Analysis of
Current
Implementation,
Sustainability and
Potential
Expansion of
Michigan on the
PATH
Joan Ilardo, PhD, Co-Director, Geriatric
Education Center of Michigan, Michigan State
University College of Human Medicine
Linda Cronk, MA, Core Faculty, Geriatric
Education Center of Michigan and
Michigan State University Extension
Taran Silva, Research Assistant, Geriatric
I trodu tio
The Michigan Partners on the PATH (Personal Action Toward Health) help Michigan seniors
manage their existing chronic conditions. PATH partners are both public and private agencies,
organizations, and programs that offer evidence-based disease prevention and
self-management programs. These programs provide seniors with an opportunity to learn to set
goals in nutrition and fitness, help those with chronic disease learn to take control of their
condition, as well as learn how to communicate with their medical care provider more
effectively.
Fidelity assessment is an integral part of programs like PATH that depend on a cohort of
trainers who are not under the direct supervision of the sponsoring agency (Michigan Office of
Services to the Aging/Michigan Department of Community Health). The assessment of the
Michigan Partners on the PATH program conducted by Michigan State University (MSU)
researchers found that the PATH leaders in Michigan value adhering to the fidelity to the
Stanford Chronic Disease Self-Management Program. Fidelity to models of evidence-based
programs means that the programs should produce similar results as when the programs were
studied for outcomes.
A second aspect of the study involved medical students who were trained in PATH. Eight
Michigan State University College of Human Medicine students completed PATH leader training
which provided them with insights on how PATH complemented what they learn in their
medical school curriculum. Two MSU College of Human Medicine students worked with MSU
researchers to develop a PATH Leader Guide about health literacy. Health literacy is the
degree to hi h i di iduals a o tai , pro ess, u dersta d a d o u i ate a out health
-related i for atio eeded to ake i for ed health de isio s (Healthy People 2020). This
aspect of the project exposed these physicians-in-training to the concepts of health literacy and
chronic disease self-management programs, both of which should have a positive influence on
Curre t I ple e tatio of PATH i Mi higa
Data gathered by the Michigan Department of Community (MDCH) regarding PATH participants
provide insights into the implementation of PATH in Michigan over the past several years. The
following data represent participation from April 1, 2013 to March 31, 2014.
The target population of OSA is Michigan residents age 60 and over. The majority of PATH
participants (70%) are in this age cohort with only 12% age 49 and under, which indicates that
PATH programs are serving the OSA target population. Only 21% of the Michigan population is
in the 60 and over cohort with 39% of the general population in the 0-29 cohort. As the
following chart of PATH participants compared to the general Michigan population
demonstrates, the PATH workshops are reaching their target population of adults age 60 and
over.
PATH participants were asked two questions that indicate their level of disability. Half of the
PATH participants (50%) reported that they either use special equipment or have limited
activity due to a disability.
0% 5% 10% 15% 20% 25% 30% 35% 40% 45%
00-29 30-39 40-49 50-59 60-69 70-79 80-89 90+
Age Distribution
PATH ParticipantsParticipant Disabled (Yes to one or
As the previous chart illustrates, when compared to the general adult population of Michigan, a
significantly higher proportion of PATH participants report having a disability. Only 21% of the
Michigan population is disabled compared to 50% of the PATH participants that are disabled.
(Source: http://www.michigan.gov/mdch/0,1607,7-132-2940_2955_54051_54052-255399--,00.html )
PATH participants were asked about their chronic conditions. Almost two-thirds (65%) report
that they have 3 or more chronic conditions. Only 6% of PATH participants reported not having
Of the prevalent conditions cited by PATH participants, 62% reported having high blood
pressure, 51% reported having arthritis, 46% reported having high cholesterol, and 46%
reported having diabetes.. The least prevalent conditions cited by PATH participants were
The project team looked at the participant educational level in comparison to the education
level of the general Michigan population age 45 and over. As the following pie charts indicate,
PATH participants were asked about their education level. 85% of PATH participants had
completed at least high school or its equivalent whereas 79% of the general population age 45
years and over had completed at least high school or its equivalent. Ten percent of PATH
participants completed less than a high school education while 21% of the general population
had completed less than a high school education. The data indicates that PATH participants
tend to have a higher education level than the general Michigan population.
Sustai a ilit of PATH
PATH Leaders In Michigan
A PATH leader survey was conducted in 2013 with 156 responses. Almost a quarter (24%) of the
respondents completed their PATH leader training in 2011, 18% in 2012 and 15% in 2013. On
the other end of the spectrum, 16% of the respondents were trained in 2010, 12% in 2009, 4%
in 2008 and 11% in 2007 or before. Considerable expansion in the number of people trained as
PATH leaders has occurred since 2011. However with 43% of the respondents being trained
prior to 2011, there is also a significant pool of seasoned PATH leaders.
The Michigan Department of Community Health (MDCH), the Office of Services to the Aging
(OSA), and the National Kidney Foundation of Michigan (NKFM) comprised 88% of those who
provided their licensing type. The following table lists the entities that have Stanford CDSMP
licenses in Michigan.
Multi-Site
Michigan Office of Services to the Aging
Ann Arbor
National Kidney Foundation of Michigan
VISN 11 VA Healthcare System
Auburn Hills
McLaren Physician Hospital Organization
Battle Creek
Integrated Health Partners
Detroit
Adult Well-Being Services
Grand Rapids
Kent Health Plan
Metro Health PHO
Priority Health
United Methodist Community House
Hancock
Jackson
Michigan Department of Community Health, Diabetes & Other Chronic Diseases Section
Michigan Office of Services to the Aging
Muskegon
based curriculum based on the Stanford Chronic Disease Self-Management Program and were
aware of the past research that showed positive results for participants who apply what they
learn. All reported that the master trainers did well emphasizing the i porta e of sti ki g to
the ook a d ot addi g, lea i g out, paraphrasi g, or other ise i terpreti g aterial fro
the curriculum, but instead staying true to the script. This adherence to the PATH model
program should result in similar overall outcomes being achieved in Michigan as were reported
in the evidence base derived from Stanford CDSMP published studies.
PATH Marketing and Participant Recruitment
Marketing and recruitment of participants is done on a local basis. There has been no statewide
public awareness campaign. To date, the preponderance of recruitment is done through the
regional coordinators and PATH leaders. According to the survey responses, most PATH leaders
(69%) were personally involved in the recruitment of workshop participants. For those not
involved in their own recruiting, clinic staff and senior center staff assisted with this effort.
Overwhelmingly, the top way to recruit participants was word of mouth (92%). Second best was
with flyers (83%). Referrals from community agencies (65%) and program brochures (66%) were
health fairs, and general announcements at community centers. A few additional recruitment
techniques explained by PATH leaders included sharing the DVD/program with service clubs,
sending personal letters of invitation to potential participants, and making personal contacts
with physicians and medical clinics to keep referrals flowing.
PATH leaders licensed under MDCH, OSA, or NKFM were more involved with their own
recruiting when compared to leaders licensed under a different organization. The survey
respondents licensed under the Office of Services to the Aging had the highest percentage of
(76%) doing their own recruiting with NKFM at 65% and MDCH at 60%. The leaders who did not
do their own recruiting reported that they most often relied on their Community Service
Organization leader to do PATH participant recruiting.
The survey data demonstrated a positive correlation between the number of workshops led
and personal involvement in recruiting workshop participants. The ratio of leaders who
reported being personally involved in recruiting participants compared to those who are not
increased as the level of expertise became more advanced. It was also noted that as the
number of workshops that a respondent co-led increased, there was an increase in the number
of recruitment resources that were utilized. As a PATH Leader becomes more seasoned, he/she
tends to utilize referrals from medical clinics, direct physician referrals, flyers, and
sessions/announcements at community centers more commonly as forms of recruitment.
According to the survey respondents, healthcare professionals are more than twice as likely to
conduct their own recruitment as non-healthcare professionals. Healthcare professionals are
also twice as likely to use patients from their practices as a method of recruiting, but are half as
likely to use newsletters in comparison to non-healthcare professionals.
Sometimes workshops were cancelled due to low enrollment; 56% (n=59) of survey
respondents had cancelled or postponed a workshop. Only 20% (n=21) of leaders had to
schedule additional workshops because there was a waiting list of potential participants.
Almost half of PATH leaders (48%) have not noticed a difference in seasons that work best for
recruiting. Of those who cited a popular recruiting time, spring and fall were identified as the
There were differences by license type of the reasons that make it difficult for the survey
respondents to lead PATH workshops. A greater proportion of NKFM respondents (60%) than
OSA (30%) or MDCH (27%) respondents stated they need help marketing the workshops. In
addition, a greater proportion of NKFM respondents (33%) than MDCH (10%) or OSA (4%)
respondents stated that it is difficult to find suitable locations for workshops.
How PATH Workshop Experiences Are Influenced by Participant Type
More than half (55%) of PATH leader survey respondents agreed that the type of participants in
a workshop series change the way the material is covered during the 6-week sessions. Nearly all
(92%) respondents had observed the amount of discussion influenced by participant type (i.e.,
caregivers, patients, type of chronic disease, literacy level). Other ways the workshop changed
was the attention span (58%) of participants, the number of difficult participants (46%), and
that caregiver/patient mixes (33%) influenced the way PATH materials were covered in
sessions.
About 60% of the survey respondents shared a situation when the PATH workshop experience
was influenced by participant type. Comments related to this were categorized into seven
themes: literacy issues, elderly groups, quiet groups, chatty groups, diverse groups, dominating
individuals and self-interested individuals.
Literacy issues were an overarching challenge for the PATH workshops, influencing the pace
and structure of the 6-week series. Problematic individuals were also an influence on PATH
workshop fidelity, which was expected given this is also part of the PATH leader training
development. Examples of how the PATH workshop experience is influenced by participant type
are described in the following PATH leader comments.
Literacy issues as well as income and socio-economic status differences (including
edu atio al le el a d o upatio al diffe e es). Whe pa ti ipa ts ha e a lo e
educational level more explanation overall is needed. They also tend to either discuss far
Frail, elderly groups take more class time (i.e., could not see charts, needed more coaching in setting weekly goals).
Quiet groups ithout a dis ussio s e t ui kl . The e ha e ee lasses, he e
pa ti ipa ts a e o e i t o e ted a d diffi ult to d a out.
Chatty groups that already knew each other (e.g. church setting) had longer discussions,
but were highly compliant on homework like action plans.
Diverse groups can affect the types of workshop discussion (mostly caregivers, patients or
i flue e of p ofessio al a d/o pe so al e pe ie es). The pe son who is a caregiver
does not seem to have as much in common with someone who is dealing with chronic
ill ess. Medi all edu ated a egi e s te d to u ith dis ussio s.
Dominating individuals steer discussion off track (i.e., interruptive, aggressive, too
talkati e). Whe so eo e has a aha o e t a d ealizes the CAN take o t ol of thei o ditio a d the e o e e pe ts o hat othe people should do.
Self-interested individualsstee o e satio s to topi s of thei i te est. Pa ti ipa t had
a ph si al issues a d p ofessio al pa ti ipa t as a ki g the eeds fo he . All
were living with diabetes. Some were looking for diabetes-spe ifi i fo atio .
E pa sio of Mi higa Part ers o the PATH
Economic Impact of EBP Self-management Programs for Michigan
With the advent of the Affordable Care Act and initiatives for medical practices to become
Patient-Centered Medical Homes, the role of evidence-based self-management programs
moves from being an ancillary community resource to one of vital importance as patients are
encouraged to become partners in their own health. When people with chronic conditions
become more knowledgeable about how to live a healthy life, it creates a win-win situation.
The individuals win because they have better health, which improves their quality of life, and
the public and private funders of health care win because the cost of care decreases as
individuals become better managers of their chronic conditions and decrease the incidence of
According to research conducted by Stanford University on the CDSMP, program participants
show improvements in exercise, cognitive symptom management, communication with
physicians, self-reported general health, and disability. They spend fewer days in the hospital
and fewer outpatient visits, thus providing a cost to saving ratio of approximately 1:4. By
ensuring that PATH sessions are true to the CDSMP model, Michigan on the PATH workshops
should produce similar overall results. Infusing the concepts of patient self-management, health
literacy, and effective use of community resources in medical student training should improve
their patient outcomes and cost-effectiveness of care plans. (See the Stanford website at
http://patienteducation.stanford.edu/programs/cdsmp.html for additional information regarding the Stanford cost studies).
The National Council on Quality Assurance (NCQA) 2014 Patient-Centered Medical Home Standards
The National Council on Quality Assurance (NCQA) has a set of standards for Patient-Centered
Medical Home recognition. Several of the standards relate directly to evidence-based practice,
patient self-management, and community resources. The standards were updated in July 2014.
The new standards that pertain to CDSME are:
PCHM 4, Element B, Factors 3-5: Care Management and Support: Factor 3: The practice works
with patient/families/caregivers, other providers and community resources to assess and
address potential barriers to achieving treatment and functional/lifestyle goals. Factor 4: The
practice works with patients/families/caregivers to develop a self- a age e t pla … a age
complex conditions or may have other significant potential barriers are given instructions and
resources. Factor 5: The written care plan is given to the patient/family/caregiver. When
possible, the plan is tailored to account for health literacy and language considerations.
PCMH 4, Element E, Factors 2-7: Support Self-Care and Shared Decision Making: Factor 2:
Educational programs and resources may include information about a medical condition or
a out the patie t’s role i a agi g the o ditio . Resour es i lude… o u it resour es
(e.g. programs, support groups). Factor 3: Self-management tools enable patients to collect
decision involves multiple options with features that people may value differently, a shared
decision-making aid provides detailed information without advising the audience to choose one
decision over another. Factor 5: The practice provides (or makes available) health education
classes which may include alternative approaches such as peer-led discussion groups or shared
edi al appoi t e ts. Fa tor 6: The resour e list…i ludes progra s a d ser i es to help
patients in self-care or to give the patient population access to care related to at least 5 topics
or key community services areas. Factor 7: The practice reviews and requests feedback from
patients/families/caregivers about community referrals.
PCMH 6, Element B, Factor 1: Measure Resource Use and Care Coordination: Factor
1…Orga izi g are i ol es the arshali g of perso el a d other resour es eeded to arr
out all required patient care activities.
The NCOA PCMH standards are designed to encourage health providers to engage their
patients to become partners in their health by learning more about their chronic conditions.
Patients learn how to set achievable goals that improve their quality of life by successfully
managing their conditions. The PCMH standards related to patient self-management and
referrals to community resources can be compelling reasons for establishing healthcare
systems and provider referral strategies to PATH programs for patients with chronic conditions.
National Initiatives that Address Multiple Chronic Conditions
In a 2013 CMS report on the prevalence of multiple chronic conditions among Medicare
recipients, it stated that over two-thirds of Medicare beneficiaries in traditional Medicare
have two or more chronic conditions and about 1 in 7 (14%) have 6 or more. In 2010 Health
a d Hu a “er i es lau hed the “trategi Fra e ork o Multiple Chro i Co ditio s . Within the goals of the framework, support for sustaining and expanding the role of CDSME is
evident. The PATH program in Michigan directly addresses one of the goals of the strategic
framework to maximize the use of proven self-care management and other services by
of facilitating self-care management and facilitating the capacity of community-based services
to offer self-management support.
The core strategy of the CDSME is to improve the self-efficacy of individuals with chronic
conditions in order to improve their ability to self-manage their condition(s). The
development and maintenance of the Michigan Partners on the PATH network of PATH
workshops has increased the capacity of community-based services throughout Michigan to
support the Michigan Partners on the PATH network.
In addition, another goal of the fra e ork e ourages o u ities to pro ide etter tools
and information to health care, public health, and social services workers who deliver care to
individuals with multiple chronic conditions. The Michigan Partners on the PATH project both
identified best practices through the implementation of the CDSME programs and enhanced
health professio als’ trai i g through aster a d leader trai i gs i PATH for hro i
conditions, PATH for Diabetes and PATH for Chronic Pain. While the CDSME is designed for
peer-led leaders, the majority of PATH leaders and master trainers in Michigan are health and
education professionals.
National Council on Aging: Communities Putting Prevention to Work
As part of the American Recovery and Reinvestment Act, additional federal funds were
designated for expansion of evidence-based chronic disease self-management education for
adults age 60 and over. The National Council on Aging (NCOA) was designated to conduct an
evaluation of the program to do u e t su esses, halle ges, a o plish e ts, lesso s
lear ed, a d produ ts produ ed .
The evaluation yielded a set of best practices that can be used by decision makers in Michigan
regarding expansion and sustainability of PATH. The following table lists the best practices and
Best Practice Current Implementation Status in Michigan
A. Creation of a state-level advisory council or collaborative
Michigan Partners on the PATH. More than 50 agencies currently participate with MI PATH, among them: Health Alliance Plan, Arthritis Foundation Michigan Chapter, the National Kidney Foundation of MI, UPDON, and regional Area Agencies on Aging.
B. Establishment of a free-standing not-for-profit entity
Currently the coordination is shared by OSA and MDCH with federal and state funding. Each agency serves specific target populations.
Having a free-standing entity entails establishing a steady funding stream. Potential sources to be considered could include ACL/AoA, Medicaid, Medicare, health plan per member/per month fees, provider practice annual enrollment fees.
Colorado (Consortium for Older Adult Wellness) at
http://coaw.org/home.aspx and Arizona (Arizona Living Well Institute)
at http://azlwi.org/ have established free-standing entities.
Michigan Public Health Institute and the Michigan State University Extension are examples of potential not-for-profit entities that could serve this role.
OSA has made a concerted effort to expand the number of trainers as noted in the first section of this report. The NCOA report uses Michigan as an exemplar of capacity building in the aging network.
Current capacity issues include:
1. Workshop schedules are not consistent. This can make finding a workshop difficult and referring patients to workshops
problematic. Example of a consistent schedule is workshops start on the first Wednesday of every month at 1PM and the third Tuesday of every month at 6PM.
D. Partnering with
Potential healthcare entities with which PATH could partner include:
1. Area Agencies on Aging
2. Local public health departments 3. Community Mental Health Agencies
4. Health systems – outpatient for PCMH, inpatient for care transitions
5. Federally qualified health plans 6. Veterans Affairs
7. Health plans (BCBSM, HMOs, PPOs)
Section 2.5.4 of the report describes Centralized and Coordinated Processes for Marketing,
Referral and Registration. The first issue to be addressed to determine the feasibility of a
centralized system is hether if ou uild it, the ill o e here they are the potential
partners identified in the previous table. To ascertain the willingness of the potential partners
and the ways they envision such a system functioning, they should be queried through a
combination of surveys, stakeholder interviews and/or focus groups.
Centralization brings benefits related to economies of scale, access to registration in all venues
in a geographic catchment area, quality monitoring and improvement, leader training, technical
assistance, and tracking participant outcomes (depending on the availability of electronic health
records). A statewide centralized system would create a database that can be used to discern
health trends that could be addressed through public awareness campaigns in collaboration
with the PATH partners. A centralized system would also lend itself to becoming part of the
Michigan Health and Wellness Dashboard.
The full NCOA evaluation report is located at http://www.ncoa.org/improve-health/center-for-healthy-aging/content-library/ARRA-GRANTEE-Capping-Report-Final-6-25-1.pdf
Inclusion of EBP Self-Management Principles into Medical School Education
A focus group consisting of seven Michigan State University College of Human Medicine
students who completed PATH leader training provided some useful insights regarding PATH as
a component of care plans. Through working with the medical students, the project team
learned that these physicians-in-training found PATH to be consistent with their curriculum.
From the stude ts’ comments, the project team observed that PATH is consistent with what
the medical students are learning about patient-centered practice, effective use of community
resources, and cost-effective care. The following themes emerged from a focus group
conducted with the medical students who had completed PATH leader training.
Regarding the PATH leader training and their medical school curriculum:
• Fits nicely as supplement to med curriculum – no contradictions
• Expands on patient-centered learning
• Motivational interviewing similarities
• Non-judgmental tone
• More realisti e pe tatio s of patie ts regardi g o plia e ith treat e t
• Learning about healthcare costs and quality measures in health policy class
Regarding their understanding of community resources:
• Broader u dersta di g of o u it ’s role i supporti g patie t’s health
• Using community resources is good way to reduce costs
• Knowing about all community resources is huge challenge for primary care doctors
• Community resources help physicians in their efforts with patients
• Nice to have collaborations
Regarding the influence PATH has on their approach to patient care:
• Participants gain more understanding of self, goals, motivation
• Helps us u dersta d patie t’s e perie e
• Increases understanding a out ph si ia ’s role i o erall patie t’s health
• Action plans are applicable to anyone
Regarding health literacy:
• Better understanding of the balance between being understandable without seeming condescending
• Isolated i a ed s hool u le – hard to speak like a normal person
• Raises concerns about how to fit all this into a short office visit
• Requires PRACTICE
Whe the stude ts’ per eptions of what they learned through PATH leader training are
compared with the NCQA Patient-Centered Medical Home standards, it is noted that what the
students take away from their PATH training is consistent with the concepts of the PCMH.
Ne t Steps for Mi higa Part ers o the PATH
During the final year of the PATH project, the project team proposes the following activities be
conducted:
1. Gather information through surveys, focus groups and/or interviews from health plans,
health systems and large healthcare practices on their plans for using EBP
Self-management with their patients.
2. Develop a statewide marketing strategy that targets health systems based on
information gathered through surveys, interviews, and/or focus groups.
3. Investigate the potential benefits to systematic PATH recruitment through specialty
providers such as rehabilitation, physical and occupational therapy, and chronic pain
providers.
5. Determine the feasibility of introducing other medical schools in Michigan to concepts
of EBP Self-management.
6. Explore how PATH could be incorporated into the Michigan Prevention and Wellness
Dashboard.
Co lusio s
A structure that includes OSA, MDCH, health systems, and community-based organizations can
support sustainability and expansion of evidence-based self-management programs in
Michigan. The current PATH model receives substantial funding from federal and other public
sources. To sustain and expand the EBP Self-management footprint in Michigan, the PATH
program must be viewed as an ongoing, predictable, and self-sustaining patient education
partner. This will enable health providers to view PATH as an integral part of the health services
