Using Health Confidence to Improve Patient Outcomes


Tracking patient engagement is a key step to enhancing health and reducing costs.

Fam Pract Manag. 2016 Nov-Dec;23(6):21-24.

Author disclosures: no relevant financial affiliations disclosed.

Active patient engagement is associated with improved patient outcomes.1 Health confidence is an easy-to-measure proxy for patient engagement that can lead to interventions that produce improved outcomes. The concept of health confidence and its implementation were introduced in a previous Family Practice Management article.2 You can measure health confidence by asking patients a single question, “How confident are you that you can control and manage most of your health problems?” Patients can respond using a numerical scale from 0 (not confident) to 10 (extremely confident). A score of 8 or more is considered ideal. Alternatively, patients could answer “very confident,” “somewhat confident,” “not very confident,” or “I don't have any health problems.”

Our group of five family physicians and four nurse practitioners and physician assistants decided to measure health confidence for one year, use it to guide interventions, and study the effects. This article describes what we learned.

Measuring health confidence

We identified 287 patients in our practice and recorded health confidence scores in structured data fields in our electronic health record (EHR). This allowed us to extract health confidence values recorded on certain encounter dates for patient populations we wanted to study.

Within the general patient pool, we identified a small cohort of 32 “at-risk” patients, which included individuals with high hospital utilization, poorly controlled chronic conditions, or some combination, who were willing to engage with the practice in focused care coordination. We measured the health confidence scores for this group even more regularly and systematically, and these patients received a range of interventions provided by a care coordinator. (See “Interventions for at-risk patients.”)

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Assess health confidence


Ask patient directly and record as structured data in electronic health record. (See visual aid and additional free health assessment resources at

Define patient as belonging to “at-risk” population


Identify patients with health confidence scores of less than 8.

Label chart of “at-risk” patients


Flag patient record to identify at-risk patients as part of a cohort requiring enhanced services.

Perform medication reconciliation


Perform medication reconciliation in person or by telephone regularly and after any hospital contacts.

Assess medication adherence


Ask questions based on Morisky Medication Adherence Scale;1 record answers in structured data fields.

Perform enhanced previsit preparation


Use a team approach involving nurses, care coordinators, medical assi

About the Authors

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Dr. Nunlist is a family physician, an electronic health records consultant, and clinical assistant professor of community and family medicine at Dartmouth College's Geisel School of Medicine in Hanover, N.H....

Dr. Blumberg is a family physician and partner at White River Family Practice and a clinical assistant professor of community and family medicine at Dartmouth.

Dr. Uiterwyk is a family physician and senior medical director for performance excellence at Atrius Health in Newton, Mass.

Toni Apgar provides care coordination and hospice care under a Center for Medicare & Medicaid Innovation project with Bayada Home Health Care in rural Vermont.

Drs. Nunlist and Uiterwyk and Toni Apgar were previously with White River Family Practice.

Author disclosures: no relevant financial affiliations disclosed.



1. Bodenheimer T, Lorig K, Holman H, Grumbach K. Patient self-management of chronic disease in primary care. JAMA. 2002;288(19):2469–2475.

2. Wasson J, Coleman EA. Health confidence: an essential measure for patient engagement and better practice. Fam Pract Manag. 2014;21(5):8–12.

3. Wasson JH. A patient-reported spectrum of adverse health care experiences: harms, unnecessary care, medication illness, and low health confidence. J Ambul Care Manage. 2013;36(3):245–250.


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