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Working within a social model of health, Your Community Health partner with people and communities to deliver accessible health and wellbeing services, with a strong focus on equity, inclusion and person-centred care. Through its Dietetics, Diabetes Education, Community Nursing and nurse-led care coordination teams, they support people living with chronic and complex conditions, including diabetes, often alongside broader social, cultural and health literacy needs.
For many years, these teams trialled a range of disease-specific outcome measures. While useful in some areas, the tools were not always sensitive enough to capture the meaningful progress clients were making in their lifestyles and self-management. Clients often developed greater confidence and capability in managing their health, even when these improvements were not immediately reflected through traditional clinical indicators such as HbA1c for those living with diabetes.
Having previously partnered with Safer Care Victoria on health and community care integration projects, Your Community Health welcomed the opportunity to participate in the Patient Activation Measure® (PAM®) Pilot. The pilot strongly aligned with the organisation’s interest in identifying a practical, validated outcome measure that could be embedded into routine care and used to better understand changes in client confidence, capability and self-management.
“We were looking for a practical way to measure the behaviour change work that is central to our care. PAM® gave us an opportunity to better understand changes in client confidence, capability and self-management.”
For Your Community Health, the value of PAM® extended beyond measurement. It became a practical tool to support conversations, guide care planning and better understand each client’s activation level, while providing a consistent way to measure changes.
PAM® is a validated tool that assesses a person’s knowledge, skills and confidence to manage their own health and healthcare (Hibbard, Stockard, Mahoney, & Tusler, 2004). PAM® offered a structured way to better understand where each client was in their self-management journey and how care could be tailored to their individual needs.
Rather than replacing clinical judgement, PAM® helped reinforce and strengthen it. Clinicians found that activation scores, supported by the PAM® statements, provided a useful framework for identifying education gaps, guiding appointment planning and tailoring self-management support.
“PAM® reinforced what clinicians were already seeing in practice, while giving us a structured and measurable way to understand each client’s self-management needs.”
PAM® also helped create a shared language across the team and encouraged greater curiosity about activation and its role in care planning. Re-administration data provided a practical way to measure change over time, helping clinicians demonstrate the impact of care in areas that are often difficult to capture through clinical indicators alone.
Your Community Health took a team-based approach to implementation. PAM® champions were identified across Diabetes Education, Dietetics and Community Nursing. These champions, alongside team coordinators, attended training sessions delivered by CFEP Surveys and Phreesia, then shared key learnings with the broader team.
Processes were developed collaboratively and refined through team meetings. This helped PAM® become part of everyday practice rather than an additional administrative task. This approach also supported the onboarding of new staff, including Nurse Care Coordinators who joined after the pilot commenced, by providing a consistent framework for training and integrating PAM® into routine practice.
Clinicians generally introduced PAM® during initial consultations, finding it most effective towards the end of the appointment once rapport had been established. This allowed the questions and results to support a more natural conversation about confidence, knowledge, motivation and support needs.
PAM® was then re-administered at the end of a course of care or after approximately six months of care by one clinician, enabling the team to monitor change over time.
“Introducing PAM® towards the end of the consultation worked well because rapport had been established, and the questions could become part of a broader conversation about self-management.”
PAM® supported clinicians to tailor care more deliberately by providing a structured way to understand each client’s level of activation, confidence and self-management needs. Activation scores helped inform care planning, appointment frequency, education priorities and the level of support required for each client. For example, clinicians described adapting the amount of information provided at one time according to a client’s activation level, allowing the level of support given, to be based on the client’s confidence and capability to self-manage.
The PAM® statements encouraged reflection for clients about how they were managing their diabetes, broader health needs or long-term conditions. This created opportunities for more meaningful conversations, collaborative goal setting and greater engagement in care.
For clinicians, PAM® provided an opportunity to reflect on and reinforce their clinical judgement. This was considered one of the most valuable aspects of the program, enabling clinicians to use a validated tool to measure and respond to client needs.
PAM® also helped establish a common language across the team. The 13-item survey provided a reliable framework for identifying education gaps and tailoring interventions, while prompting greater curiosity among clinicians about how activation levels influence health behaviours and outcomes.
“The PAM® questions helped open up conversations with clients about how they were managing their health, what support they needed, and where education could be better tailored.”
Once staff became familiar with the tool, it became easier to integrate PAM® into routine clinical practice. The re-administration process was particularly valuable, enabling clinicians to monitor changes in activation over time. For the diabetes educators and community nurses this provided measurable evidence of the impact of their care and support beyond traditional clinical indicators alone.
Between the 1st of January 2024 and the 31st of December 2025, Your Community Health completed 236 PAM® assessments across 154 individuals. Of these individuals, 58 completed at least two PAM® assessments during the reporting period, enabling change in activation to be measured over time.
Table 1: Change in PAM® scores for Your Community Health clients who completed repeat PAM® assessments, 1st January 2024 to 31st December 2025.
Re-administration data showed encouraging improvements in activation, particularly among clients who commenced at lower activation levels. Clients beginning at Level 1 demonstrates the strongest improvement, with an average PAM® score increase of 13.9 points. Positive changes were also seen among clients who began at Levels 2 and 3, with average increases of 7.9 and 5.3 points respectively.
These results are particularly meaningful as PAM® reporting guidance places emphasis on change among people at lower activation levels, particularly Levels 1 and 2. Broader research shows that higher levels of patient activation are associated with stronger self-management behaviours and better health outcomes. As people become more activated in their care, they are more likely to take an active role in managing their health and engaging in behaviours that support their wellbeing.
Australian research highlights the potential importance of activation for people living with chronic conditions. Research involving people living with diabetes found that those at the lower PAM® activation level were more likely to be hospitalised and more likely to attend an emergency department than those at the highest PAM® activation level. (Begum, N., et al. (2011)). Research with Australian health consumers also links higher activation with stronger prevention behaviours, medication adherence, reduced unnecessary emergency department use and lower readmission rates. (Dammery, G., et al. (2023)).
For Your Community Health, these results helped demonstrate the impact of care in a way that complemented clinical indicators. This was particularly valuable for clinicians whose work focuses on supporting behaviour change, building confidence and strengthening clients’ capacity to self-manage.
The pilot reinforced that successful implementation requires more than introducing a validated tool. For Your Community Health, investing time in staff training, identifying PAM® champions, developing clear workflows, and creating space for ongoing team discussions were essential to embedding PAM® into routine practice.
Adequate time and resourcing were also important. Clinicians needed practical processes that allowed them to use PAM® meaningfully, while maintaining their focus on delivering quality clinical care.
The project also highlighted the importance of considering health literacy and accessibility. Some clients with low literacy or low health literacy required additional support to complete the measure. Similar considerations were experienced when using the Parent and Carer PAM®, particularly within Dietetics, where referrals were often broader and not necessarily centred on a specific health condition.
PAM® re-administration also presented challenges, particularly during busy appointments where there was limited time to complete follow-up assessments. Involving other health professionals or support staff in follow-up and re-administration helped to make the process more manageable. At Your Community Health, Allied Health Assistants were incorporated into this process, which helped support timely completion of repeat PAM® assessments.
Drawing on these experiences, Your Community Health encourages other services to be clear from the beginning about why PAM® is being used, how the information will inform care and how barriers for clients and clinicians can be minimised.
Organisational support to invest time and resources in training and establishing practical processes before implementation is important. PAM® works best when it is embedded into care conversations and supported by practical workflows, rather than treated as a standalone form.
“Training, champions and clear workflows were critical. PAM® worked best when it was embedded into care conversations, not treated as a standalone form.”
Looking ahead, Your Community Health continues to see opportunities to expand the use of PAM®. The measure is now being used within the Your Community Health Seniors Lifestyle Program, with future potential to support group-based interventions, risk stratification, tailored care planning and ongoing outcome measurement. As part of this ongoing implementation, Allied Health Assistants are also being trained to administer the PAM®, further supporting its integration into routine care. Continued collection of re-administration data will help the team better understand changes in patient activation over time and further demonstrate the impact of person-centred care.
For Your Community Health, the PAM® Pilot provided an opportunity to trial a validated tool that aligned strongly with its approach to care.
PAM® helped clinicians measure the behaviour change work they were already doing, support more tailored conversations and better understand each client’s confidence, knowledge and self-management needs.
The pilot showed that when outcome measures, such as PAM®, are embedded thoughtfully into workflow and care planning, it can strengthen person-centred care and provide meaningful evidence of impact beyond clinical indicators alone.
Phreesia, Inc. ‘Patient Activation Measure®© University of Oregon. All rights reserved.’ Confidential. For use only with a valid PAM® License Agreement.
Safer Care Victoria supported the PAM® pilot through funding for PAM® licenses and training, and provided implementation support to participating community health services throughout the pilot. Safer Care Victoria is Victoria’s leading authority for healthcare quality and safety, supporting health services to deliver safer, high-quality care for all Victorians.
Thank you to Your Community Health and Safer Care Victoria for sharing outcomes from their PAM® journey so far.
The PAM® Pilot project update and link to summary report has been published on SCV’s website: https://www.safercare.vic.gov.au/improvement/projects/patient-activation-measure
To learn more about Your Community Health visit: www.yourch.org.au
To learn more about Safer Care Victoria visit: www.safercare.vic.gov.au
Dammery, G., Vitangcol, K., Ansell, J., Ellis, L. A., Smith, C. L., Carrigan, A., Braithwaite, J., & Zurynski, Y. (2023). The Patient Activation Measure (PAM) and the pandemic: Predictors of patient activation among Australian health consumers during the COVID-19 pandemic. Health Expectations, 26, 1107–1117.
CFEP Surveys. (2025). Patient Activation and Health Service Use: A Conservative Cost Impact Model for Estimating Potential Savings in Australia.
Begum, N., Donald, M., Ozolins, I. Z., & Dower, J. (2011). Hospital admissions, emergency department utilisation and patient activation for self-management among people with diabetes. Diabetes Research and Clinical Practice.
Hibbard, J. H., Stockard, J., Mahoney, E. R., & Tusler, M. (2004). Development of the Patient Activation Measure (PAM): Conceptualizing and measuring activation in patients and consumers. Health Services Research.
Kearns, R., et al. (2020). Implementing the Patient Activation Measure (PAM) in clinical settings for patients with chronic conditions: A scoping review.
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