Step By Step: Creating A Pathway To Better Health

Half of the 135,000 residents in Humboldt County, CA, live outside its small towns. Like many rural areas, Humboldt has significant health challenges, including limited access to certain types of care, hundreds of miles separating some residents from their doctors, and higher rates of those with chronic health conditions or no health insurance.

Fortunately, Humboldt County also is home to one of the most promising health care initiatives helping people with chronic conditions manage their own care more effectively.

To improve overall health and reduce costs in an overextended system of care, there is an increasing focus on chronic disease self-management programs (CDSMP) like Humboldt’s “Our Pathways to Health.” The effort is supported by the Robert Wood Johnson Foundation’s Aligning Forces for Quality (AF4Q) initiative.

Through AF4Q and with the support of local patient advocates, a series of free, six-week-long Our Pathways to Health (Pathways) workshops was launched in 2008. Coordinated by Aligning Forces Humboldt, it is a locally branded version of a nationally recognized CDSMP developed by Kate Lorig, RN, DrPH, of the Stanford Patient Education Research Center. Dr. Lorig is a leader in developing patient-driven health solutions that provide skills to manage chronic conditions like diabetes, arthritis, pain, depression, obesity, and heart problems.

During each Pathways workshop session, individuals or their caregivers learn how to overcome barriers to better health. The self-management toolbox provides guidance on goal setting and step-by-step action plans. To facilitate efforts to

get well and stay well, Pathways guides them on incorporating health-related activities into their daily routine, like organizing medications, communicating with medical providers, understanding emotions, managing pain, and increasing physical activity. Other Pathways course materials include a book, Living a Healthy Life with Chronic Conditions, and A Time for Healing relaxation CD.

“Pathways participants may not have the same condition, but they face the same challenges,” said Michelle Comeau, Aligning Forces Humboldt’s operations coordinator for Our Pathways to Health. “They’re dealing with a wide range of emotions, as well as isolation. They may struggle with how to communicate what they’re going through or the symptoms they’re experiencing. They also struggle with how to manage a complex medical system and partner with their doctors more effectively.”

The workshops, which are offered in English and Spanish, became highly regarded in the community. By 2011, there were more than 30 trained Pathways leaders and more than 25 workshops a year. In July 2010 their CDSM program had the highest participation rate, per capita, in the state of California, according to the Partners in Care Foundation.

Yet, as the program grew, so did some management challenges. First, Comeau said, it became apparent Pathways needed a more efficient, sustainable management structure. Second, Pathways needed a more streamlined and broader referral network to fill a growing number of Pathways workshops.

“While Our Pathways to Health is lifted directly from the Stanford model, how we work with volunteers and recruit people is different,” Comeau said. “The biggest challenge was knowing that we needed to change to a more efficient structure, but also maintain our deep commitment protecting the consumer voice and our valuable trained leaders.”

Originally, Pathways was managed by peer-to-peer consensus. However, as the program grew, it became evident that implementing a new management strategy was necessary for keeping up with workshop demand. Comeau said that one of the most important lessons was the realization that successful restructuring of the program had to come from outside Pathway’s leadership team.

Enter the University of Maryland. Pathways worked with representatives from the university who provided outside technical assistance throughout the restructuring while maintaining Stanford’s curriculum and a core focus on consumer engagement. The assistance included a day-long workshop using the Myers-Briggs approach to recognize the skills and communications styles of volunteer leaders and staff.

“We learned about how people process new information and approach tasks,” Comeau said. “We came to better understand how people perceive the roles and responsibilities within an organization. That informed how we structured Pathways to make it more successful.”

The clarity of roles was considered a refreshing change and laid the groundwork for continued progress. Day-to-day operations became more efficient, and a clear chain of command enabled staff and volunteers to work together more effectively. A new, separate advisory group began to meet monthly to focus on the leader and consumer perspective.

The program’s expansion also necessitated the development of new recruitment strategies. Word-of-mouth recommendations, free radio and television PSAs, and newspaper articles drove initial workshop attendance but did not have a sustained impact. Additionally, while many medical offices were aware of Pathways, they were not providing patient referrals to the program.

To enhance the referral network, Pathways targeted medical offices to reach potential participants. The program launched a pilot with Eureka Internal Medicine, asking it to incorporate referral recruitment into its routine for one day. That secured 23 referrals and 11 people who signed up for the workshop—a promising result. Recognizing the time commitment required for sustaining the referrals, Pathways and Eureka Internal Medicine devised a more streamlined, targeted, and manageable approach.

Dr. Lorig from Stanford provided an additional nudge and encouraged more community participation. At a local meeting of health care providers and staff, she challenged attendees to join the program and strive for at least two patient referrals per month—a manageable goal.

Dr. Lorig emphasized the Stanford model’s success, as well as the power of the personal touch in recruiting participants. She explained that providing a more detailed explanation to patients about the program’s benefits and getting permission for a follow up was far more effective than just providing a brochure and a simple recommendation that patients register for the program.

After some initial reluctance, the program became integrated into medical practices. In December 2011 alone, Pathways logged 60 new referrals through electronic and fax referrals—a 300 percent increase. Now, approximately 30 local medical providers are referring 20 to 30 candidates each a month.

“We used to get very few referrals from medical offices—maybe one or two every few months,” said Comeau. “In 2010-2011, 28 percent of referrals we received were from medical providers. Now it’s 40 percent.

Studies show CDSMPs can reduce health care costs through fewer and shorter hospitalizations and fewer emergency room and outpatient visits. Those who participate in self-management programs also are more likely to see significant improvements in managing their health conditions.

Our Pathways to Health continues its relentless quest for the health and well- being of residents in Humboldt County. Through 94 workshops since 2008, the program recently surpassed a milestone of serving 1,000 participants. Of those participants, 720 have graduated from the program, meaning they have attended at least four workshops.  Pathways also partners with other community organizations and offers “closed” workshops to groups with specific needs. The program began tailoring its services for veterans, senior groups and homes,and the visually impaired.

Virtually all participants attribute the Pathways workshops to their increased ability to manage their own care. By enhancing its management structure and more effectively targeting its recruitment and partnership efforts, Pathways is well positioned to serve more residents in Humboldt and improve the overall health of the community.

“I came into this six-week program a death-fearing, self-pitying, chronically ill person,” says Eunice Noack of Eureka. “Now I am mainly chronically well.”