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The Patient Activation Measure (PAM) assesses an individual’s knowledge, skill, and confidence for managing one’s health and healthcare. Individuals that measure high on this assessment typically understand the importance of taking a pro-active role in managing their health and have the skills and confidence to do so. The PAM was developed using qualitative methods, Rasch analysis, and classical test theory psychometric methods. Developed by Judith Hibbard and colleagues at the University of Oregon, the resulting13-item measure, is a uni-dimensional, interval level, Guttman-like scale. (1- 2) The PAM, has strong psychometric properties, and has been translated into 19 different languages. The measure is currently used to assess patient activation or engagement by researchers and clinicians around the world (3-7).
The Patient Activation Measure (PAM) assesses an individual’s knowledge, skill, and confidence for managing one’s health and healthcare. Individuals that measure high on this assessment typically understand the importance of taking a pro-active role in managing their health and have the skills and confidence to do so. The PAM was developed using qualitative methods, Rasch analysis, and classical test theory psychometric methods. Developed by Judith Hibbard and colleagues at the University of Oregon, the resulting13-item measure, is a uni-dimensional, interval level, Guttman-like scale<ref>{{cite journal|last=Hibbard|first=Judith|coauthors=Stockard, Mahoney, Tusler|title=Development of the Patient Activation Measure (PAM): Conceptualizing and measuring activation in patients and consumers|journal=Health Services Research|year=2004|month=August|volume=39|issue=4|pages=1005-10026}}</ref><ref>{{cite journal|last=Hibbard|first=Judith|coauthors=Mahoney, Stockard, Tusler|title=Development and testing of a short form of the patient activation measure|journal=Health Services Research|year=2005|month=December|volume=40|issue=6|pages=1918-1930}}</ref>. The PAM, has strong psychometric properties, and has been translated into 19 different languages. The measure is currently used to assess patient activation or engagement by researchers and clinicians around the world<ref>{{cite journal|last=Rademakers|first=Jany|coauthors=Nijman, van der Hoek, Heijmans|title=Measuring patient activation in the Netherlands: translation and validation of the American short form Patient Activation Measure (PAM13).|journal=BMC Public Health|date=31|year=2012|month=July|volume=12|pages=577|doi=10.1186/1471-2458-12-577}}</ref> <ref>{{cite journal|last=Herrmann|first=W|coauthors=Brenk-Franz, Hibbard, Freund, Djalali, Steurer-Stey, Sonnichsen, Storch, Schneider, Genischen|title=Evaluation of the German version of the Patient Activation Measure (PAM-13D) in the primary care setting|journal=WONCA Europe|year=2012|location=Vienna, Austria}}</ref> <ref>{{cite journal|last=Fujita|first=E|coauthors=Kuno, Kato, Kokochi, Uehara, Hirayasu|title=Development and Validation of the Japanese Version of the Patient Activation Measure 13 for Mental Health|journal=Seishingaku|year=2010|pages=765-772}}</ref><ref>{{cite journal|last=Steinsbekk|first=A|title=Patient Activation Measure|journal=Tidsskr Nor Lageforen|year=2008|month=Oct.|volume=128|issue=20|pages=2316-2318}}</ref>.


Multiple studies show that PAM scores are predictive of most health behaviors, including preventive behaviors (e.g. obtaining screenings and immunizations); healthy behaviors (e.g. healthy diet and regular exercise); self-management behaviors (e.g. monitoring and medication management); and health information seeking<ref>{{cite journal|last=Greene|first=Jessica|coauthors=Hibbard|title=Why Does Patient Activation Matter? An Examination of the Relationship Between Patient Activation and Health-Related Outcomes|journal=Journal of General Internal Medicine|year=2011|month=November}}</ref> <ref>{{cite journal|last=Hibbard|first=Judith|coauthors=Mahoney, Stock, Tusler|title=Do increases in patient activation result in improved self-management behaviors?|journal=Health Services Research|year=2007|month=August|volume=42|issue=4|pages=1443-1463}}</ref> <ref>{{cite journal|last=Fowles|first=JB|coauthors=Terry, Xi, Hibbard, Bloom, Harvey|title=Measuring self-management of patients' and employees' health: further validation of the Patient Activation Measure (PAM) based on its relation to employee characteristics|journal=Patient Education and Counseling|year=2009|month=October|volume=77|issue=1|pages=116-122}}</ref><ref>{{cite journal|last=Mosen|first=DM|coauthors=Schmittdiel, Hibbard, Sobel, Remmers, Bellows|title=Is patient activation associated with outcomes of care for adults with chronic conditions?|journal=Journal of Ambulatory Care Management|year=2007|month=January-March|volume=30|issue=1|pages=21-29}}</ref> <ref>{{cite journal|last=Becker|first=ER|coauthors=Roblin|title=Translating primary care practice climate into patient activation: the role of patient trust in physician|journal=Medical Care|year=2008|month=August|volume=46|issue=8|pages=795-805}}</ref> <ref>{{cite journal|last=Hibbard|first=Judith|coauthors=Cunningham|title=How engaged are consumers in their health and health care, and why does it matter?|journal=Research Briefs|year=2008|month=October|volume=8|pages=1-9}}</ref> <ref>{{cite journal|last=Tabrizi|first=J|coauthors=Wilson, O'Rourke|title=Customer Quality and Type 2 Diabetes from the Patients' Perspective: A Cross-Sectional Study|journal=Journal of Research in Health Sciences|year=2010|volume=10|series=2|pages=69-76}}</ref> <ref>{{cite journal|last=Rask|first=KJ|coauthors=Ziemer, Kohler, Hawley, Arinde, Barnes|title=Patient activation is associated with healthy behaviors and ease in managing diabetes in an indigent populations|journal=Diabetes Education|year=2009|month=July-August|volume=35|issue=4|pages=622-630}}</ref> <ref>{{cite journal|last=Rogvi|first=S|coauthors=Tapager, Almdal, Schiotz, Willaing|title=Patient factors and glycaemic control -- associations and explanatory power|journal=Diabetes Medicine|year=2012|month=April}}</ref> <ref>{{cite journal|last=Salyers|first=MP|coauthors=Matthias, Spann, Lydick, Rollins, Frankel|title=The role of patient activation in psychiatric visits|journal=Psychiatric Services|year=2009|month=November|volume=60|series=11|pages=1535-1539}}</ref> <ref>{{cite journal|last=Remmers|first=C|coauthors=Hibbard, Mosen, Wagenfield, Hoy, Jones|title=Is patient activation associated with future health outcomes and healthcare utilization among patients with diabetes?|journal=Journal of Ambulatory Care Management|year=2009|month=October-December|volume=32|issue=4|pages=320-327}}</ref>. Higher activated individuals also have better health outcomes and lower rates of costly utilization, such as emergency department use and hospitalizations <ref>{{cite journal|last=Greene|first=Jessica|coauthors=Hibbard|title=Why Does Patient Activation Matter? An Examination of the Relationships Between Patient Activation and Health-Related Outcomes|journal=Journal of General Internal Medicine|year=2011|month=November}}</ref> <ref>{{cite journal|last=Rogvi|first=S|coauthors=Tapager, Almdal, Schiotz, Willaing|title=Patient factors and glycaemic control -- associations and explanatory power|journal=Diabetes Medicine|year=2012|month=April}}</ref> <ref>{{cite journal|last=Salyers|first=MP|coauthors=Matthias, Spann, Lydick, Rollins, Frankel|title=The role of patient activation in psychiatric visits|journal=Psychiatric Services|year=2009|month=November|volume=60|issue=11|pages=1535-1539}}</ref> <ref>{{cite journal|last=Remmers|first=C|coauthors=Hibbard, Mosen, Wagenfield, Hoye, Jones|title=Is patient activation associated with future health outcomes and healthcare utilization among patients with diabetes?|journal=Journal of Ambulatory Care Management|year=2009|month=October-December|volume=32|issue=4|pages=320-327}}</ref> <ref>{{cite journal|last=Begum|first=N|coauthors=Donald, Ozolins, Dower|title=Hospital admissions, emergency department utilisation and patient activation for self-management among people with diabetes|journal=Diabetes Research and Clinical Practice|year=2011|month=August|volume=93|issue=2|pages=260-267}}</ref> .
Multiple studies show that PAM scores are predictive of most health behaviors, including preventive behaviors (e.g. obtaining screenings and immunizations); healthy behaviors (e.g. healthy diet and regular exercise); self-management behaviors (e.g. monitoring and medication management); and health information seeking (8-18). Higher activated individuals also have better health outcomes and lower rates of costly utilization, such as emergency department use and hospitalizations (8, 16-18).


Further there is evidence that with support and appropriate interventions it is possible to increase activation levels in patients <ref>{{cite journal|last=Lorig|first=K|coauthors=Ritter, Laurent, Plant, Green, Jernigan|title=Online Diabetes Self-Management Program: A randomized study|journal=Diabetes Care|year=2010|month=June|volume=33|issue=6|pages=1275-1281}}</ref> <ref>{{cite journal|last=Druss|first=BG|coauthors=Zhao, von Essenwein, Bona, Fricks, Jenkins-Tucker|title=The Health and Recovery Peer (HARP) Program: a peer-led intervention to improve medical self-management for persons with serious mental illness|journal=Schizophrenia Research|year=2010|month=May|volume=118|issue=1-3|pages=264-270}}</ref><ref>{{cite journal|last=Terry|first=PE|coauthors=Fowles, Xi, Harvey|title=The ACTIVATE study: results from a group-randomized controlled trial comparing a traditional worksite health promotion program with an activated consumer program|journal=American Journal of Health Promotion|year=2011|month=November-December|volume=26|issue=2|pages=e64-73}}</ref> <ref>{{cite journal|last=Shively|first=MJ|coauthors=Gardetto, Kodiath, Kelly, Smith, Stepnowsky|title=Effect of Patient Activation on Self-Management in Patients with Heart Failure|journal=Journal of Cardiovascular Nursing|year=2012|month=February}}</ref> <ref>{{cite journal|last=Hibbard|first=Judith|coauthors=Greene, Tusler|title=Improving the outcomes of diease management by tailoring care to the patient's level of activation|journal=American Journal of Managed Care|year=2009|month=June|volume=15|issue=6|pages=353-360}}</ref>.
Further there is evidence that with support and appropriate interventions it is possible to increase activation levels in patients (19-23).


The Patient Activation Measure is being used in a number of ways to improve the delivery of health care, including:
The Patient Activation Measure is being used in a number of ways to improve the delivery of health care, including:
Line 12: Line 12:
• to segment an enrolled patient population, and direct more resources to the low activated patients (a more efficient use of resources ).
• to segment an enrolled patient population, and direct more resources to the low activated patients (a more efficient use of resources ).








==References==
{{reflist}}

*1. Hibbard JH, Stockard J, Mahoney ER, Tusler M. Development of the Patient Activation Measure (PAM): conceptualizing and measuring activation in patients and consumers. Health Serv Res. 2004 Aug;39(4 Pt 1):1005-26.
2. Hibbard JH, Mahoney ER, Stockard J, Tusler M. Development and testing of a short form of the patient activation measure. Health Serv Res. 2005 Dec;40(6 Pt 1):1918-30.
3. Rademakers J, Nijman J, van der Hoek L, Heijmans M, M R. Measuring patient activation in the Netherlands: translation and validation of the American short form Patient Activation Measure (PAM13). 2012. p. 577.
4. Herrmann W, Brenk-Franz K, Hibbard JH, Freund T, Djalali S, Steurer-Stey C, et al. Evaluation of the German version of the Patient Activation Measure (PAM-13D) in the primary care setting. WONCA Europe; Vienna, Austria2012.
5. Fujita E, Kuno E, Kato D, Kokochi M, Uehara K, Hirayasu Y. Development and Validation of the Japanese Version of the Patient Activation Measure 13 for Mental Health. Seishingaku (Clinical Psychiatry). 2010;52:765-72.
6. Maindal HT, Sokolowski I, Vedsted P. Translation, adaptation and validation of the American short form Patient Activation Measure (PAM13) in a Danish version. BMC Public Health. 2009;9:209.
7. Steinsbekk A. [Patient Activation Measure]. Tidsskr Nor Laegeforen. 2008 Oct;128(20):2316-8.
8. Greene J, Hibbard JH. Why Does Patient Activation Matter? An Examination of the Relationships Between Patient Activation and Health-Related Outcomes. J Gen Intern Med. 2011 Nov.
9. Hibbard JH, Mahoney ER, Stock R, Tusler M. Do increases in patient activation result in improved self-management behaviors? Health Serv Res. 2007 Aug;42(4):1443-63.
10. Fowles JB, Terry P, Xi M, Hibbard J, Bloom CT, Harvey L. Measuring self-management of patients' and employees' health: further validation of the Patient Activation Measure (PAM) based on its relation to employee characteristics. Patient Educ Couns. 2009 Oct;77(1):116-22.
11. Mosen DM, Schmittdiel J, Hibbard J, Sobel D, Remmers C, Bellows J. Is patient activation associated with outcomes of care for adults with chronic conditions? J Ambul Care Manage. 2007 2007 Jan-Mar;30(1):21-9.
12. Becker ER, Roblin DW. Translating primary care practice climate into patient activation: the role of patient trust in physician. Med Care. 2008 Aug;46(8):795-805.
13. Hibbard JH, Cunningham PJ. How engaged are consumers in their health and health care, and why does it matter? Res Briefs. 2008 Oct(8):1-9.
14. Tabrizi J, Wilson A, O'Rourke P. Customer Quality and Type 2 Diabetes from the Patients' Perspective: A Cross-Sectional Study. Journal of Research in Health Sciences. 2010;10(2):69-76.
15. Rask KJ, Ziemer DC, Kohler SA, Hawley JN, Arinde FJ, Barnes CS. Patient activation is associated with healthy behaviors and ease in managing diabetes in an indigent population. Diabetes Educ. 2009 2009 Jul-Aug;35(4):622-30.
16.Rogvi S, Tapager I, Almdal TP, Schiøtz ML, Willaing I. Patient factors and glycaemic control - associations and explanatory power. Diabet Med. 2012 Apr
17. Salyers MP, Matthias MS, Spann CL, Lydick JM, Rollins AL, Frankel RM. The role of patient activation in psychiatric visits. Psychiatr Serv. 2009 Nov;60(11):1535-9.
18. Remmers C, Hibbard J, Mosen DM, Wagenfield M, Hoye RE, Jones C. Is patient activation associated with future health outcomes and healthcare utilization among patients with diabetes? J Ambul Care Manage. 2009 2009 Oct-Dec;32(4):320-7.
18. Begum N, Donald M, Ozolins IZ, Dower J. Hospital admissions, emergency department utilisation and patient activation for self-management among people with diabetes. Diabetes Res Clin Pract. 2011 Aug;93(2):260-7.
19. Lorig K, Ritter PL, Laurent DD, Plant K, Green M, Jernigan VB, et al. Online diabetes self-management program: a randomized study. Diabetes Care. 2010 Jun;33(6):1275-81.
20. Druss BG, Zhao L, von Esenwein SA, Bona JR, Fricks L, Jenkins-Tucker S, et al. The Health and Recovery Peer (HARP) Program: a peer-led intervention to improve medical self-management for persons with serious mental illness. Schizophr Res. 2010 May;118(1-3):264-70.
21. Terry PE, Fowles JB, Xi M, Harvey L. The ACTIVATE study: results from a group-randomized controlled trial comparing a traditional worksite health promotion program with an activated consumer program. Am J Health Promot. 2011 2011 Nov-Dec;26(2):e64-73.
22. Shively MJ, Gardetto NJ, Kodiath MF, Kelly A, Smith TL, Stepnowsky C, et al. Effect of Patient Activation on Self-Management in Patients With Heart Failure. J Cardiovasc Nurs. 2012 Feb.
23. Hibbard JH, Greene J, Tusler M. Improving the outcomes of disease management by tailoring care to the patient's level of activation. Am J Manag Care. 2009 Jun;15(6):353-60.

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Revision as of 19:28, 26 December 2012

The Patient Activation Measure (PAM) assesses an individual’s knowledge, skill, and confidence for managing one’s health and healthcare. Individuals that measure high on this assessment typically understand the importance of taking a pro-active role in managing their health and have the skills and confidence to do so. The PAM was developed using qualitative methods, Rasch analysis, and classical test theory psychometric methods. Developed by Judith Hibbard and colleagues at the University of Oregon, the resulting13-item measure, is a uni-dimensional, interval level, Guttman-like scale[1][2]. The PAM, has strong psychometric properties, and has been translated into 19 different languages. The measure is currently used to assess patient activation or engagement by researchers and clinicians around the world[3] [4] [5][6].

Multiple studies show that PAM scores are predictive of most health behaviors, including preventive behaviors (e.g. obtaining screenings and immunizations); healthy behaviors (e.g. healthy diet and regular exercise); self-management behaviors (e.g. monitoring and medication management); and health information seeking[7] [8] [9][10] [11] [12] [13] [14] [15] [16] [17]. Higher activated individuals also have better health outcomes and lower rates of costly utilization, such as emergency department use and hospitalizations [18] [19] [20] [21] [22] .

Further there is evidence that with support and appropriate interventions it is possible to increase activation levels in patients [23] [24][25] [26] [27].

The Patient Activation Measure is being used in a number of ways to improve the delivery of health care, including: • a metric to assess the degree to which patient's are prepared and able to self-manage • to tailor support and education to help them increase in activation • to track the impact of interventions and tailored support on increasing patient activation levels • to segment an enrolled patient population, and direct more resources to the low activated patients (a more efficient use of resources ).





  1. ^ Hibbard, Judith (2004). "Development of the Patient Activation Measure (PAM): Conceptualizing and measuring activation in patients and consumers". Health Services Research. 39 (4): 1005–10026. {{cite journal}}: Unknown parameter |coauthors= ignored (|author= suggested) (help); Unknown parameter |month= ignored (help)
  2. ^ Hibbard, Judith (2005). "Development and testing of a short form of the patient activation measure". Health Services Research. 40 (6): 1918–1930. {{cite journal}}: Unknown parameter |coauthors= ignored (|author= suggested) (help); Unknown parameter |month= ignored (help)
  3. ^ Rademakers, Jany (31). "Measuring patient activation in the Netherlands: translation and validation of the American short form Patient Activation Measure (PAM13)". BMC Public Health. 12: 577. doi:10.1186/1471-2458-12-577. {{cite journal}}: Check date values in: |date= and |year= / |date= mismatch (help); Unknown parameter |coauthors= ignored (|author= suggested) (help); Unknown parameter |month= ignored (help)CS1 maint: unflagged free DOI (link)
  4. ^ Herrmann, W (2012). "Evaluation of the German version of the Patient Activation Measure (PAM-13D) in the primary care setting". WONCA Europe. Vienna, Austria. {{cite journal}}: Unknown parameter |coauthors= ignored (|author= suggested) (help)
  5. ^ Fujita, E (2010). "Development and Validation of the Japanese Version of the Patient Activation Measure 13 for Mental Health". Seishingaku: 765–772. {{cite journal}}: Unknown parameter |coauthors= ignored (|author= suggested) (help)
  6. ^ Steinsbekk, A (2008). "Patient Activation Measure". Tidsskr Nor Lageforen. 128 (20): 2316–2318. {{cite journal}}: Unknown parameter |month= ignored (help)
  7. ^ Greene, Jessica (2011). "Why Does Patient Activation Matter? An Examination of the Relationship Between Patient Activation and Health-Related Outcomes". Journal of General Internal Medicine. {{cite journal}}: Unknown parameter |coauthors= ignored (|author= suggested) (help); Unknown parameter |month= ignored (help)
  8. ^ Hibbard, Judith (2007). "Do increases in patient activation result in improved self-management behaviors?". Health Services Research. 42 (4): 1443–1463. {{cite journal}}: Unknown parameter |coauthors= ignored (|author= suggested) (help); Unknown parameter |month= ignored (help)
  9. ^ Fowles, JB (2009). "Measuring self-management of patients' and employees' health: further validation of the Patient Activation Measure (PAM) based on its relation to employee characteristics". Patient Education and Counseling. 77 (1): 116–122. {{cite journal}}: Unknown parameter |coauthors= ignored (|author= suggested) (help); Unknown parameter |month= ignored (help)
  10. ^ Mosen, DM (2007). "Is patient activation associated with outcomes of care for adults with chronic conditions?". Journal of Ambulatory Care Management. 30 (1): 21–29. {{cite journal}}: Unknown parameter |coauthors= ignored (|author= suggested) (help); Unknown parameter |month= ignored (help)
  11. ^ Becker, ER (2008). "Translating primary care practice climate into patient activation: the role of patient trust in physician". Medical Care. 46 (8): 795–805. {{cite journal}}: Unknown parameter |coauthors= ignored (|author= suggested) (help); Unknown parameter |month= ignored (help)
  12. ^ Hibbard, Judith (2008). "How engaged are consumers in their health and health care, and why does it matter?". Research Briefs. 8: 1–9. {{cite journal}}: Unknown parameter |coauthors= ignored (|author= suggested) (help); Unknown parameter |month= ignored (help)
  13. ^ Tabrizi, J (2010). "Customer Quality and Type 2 Diabetes from the Patients' Perspective: A Cross-Sectional Study". Journal of Research in Health Sciences. 2. 10: 69–76. {{cite journal}}: Unknown parameter |coauthors= ignored (|author= suggested) (help)
  14. ^ Rask, KJ (2009). "Patient activation is associated with healthy behaviors and ease in managing diabetes in an indigent populations". Diabetes Education. 35 (4): 622–630. {{cite journal}}: Unknown parameter |coauthors= ignored (|author= suggested) (help); Unknown parameter |month= ignored (help)
  15. ^ Rogvi, S (2012). "Patient factors and glycaemic control -- associations and explanatory power". Diabetes Medicine. {{cite journal}}: Unknown parameter |coauthors= ignored (|author= suggested) (help); Unknown parameter |month= ignored (help)
  16. ^ Salyers, MP (2009). "The role of patient activation in psychiatric visits". Psychiatric Services. 11. 60: 1535–1539. {{cite journal}}: Unknown parameter |coauthors= ignored (|author= suggested) (help); Unknown parameter |month= ignored (help)
  17. ^ Remmers, C (2009). "Is patient activation associated with future health outcomes and healthcare utilization among patients with diabetes?". Journal of Ambulatory Care Management. 32 (4): 320–327. {{cite journal}}: Unknown parameter |coauthors= ignored (|author= suggested) (help); Unknown parameter |month= ignored (help)
  18. ^ Greene, Jessica (2011). "Why Does Patient Activation Matter? An Examination of the Relationships Between Patient Activation and Health-Related Outcomes". Journal of General Internal Medicine. {{cite journal}}: Unknown parameter |coauthors= ignored (|author= suggested) (help); Unknown parameter |month= ignored (help)
  19. ^ Rogvi, S (2012). "Patient factors and glycaemic control -- associations and explanatory power". Diabetes Medicine. {{cite journal}}: Unknown parameter |coauthors= ignored (|author= suggested) (help); Unknown parameter |month= ignored (help)
  20. ^ Salyers, MP (2009). "The role of patient activation in psychiatric visits". Psychiatric Services. 60 (11): 1535–1539. {{cite journal}}: Unknown parameter |coauthors= ignored (|author= suggested) (help); Unknown parameter |month= ignored (help)
  21. ^ Remmers, C (2009). "Is patient activation associated with future health outcomes and healthcare utilization among patients with diabetes?". Journal of Ambulatory Care Management. 32 (4): 320–327. {{cite journal}}: Unknown parameter |coauthors= ignored (|author= suggested) (help); Unknown parameter |month= ignored (help)
  22. ^ Begum, N (2011). "Hospital admissions, emergency department utilisation and patient activation for self-management among people with diabetes". Diabetes Research and Clinical Practice. 93 (2): 260–267. {{cite journal}}: Unknown parameter |coauthors= ignored (|author= suggested) (help); Unknown parameter |month= ignored (help)
  23. ^ Lorig, K (2010). "Online Diabetes Self-Management Program: A randomized study". Diabetes Care. 33 (6): 1275–1281. {{cite journal}}: Unknown parameter |coauthors= ignored (|author= suggested) (help); Unknown parameter |month= ignored (help)
  24. ^ Druss, BG (2010). "The Health and Recovery Peer (HARP) Program: a peer-led intervention to improve medical self-management for persons with serious mental illness". Schizophrenia Research. 118 (1–3): 264–270. {{cite journal}}: Unknown parameter |coauthors= ignored (|author= suggested) (help); Unknown parameter |month= ignored (help)
  25. ^ Terry, PE (2011). "The ACTIVATE study: results from a group-randomized controlled trial comparing a traditional worksite health promotion program with an activated consumer program". American Journal of Health Promotion. 26 (2): e64-73. {{cite journal}}: Unknown parameter |coauthors= ignored (|author= suggested) (help); Unknown parameter |month= ignored (help)
  26. ^ Shively, MJ (2012). "Effect of Patient Activation on Self-Management in Patients with Heart Failure". Journal of Cardiovascular Nursing. {{cite journal}}: Unknown parameter |coauthors= ignored (|author= suggested) (help); Unknown parameter |month= ignored (help)
  27. ^ Hibbard, Judith (2009). "Improving the outcomes of diease management by tailoring care to the patient's level of activation". American Journal of Managed Care. 15 (6): 353–360. {{cite journal}}: Unknown parameter |coauthors= ignored (|author= suggested) (help); Unknown parameter |month= ignored (help)
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