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The Name of the Game in PHM Is Variability: Part 7 - Sustaining

by Scott MacStravic

Once targets are enrolled, i.e. as many choose to opt in or fail to opt out, there remains the next challenge of sustaining their participation, in terms of frequency and duration of interactions, cooperation in pursuing the intervention goal, and making behavior changes – and completing or continuing in the intervention, depending on which applies.  There may also be a separate challenge to sustain the changes in behavior, health status, and economic benefit delivered, since relapses relative to the behavior change targeted, or “slipping” into risk levels of some other behavior or condition is common.

PHM suppliers and sponsors seem generally to rely on the same approaches for sustaining participation and behavior changes as they do in achieving them.  Of course, the least expensive course may be simply to ignore those who succeed, and even those who do not, rather than attempt to enroll them in the same intervention again.  Re-enrollment efforts may help for those who failed to succeed or still have plenty of room for improvement, or they may be offered a different intervention, linked by assessment to a comparable or at least appreciable level of risk/reward potential.

For those who have succeeded already, some kind of “maintenance” intervention may work, with a lower intensity and cost to sponsors.  Or, since almost every member of the population is likely to have many more than one cost factor present, those who succeed in one may be invited to enroll in another, assuming there remains plenty of room for reducing one or more of the costs involved.  It may easily be possible to enroll “succeeders” in both one maintenance-level and one new intervention, without reducing the effects of either.

The most powerful approach to promoting sustained and continuous participation, however, is likely to be paying significant attention to what the participant has gained through past and current efforts.  When the PHM intervention involves personal coaching, by phone or in person, it should be an automatically included part of each interaction to check what progress each participant has made in changing behavior, improving health status, reducing healthcare use, or improving productivity/performance, as each perceives such changes.

Their perceptions, at a minimum, can be used to reinforce their confidence in success, and thereby their motivation to persist. If, in addition, an effort is made, such as by asking participants to track for themselves, the health-related quality of life, and perhaps “life asset” impact of their participation so far, and their success once achieved, this should reinforce their persistence even more.  Progress and success in changing behavior, health status, and productivity or performance, for example, when participants have their recognition of these prompted or reinforced, should add to their self-esteem as well as self-confidence.

Moreover, such changes may well have measurable impact on their life asset of “wealth” as well as “health”.  Quitting smoking can save literally thousands of dollars a year in costs of tobacco, for example.  Enabling and reminding participants to track how much they are  “wasting” while they still smoke, and “earning” while they remain abstinent, can reinforce their commitment.  It has been difficult to get smokers to recognize how much their productivity and performance have been impaired by their addiction, but measured improvement in both can add to their sense of “talent” or performance asset as well.  And if productivity/performance improvements have come with increased compensation, reminding them of that should help as well.

Participants, themselves, are most likely to be at least potentially aware of many life benefits they are gaining through participation, if they are asked about them, or encouraged to record them in a personal health log or diary.  This may be kept private for the participant’s personal use, or shared with the PHM supplier, as each participant chooses.  Those that the supplier knows about can be used to provide periodic summaries to participants, to remind them of their achievements.
For PHM suppliers or programs that include frequent assessments, and I know of one that performs assessments at 30, 90 and 180 days, for example, for some clients, at least, can use these assessments to provide reinforcement effects to sustain participation, if it is intended to be longer than 30 or 90 days for example, or sustain change if repeated again after a year.  Having three opportunities for participants to report their progress means they will be reminding themselves every time they are asked.  If they also keep a shared log of results, the supplier can add its own summaries to these reminders.

Others, including incentaHEALTH and Virgin Health, use self-service kiosks that employees can use to “check in” with weight and other biometric measures whenever they choose.  Each participant registers a confidential ID when using the kiosk, so that each’s efforts and biometrics can be tracked, making periodic reporting of progress and achievement easy for PHM providers.

Of course, like so many of the elements of PHM, supplying extra reminders, even asking separately about participant progress and achievement, may add some costs, so balancing the positive effects or sustaining efforts with their costs will be necessary.  I know of no PHM supplier that has separated out such costs and effects, so there is no experience that I know of to look at.  But research has clearly indicated that the prospect of future benefits is an even more powerful stimulant for continuing relationships than is recognition of past benefits, so reinforcing both seems likely to help. [K. Lemon et al. “Dynamic Customer Relationship Management: Incorporating Future Considerations into the Service Retention Decision” Journal of Marketing, 66:1 Jan 2002 1-14]

With so little known about how suppliers and clients have sustained participation and success in the past, it is difficult to say how much variations in this element add to the overall variability of PHM strategies and interventions.  But when efforts are used, or even if they become only gradually added to PHM efforts, they will likely add to the overall variability, since there is no evidence at all, as far as I know, of which methods work best.


2 Comments »

  Brett wrote @ May 7th, 2008 at 12:38 pm

Should this be Part 6 intead of 7?

I don’t see a 6 listed anywhere?

  Scott MacStravic wrote @ May 7th, 2008 at 3:58 pm

Part 6 immediately preceded Part & on the blog.

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