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BMJ Open. 2018 Oct 31;8(10):e023068. doi: 10.1136/bmjopen-2018-023068.

How do healthcare professionals working in accountable care organisations understand patient activation and engagement? Qualitative interviews across two time points.

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The Dartmouth Institute of Health Policy and Clinical Practice, Lebanon, New Hampshire, USA.
Geisel School of Medicine at Dartmouth, Hanover, New Hampshire, USA.
Berkeley School of Public Health, University of California, Berkeley, California, USA.



If patient engagement is the new 'blockbuster drug' why are we not seeing spectacular effects? Studies have shown that activated patients have improved health outcomes, and patient engagement has become an integral component of value-based payment and delivery models, including accountable care organisations (ACO). Yet the extent to which clinicians and managers at ACOs understand and reliably execute patient engagement in clinical encounters remains unknown. We assessed the use and understanding of patient engagement approaches among frontline clinicians and managers at ACO-affiliated practices.


Qualitative study; 103 in-depth, semi-structured interviews.


Sixty clinicians and eight managers were interviewed at two established ACOs.


We interviewed healthcare professionals about their awareness, attitudes, understanding and experiences of implementing three key approaches to patient engagement and activation: 1) goal-setting, 2) motivational interviewing and 3) shared decision making. Of the 60 clinicians, 33 were interviewed twice leading to 93 clinician interviews. Of the 8 managers, 2 were interviewed twice leading to 10 manager interviews. We used a thematic analysis approach to the data.


Interviewees recognised the term 'patient activation and engagement' and had favourable attitudes about the utility of the associated skills. However, in-depth probing revealed that although interviewees reported that they used these patient activation and engagement approaches, they have limited understanding of these approaches.


Without understanding the concept of patient activation and the associated approaches of shared decision making and motivational interviewing, effective implementation in routine care seems like a distant goal. Clinical teams in the ACO model would benefit from specificity defining key terms pertaining to the principles of patient activation and engagement. Measuring the degree of understanding with reward that are better-aligned for behaviour change will minimise the notion that these techniques are already being used and help fulfil the potential of patient-centred care.


accountable care organizations; patient activation; patient engagement

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Conflict of interest statement

Competing interests: GE has been a consultant to Emmi Solutions, which develops patient decision support tools; National Quality Forum on certification of decision support tools; Washington State Health Department on certification of decision support tools; PatientWisdom; SciMentum, Amsterdam and Access Community Health Network, Chicago. He has edited/published books that provide royalties on sales by the publishers: the books include SDM (Oxford University Press) and Groups (Radcliffe Press). He also initiated and leads the Option Grid patient decision aids collaborative, which produces and publishes patient knowledge tools in the form of comparison tables ( and has part ownership of the registered trademark. He owns a copyright in CollaboRATE, IntegRATE and Observer OPTION measures of SDM and care integration. These measures are freely available for use. EF reports personal fees from Christiana Care Health System, personal fees from American College of Pathologists, personal fees from Angiodynamics (for profit company), personal fees from Blue Cross, Blue Shield of LA, personal fees from National Confederation of General Insurance, Private Pension and Life, Supplementary Health and Capitalization Companies, Brazil, personal fees from Blue Cross, Blue Shield of South Carolina, personal fees from Vizient, personal fees from Signature Healthcare Foundation, grants from Commonwealth Fund, grants from Agency for Healthcare Research and Quality, outside the submitted work; and he is a member of the Board of Directors of the Institute for Healthcare Improvement and the Fannie E Rippel Foundation.

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