objectives: Previous research suggests an association between working alliance, the collaborative and affective bond between patient and therapist, and improved therapeutic treatment outcomes within treatment of severe mental illness (SMI). However, little is known about the mechanisms through which working alliance improves outcomes in this population. Through investigating key elements of recovery within SMI, two possible mediators—patient activation and hope—appear particularly relevant to the relationship between working alliance and improved treatment outcomes. The current study aimed to examine patient activation and hope as potential mediators in the relationship between working alliance and improved depression in individuals with SMI. Additionally, the current study investigated whether or not the patient’s evaluation of which provider is most important to their recovery significantly moderated the relationship between working alliance and patient activation/hope.</p><p>Methods: The current study was a secondary analysis of longitudinal (baseline, 6-month, and 12-month) data comparing two interventions aimed at reducing treatment provider burnout in community mental health settings primarily serving individuals with SMI. Participants (maximum N for analyses = 346) completed measures of working alliance with a linked provider on their treatment team, patient activation, hope, and depression at baseline, 6 months, and 12 months. Using moderated mediation analysis, 6-month patient activation and 6-month hope were examined as mediators in the relationship between baseline working alliance and 12-month improved depression (change score between 12-month and baseline depression). Additionally, whether or not the patient deemed their linked provider as most important to their recovery was tested as a moderator in the relationship between baseline working alliance and 6-month patient activation/hope.</p><p>Results: Overall, the current study’s hypothesized model was not supported. Baseline working alliance did not significantly predict improved depression 12 months later. Further, both patient activation and hope measured at month 6 in the study did not significantly mediate the relationship between working alliance quality at baseline and improved depression at month 12. Additionally, whether or not the patient believed their linked provider was most important to their recovery did not significantly moderate the relationship between baseline working alliance and 6-month patient activation or 6-month hope. However, results indicate that better quality working alliance at baseline did significantly predict higher patient activation at 6 months. Lastly, the current study found a significant positive correlation between importance of provider and baseline working alliance.</p></div></div></div><div><div><div><p>Discussion: Results suggest that improvement in depression may not be a key SMI treatment outcome that relates to working alliance, patient activation, and hope. Further, fostering a positive working alliance (e.g., collaboratively developing goals/tasks in-session) may increase patient’s ability, willingness, and confidence in managing their own mental health care. Additionally, a positive working alliance may also contribute to how important the patient believes the provider is to their recovery. However, those that have seen their provider for longer (e.g., more chronically ill) may be less active in managing their own mental health care. Limitations and possible future directions are discussed.</p></div></div></div>

Indiana University-Purdue University Indianapolis (IUPUI) / Poor long-term kidney transplant outcomes are a significant problem in the U.S. Interventions must focus on preserving allograft function by managing modifiable risk factors. An instrument capable of identifying problems with post-kidney transplant self-management behaviors may enable the design and testing of self-management interventions. This study’s purpose was to test the psychometric properties of the new Kidney Transplant Self-Management Scale (KT–SM). The Zimmerman framework adapted for kidney transplant self-management guided the cross-sectional study. A total of 153 kidney recipients recruited from Facebook® completed the Self-Efficacy for Managing Chronic Disease (SEMCD), Patient Activation Measure (PAM), Kidney Transplant Questionnaire (KTQ), and KT–SM Scale instruments via a REDCap® survey. Most participants were female (65%), White (81.7%), and middle-aged (M = 46.7; SD = 12.4 years) with a history of dialysis (73%) and received a kidney transplant an average of 6.58 years previous (SD = 6.7). Exploratory factor analysis results supported the 16-item KT–SM Scale as a multidimensional scale with five domains with loadings ranging between .39 and .89: medication adherence, protecting kidney, cardiovascular risk reduction, ownership, and skin cancer prevention. Internal consistency reliability for the total scale (Cronbach’s α = .84) and five domains ranged from .71 to .83. The total and domains were positively correlated, ranging from r = .51 to .76, p = .01. Criterion-related validity was evidenced by significant correlations of KT–SM and domains with SEMCD (r =.22 to .53, p = .01), PAM (r = .31 to .52, p = .01), and the overall KTQ (r = .20 to .32, p = .01) except for one KT–SM domain: protecting kidney. Construct validity was evaluated using multivariate regression analysis. The linear combination of age, patient activation, and self-efficacy explained 45% of the variance in KT–SM behaviors; 47% of the variance in KTQ (measuring quality of life) was predicted by age, comorbidity, and self-efficacy. These findings provide beginning evidence of reliability and validity for the newly developed KT–SM scale. Instruments like this may provide a means to capture the self-management behaviors of the kidney transplant population, which is critical for future work on interventions.

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