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Capping Report
2012 Prevention and Public Health Fund: “Empowering Older Adults and Adults with Disabilities through
Chronic Disease Self-Management Education Programs”
February 23, 2016
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Acknowledgments The National Resource Center for Chronic Disease Self-Management Education (CDSME) Programs would like to acknowledge all those who provided information for and worked on the completion of this Capping Report. In particular, we would like to acknowledge the Administration for Community Living, Administration on Aging (ACL/AoA) for their funding and support of this project and recognize the crucial role of ACL/AoA grantees in sharing their progress, challenges and learnings from their grant activities. A special thanks for the expert work provided by three consultants: Janet C. Frank, DrPH, Applied Aging Resources; Katherine H. Leith, PhD, LMSW, Research Assistant Professor and Director of the Certificate of Graduate Study in Gerontology, College of Social Work, University of South Carolina; and Mary Walsh, M.Ed., Independent Consultant. Finally, we would like to acknowledge the many older adults and adults with disabilities from across the country who attended a CDSME workshop, as this project and report would not be possible without them. This project was supported, in part by grant number 90CR2001-01-00, from the U.S. Administration for Community Living, Department of Health and Human Services, Washington, D.C. 20201. Grantees undertaking projects under government sponsorship are encouraged to express freely their findings and conclusions. Points of view or opinions do not, therefore, necessarily represent official Administration for Community Living policy.
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Table of Contents Acknowledgments .......................................................................................................................................... i
List of Tables ................................................................................................................................................ iv
List of Figures ............................................................................................................................................... iv
I. Executive Summary ................................................................................................................................ 1
II. Introduction ............................................................................................................................................ 2
A. Program Purpose and Scope ............................................................................................................ 2
B. Capping Report Organization and Methods .................................................................................... 2
C. Study Limitations ............................................................................................................................. 3
III. Performance Summary ........................................................................................................................... 5
IV. State Successes and Innovations ............................................................................................................ 7
A. Leadership ........................................................................................................................................ 7
1. Centralized Functions ................................................................................................................ 7
2. Coordinated Functions .............................................................................................................. 8
B. Partnerships ..................................................................................................................................... 8
C. Infrastructure Development .......................................................................................................... 12
1. Building Workforce Capacity ................................................................................................... 12
2. Referral Systems and Processes .............................................................................................. 13
3. Fidelity/Quality Assurance ...................................................................................................... 13
V. Program Outcomes and Participant Demographics ............................................................................. 15
A. Program Outcomes ........................................................................................................................ 18
1. Participant Reach and Completers .......................................................................................... 19
2. Program Type and Frequency; Enrollment/Completion Rates ............................................... 20
3. Prevalence of Chronic Conditions ........................................................................................... 26
B. Participant Demographics .............................................................................................................. 26
1. Age and Sex ............................................................................................................................. 26
2. Race/Ethnicity ......................................................................................................................... 27
3. Educational Level ..................................................................................................................... 27
4. Living Arrangement and Caregiver Status ............................................................................... 27
5. Disability Status ....................................................................................................................... 27
C. Host Organization/Implementation Site Characteristics ............................................................... 28
VI. Sustainability Strategies ....................................................................................................................... 31
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A. Business and Sustainability Planning ............................................................................................. 31
B. Sustainability Successes and Innovations ...................................................................................... 32
1. Sustainability Planning Tools and Training .............................................................................. 32
2. OAA Title III Funds ................................................................................................................... 32
3. Embedding Programs .............................................................................................................. 33
4. External Support ...................................................................................................................... 33
5. Reimbursement Contracts ...................................................................................................... 34
VII. Challenges ............................................................................................................................................ 35
A. Reach .............................................................................................................................................. 35
B. Adoption ........................................................................................................................................ 35
C. Implementation ............................................................................................................................. 35
D. Maintenance .................................................................................................................................. 36
VIII. Lessons Learned ................................................................................................................................... 37
A. Reach .............................................................................................................................................. 37
B. Effectiveness .................................................................................................................................. 38
C. Adoption ........................................................................................................................................ 38
D. Implementation ............................................................................................................................. 39
E. Maintenance .................................................................................................................................. 39
IX. Recommendations for Future Effort .................................................................................................... 41
X. Conclusions ........................................................................................................................................... 42
XI. References ............................................................................................................................................ 43
XII. Appendix - State Data Extraction Template ......................................................................................... 44
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List of Tables Table 1.
Table 2.
Table 3.
Table 4.
Table 5.
Table 6.
Table 7.
Table 8.
Table 9.
Table 10.
Table 11.
Table 12.
Table 13.
Table 14.
Type of CDSME Programs Offered………………………………………………………………………..……………
Key Bodies Involved in Managing or Directing CDSME Activities…..……………………………………
Number of States Partnering to Reach Diverse, High Risk, and Underserved Populations….
Number and Type of State-Level and Local Partners………………………………………………………….
Number of States Partnering with Health Care………..………………………………………………………..
Number of Master Trainers and Leaders, by State…..…………….………………………………………….
State Participant Outcome Evaluation Summaries………………………………………………………….....
Program Type, By State……………………………………………………………………………………………………..
Total Number of CDSME Community-Based Workshops, by Program Type……………………….
Total Number of Workshop Participants and Completers, by State……………………………………
Reach, Proposed Completion Targets, Actual Completers, by State and Reporting Period End Date……………………………………………………………………………………………………………………………
List of Chronic Condition and Percentage of Participants Reporting………………………………….
Number of Host Organizations, by State……………………………………………………………………………
States with Sustainability and/or Business Plans………………………………………….……………………
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List of Figures Figure 1.
Figure 2.
Figure 3.
Actual and Proposed Completion Targets, by State, by 8/31/2015….………...........................
Host Organizations, by Type………………………………………………………………………………………………
Implementation Sites, by Type…………………………………………………………………………………………..
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I. Executive Summary The purpose of this Capping Report is to identify the successes, innovations, outcomes, challenges, and
lessons learned from the 22 states that were funded via the 2012 Prevention and Public Health Fund
grant initiative “Empowering Older Adults and Adults with Disabilities through Chronic Disease Self-
Management Education Programs”. The states, as a whole, met the goals of the initiative, which were
to 1) Significantly increase the number of older adults and/or adults with disabilities who complete
evidence-based CDSME programs to maintain or improve their health status; and 2) Strengthen and
expand integrated, sustainable service systems within states to provide evidence-based CDSME
programs. The processes and highlights of how the states met and exceeded the goals of the initiative,
and their own objectives, are detailed throughout this report.
The data for the Capping Report were drawn from state reports and materials collected through the
NCOA National CDSME Resource Center, the 2015 CDSME Integrated Services Delivery System
Assessment Tool Results, the National CDSME Database, and the Better Choices, Better Health®
Database. The information in the Capping Report relies on the completeness and accuracy of state
provided information.
The story that unfolds through the Capping Report is that of dedicated state aging and public health
leaders and a diverse network of partners working collaboratively to expand program reach and
coverage into new geographical regions and to identify and implement strategies to sustain the
programs beyond the grant period. Through strategic approaches, grantees expanded the number and
type of programs offered and substantially increased program reach to older adults and adults with
disabilities. They were successful in targeting disparately affected populations, including rural, minority,
non-English speaking, and other underserved older adult and adults with disabilities. They developed
effective partnerships to embed programs in many different community, faith-based, and health care
organizations and integrated CDSME programs with Older Americans Act programs, including Title IIID,
and with state public health programs funded by the Centers for Disease Prevention and Control, such
as the Arthritis, Diabetes, Obesity Prevention, Heart Disease, and Cancer initiatives. Most significant,
over the three-year period, states leveraged opportunities through the Affordable Care Act to develop
partnerships with and embed programs in a variety of health care organizations to achieve integrated,
sustainable service systems. Throughout the grant period, partner networks expanded to include more
and larger referral and delivery systems. Simultaneously, centralized and coordinated processes for
marketing, referral, enrollment, quality assurance, and data management became more sophisticated;
and delivery infrastructure capacity expanded to include a greater proportion of counties within the
states that offered CDSME programs regularly. Furthermore, states learned about and implemented
sustainability and business planning strategies and developed written plans to support program
expansion and retention beyond the grant period. This Capping Report catalogues the leadership
structure, partnerships, infrastructure development, fidelity/quality assurance processes, program
outcomes, challenges, lessons learned, and recommendations for future efforts. As a whole, the states
far exceeded their project goals and created lasting systems to support the continued growth of CDSME
programs.
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II. Introduction
A. Program Purpose and Scope Twenty-two states received grants that were financed by the 2012 Prevention and Public Health Fund
opportunity “Empowering Older Adults and Adults with Disabilities through Chronic Disease Self-
Management Education Programs.”1 The overall purpose of this funding opportunity was to help ensure
that evidence-based self-management education programs are embedded into the nation’s health and
long-term services and supports systems. This effort was intended to help preserve and expand the
prevention program distribution and delivery systems that were developed through previous ACL/AoA
Evidence-Based Disease and Disability Prevention Program and American Recovery and Reinvestment
Act Chronic Disease Self-Management Program grants.
Because the growing prevalence of chronic conditions impacts the health and quality of life of older
adults, ACL/AoA has a long history of supporting Chronic Disease Self-Management Education (CDSME)
and other evidence-based programs. According to AoA’s Title IIID criteria, evidence-based programs are
those that “have been tested through randomized controlled trials and are: 1) effective at maintaining
or improving the health or functional status of older people; 2) suitable for deployment through
community-based human services organizations and involve non-clinical workers and/or volunteers in
the delivery of the intervention; 3) the research results have been published in a peer-reviewed
scientific journal; and 4) the intervention has been translated into practice and is ready for distribution
through community-based human services organizations.”1.
This funding opportunity was supportive of the Department of Health and Human Services’ Strategic
Framework on Multiple Chronic Conditions in bringing to scale and enhancing sustainability of evidence-
based self-management programs. It also helped to address the Healthy People 2020 objectives to
increase the proportion of older adults2 with one or more chronic health conditions who report
confidence in managing their conditions and to increase the proportion of older adults who access
Medicare’s Diabetes Self-Management Training benefit3.
There were two major grant goals:
1) Significantly increase the number of older adults and/or adults with disabilities who complete
evidence-based CDSME programs to maintain or improve their health status.
2) Strengthen and expand integrated, sustainable service systems within states to provide evidence-
based CDSME programs.
B. Capping Report Organization and Methods This Capping Report was developed as a collaborative process between the director and staff of NCOA’s
National Resource Center on CDSME Programs (Center) and consultants, Dr. Janet Frank, Dr. Katherine
Leith, and Mary Walsh. It provides an overview of the major accomplishments of the grantees, their
successes and innovations, and performance outcomes. It also describes challenges they faced and
lessons learned during grant implementation. Since a grant requirement was to develop a sustainability
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or business plan, a major section of the report focuses on systems enhancements and activities put in
place to increase access to CDSME programs and support sustainable infrastructures within states.
This Capping Report incorporates data from multiple sources that together provide an overall picture of
the work and accomplishments of the states during the grant cycle. The following data sources were
used to develop the report: 1) information from grantee’s original grant applications; 2) semi-annual
performance reports; 3) final reports; 4) NCOA administrative and summary reports; 5) the Funding
Opportunity Announcement that defined the goals, objectives, and expectations for this initiative; 6) the
NCOA 2015 CDSME Integrated Services Delivery System Assessment Tool Results; 7) the National CDSME
Database; and 8) the Better Choices, Better Health® Database.
The 2015 CDSME Integrated Services Delivery System Assessment Tool Results are based on data
gathered from an online sustainability assessment survey that had a 100% response rate and was also
administered in 2013 and 2014. The Assessment provides an overview of the states’ progress toward
sustainable and integrated service systems over the three-year grant period (September 1, 2012-August
31, 2015). It covers six key elements of an integrated services delivery system: 1) leadership, 2) delivery
infrastructure, 3) partnerships, 4) centralized and coordinated logistical processes, 5) business planning
and financial sustainability and 6) quality assurance and fidelity. As appropriate, information from the
Assessment was integrated into the Capping Report to augment data drawn from the other sources.
To summarize information from the grantee reports (and other sources) into a standardized format, a
State Data Extraction Template was created (see Appendix). The template allowed cataloguing of
information from the grantee reports and other data sources into the broad categories of performance,
partnerships, leadership structure and processes, successes and innovations, challenges, lessons
learned, recommendations, and sustainability strategies. Each of these broad categories contained sub-
categories. For example, the infrastructure development category included subcategories to capture
more detailed information for workforce capacity, marketing, referral processes, and fidelity and quality
assurance.
Data were extracted from the grant reports and other data sources and put into the related category on
the template. Analyses included descriptive statistics (sums and frequencies) and qualitative content
analyses to develop content groupings that identify common themes and practices, exemplary
processes and outcomes, and the creation of inventory lists. The RE-AIM (Reach, Effectiveness,
Adoption, Implementation, and Maintenance) framework was utilized to capture challenges, solutions,
and grantee key learnings. The National CDSME Database was used to report program outcomes.
C. Study Limitations The data presented in this report are derived from the self-reported materials provided by the grantees
to NCOA and ACL/AoA (e.g., semi-annual and final reports), as well as other NCOA administrative
materials (e.g. summary reports) and NCOA survey data results. There is the potential that grantee
reports may not have included all relevant information sought during the data extraction. If so, this
missing information would result in an incomplete accounting of a grantee’s accomplishments.
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Although the report covers the 22 states funded under ACL/AoA’s Empowering Older Adults and Adults
with Disabilities through Chronic Disease Self-Management Education Programs initiative, 13 states (CA,
CO, GA, KY, MI, NJ, NY, OK, OR, SC, UT, VA, and WA) received no-cost extensions (NCE) beyond the
project period end date of August 31, 2015. Additional information is still forthcoming from these
states. Twelve of these NCE states have not produced their final report, so this additional conclusive
source of information was not available as a data source for this report. The lack of this source of
information may primarily affect the “Sustainability and Lessons Learned” section of the report, since it
is feasible that the knowledge sought for these sections may not have been included in other sources
(e.g., semi-annual reports). However, the “2015 CDSME Integrated Services Delivery System Assessment
Tool Results” captures sustainability planning and metrics for all grantees as of August 2015. As
appropriate, data from state reports will be augmented by information from this report.
Sections of this report present data from the National CDSME Database (see Program Outcomes). It is
important to note that the data from the national database may be incomplete, for two reasons. First,
the data used for calculations reflect only information entered for program workshops that were
completed on or before the reporting period end date of August 31, 2015 for grantees who completed
the grant cycle on time. Because CDSME programs consist of a series of weekly workshop sessions,
some workshops may have begun but not concluded before the reporting period end date. For NCE
grantees, the end date of December 31, 2015 was used. While these grantees are continuing to offer
workshops for various programs, data collected past the end date are not included in this report.
Second, across virtually all program measures for which data are being entered into the national
database, some information is not available (data not reported, not useable, etc.) for some participants.
Finally, some missing data are due to specific program measures being added to the data collection
survey after the start of the grant period, which also accounts for some of the missing data. For
example, workshop participants may choose not to divulge what they perceive to be sensitive personal
information. They may also have difficulty reading the information and then filling out items on various
forms. The percentage of missing data varied by question and is detailed more specifically in the
“Programs Outcomes and Participant Demographics” section.
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III. Performance Summary The states’ accomplishments supported the achievement of ACL/AoA’s goals for this funding initiative.
The first goal, to “Significantly increase the number of older adults and/or adults with disabilities who
complete evidence-based CDSME programs to maintain or improve their health status,” was met.
States identified aggressive “completer” goals (i.e., the number of participants who attended at least
four of the six workshop sessions), building on the infrastructure and capacities gained through previous
efforts. Twenty of the 22 funded states (91%) met their completer goals for CDSME programs. Most
states greatly exceeded their completer goals, even those continuing with a NCE. For all 22 states
combined, the total number of projected completers during this grant cycle was 67,809. The actual
number of completers for all community-based CDSME programs offered by the 22 states was 86,080.*
Additionally, some states offered online CDSME programs, with 826 completers, bringing the total
number of completers in the 22 states to 86,906 and exceeding the goal by 28%. As shown in Table 1,
states offered a variety of CDSME programs from the Stanford suite of community-based and online
programs during the funding cycle. The Chronic Disease Self-Management Program (CDSMP) and the
Diabetes Self-Management Program (DSMP) were the most widely offered program types.
Table 1. Type of CDSME Programs Offered
Programs Offered Number of States
Chronic-Disease Self-Management Program (CDSMP) 22
Diabetes Self-Management Program (DSMP) 21
Tomando Control de su Salud (Spanish CDSMP) 19
Programa de Manejo Personal de la Diabetes (Spanish DSMP) 14
Chronic Pain Self-Management Program (CPSMP) 17
Better Choices, Better Health® (Online CDSMP) 12
Better Choices, Better Health® - Diabetes (Online DSMP) 12
Arthritis Self-Management Program (ASMP) 7
Positive Self-Management program (PSMP) 2
Cancer: Thriving and Surviving (CTS) 6
The states also made significant progress in meeting ACL/AoA’s second goal, to “Strengthen and expand
integrated, sustainable service systems within states to provide evidence-based CDSME programs.”
Business planning and sustainability concepts and technical assistance were introduced during the prior
grant cycle from 2010-2012. Subsequently, during this grant period (2012-2015), states were required
to develop a sustainability or business plan as a grant deliverable. States made meaningful progress
*For states that completed on time, these statistics are calculated through the end date 08/31/2015; for NCE grantees, they are calculated through 12/31/2015.
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toward sustainable systems development and sharpened their approaches to diversifying funding
streams by establishing and/or strengthening partnerships with the health care sector to create
opportunities for reimbursement. Further, they integrated CDSME programs into the fabric of
government and community program funding and aggressively partnered with other entities for
external funding.
By linking CDSME program expansion to national quality standards and national goals for addressing
health disparity and health policy, such as Healthy People 2020, the programs are now seen as part of
the solution to address the growing epidemic of chronic diseases. One state sums this up in their final
report, “… the CDSME grant was a turning point in the awareness of CDSME programs across public and
private entities, as well as within the state agency system. Now there is not only an awareness of
CDSME programs, but a sense that these programs are a legitimate means to helping older adults
manage their chronic disease and reduce utilization costs.”
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IV. State Successes and Innovations
A. Leadership Effective leadership and project management include a strong state unit on aging and state health
department partnership, an integrated state vision, a documented plan, and mutually agreed upon
goals. All state projects were led by a partnership at the state level of public health and aging services
and most involved a combination of a centralized hub of infrastructure support, coordinated regional
networks, and purposeful coalitions. The leadership teams had often worked together on previous
ACL/AoA-supported grant initiatives. Table 2 shows the key bodies within the states that were involved
in managing or directing CDSME activities over the course of the grant cycle.
Table 2: Key Bodies Involved in Managing or Directing CDSME Activities
Key Bodies Number of States
State unit on aging 22
State health department 22
State advisory council or other management team 8
State coalition 5
Foundation/other oversight agency 2
Other management body* 8
Source: 2015 Sustainability Report
1. Centralized Functions
Centralized and coordinated logistical processes need to be in place to optimize efficiency, decrease
costs, assure quality, and make certain that consistent messages are applied and approaches are
taken to reach the targeted populations and enroll them in workshops. Almost all states identified a
set of centralized activities for project leadership. This centralized functional unit was often within
one of the aging or public health partner leadership organizations. In some states, the centralized
unit was a separate non-governmental entity or coalition of organizations with its own
administrative hub, such as the Arizona Living Well Institute, the Healthy Living Center of Excellence
in Massachusetts, the Living Well Center of Excellence in Maryland, the Wisconsin Institute for
Healthy Aging (WIHA), and the New York State Quality and Technical Assistance Center (QTAC).
Common features of these centralized functions are exemplified by Wisconsin and New York. The
Wisconsin Institute for Healthy Aging (WIHA) maintains a multi-site, multi-program license from
Stanford, and all organizations operate under that license. In this way, the state was able to develop
the policies, procedures, and data collection and reporting protocols needed to have a
comprehensive, quality system, including the creation of a website to locate workshops and
marketing and leader toolkits for CDSME programming. All program materials are maintained on
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the website, and the statewide workshop list is updated every two weeks. In New York, the network
hub was used to create a bi-directional centralized referral system to work efficiently with their
health care partners.
2. Coordinated Functions
Often in conjunction with the centralized hub support, states utilized regional collaboratives and
local coordination activities in support of program delivery. In the aforementioned Integrated
Services Delivery System Assessment, 71% of states reported that they had coordinated, statewide
processes for program marketing, referral, and recruitment to a large or moderate extent. In Rhode
Island, for example, the Living Well Rhode Island (LWRI) Coalition, includes over 100 members
representing delivery system partners, health plans, Title IIIB and IIID grantees, senior centers,
housing facilities, community-based organizations, churches, Lay Leaders, and Master Trainers in
support of their multi-site delivery system. Wisconsin set up a network of Health Promotion
Coordinators within Aging and Disability Resource Centers (ADRCs) and other organizations that
proved to be highly functional. Massachusetts developed seven regional collaboratives to
coordinate statewide CDSME activity, and Maryland’s Department of Health and Mental Hygiene
(DHMH) Statewide Health Improvement Programs (SHIP) supported the development of 17 local
and regional health improvement coalitions with over 1,000 members representing every county in
the state. All of the coalitions have set priorities and developed action plans to be executed in
collaboration with hospital and community partners. Cross-agency events and trainings, reinforced
by regional coordination, have built relationships that continue to strengthen the network. In
addition, close coordination with other departments within the DHMH, such as the Medicaid Office,
Office of Disabilities, Mental Hygiene Administration, Office of Health Promotion/Injury Prevention,
and the Office of Chronic Disease Prevention are facilitated by the director of the SHIP.
B. Partnerships States cultivated partners for many important reasons. As described above, key agencies were brought
in as leadership partners, but partners were also cultivated to expand the program reach to underserved
audiences, to diversify sources of financial support, to expand infrastructure for programs, and to align
with state/national policy initiatives and priorities. Partnership development was often the key to
sustainability, as evidenced by Arizona’s experience:
“Ninety-six organizations have embedded the delivery and/or referral of their patients to
CDSME. These organizations include 12 Hospitals and Healthcare systems, 5 AAAs, 15 state and
local governments, 26 behavioral health agencies, 8 tribal councils, 27 community based
organizations and 3 Veterans Administration Healthcare Systems. Through our collaborations
and partnerships we were able to grow and embed CDSME into a new health screening model
that focuses on health education and behavior change. Health screening events utilizing this
model are provided by the National Kidney Foundation of Arizona once every quarter and
registering and attending a CDSME workshop is the final component of their health screening
model.”
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States were successful in recruiting partners that serve ethnic/racial populations and low-income
underserved groups. As shown in Table 3, many states involved partners with high risk populations, or
their organizational mission was to improve the health of high risk populations with health disparities,
including individuals with multiple chronic conditions and diabetes. For example, to increase access to
Spanish-language CDSME programs, Wisconsin conducted the Programa de Manejo Personal de la
Diabetes training for community health workers as a coordinated effort with Core el Centro and United
Voices in Milwaukee. In addition, one Lay Leader was contracted to provide targeted technical
assistance for Promotoras and Community Health Workers supporting the Latino and Native American
workshops. Master Trainers also assisted WIHA in translating the leader materials on the WIHA Spanish
website page.
Wisconsin also had great success in partnering with Tribal communities. Four of the five priority tribes
now have their own Lay Leaders and one smaller tribe is partnering with another. This tribe is also part
of a regional ADRC and has a good relationship with the other counties in the region. The Aging Tribal
Technical Assistance Center, funded by the multi-county AAA and located at the Great Lakes Inter-Tribal
Council, has hired a second individual assigned to work with tribal aging units and one of her program
areas is prevention.
Table 3. Number of States Partnering to Reach Diverse, High Risk, and
Underserved Populations
Partner Number of States Working
with Partner
Agencies that reach rural populations 18
Groups working with people with disabilities 16
Centers for Independent Living (CILs) 15
Ethnic/minority agencies 15
Faith-based organizations 15
Native American tribal organizations 10
Source: Sustainability Assessment Survey, August 2015
Community and system partners were extensive and were utilized to expand the integration of
programs across the state. As shown in Table 4, many states worked with senior housing, YMCAs, and
recreation centers. Other common partners included academic institutions and worksite and employee
benefit programs. Half of the states reported partnering with advocacy/support groups, assisted living
facilities/continuing care retirement communities (CCRCs), and retiree groups/groups for adults 55+.
Kentucky, Oklahoma, Virginia, and Washington reported success in working with their Department of
Corrections, and in many of these settings, the inmates were trained as Lay Leaders.
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Table 4. Number and Type of State-Level and Local Partners
Partner Number of States Working
with Partner
Senior housing 16
YMCA’s and recreation centers 16
University/academic institutions 12
Worksite programs/employee benefit programs 12
Advocacy/support groups 11
Assisted living facilities/Continuing Care Retirement Communities (CCRCs)
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Department of Corrections 11
Retiree groups/Groups for adults 55+ 11
Area Health Education Centers (AHECs) 10
Cooperative extension centers 10
Foundations 10
Civic groups 9
Senior Community Service Employment Program (SCSEP) 7
Corporations/for-profit groups 4
Source: Sustainability Assessment Survey, August 2015
Tremendous expansion of partnerships with multiple types of health care organizations and providers,
including health insurance plans and Quality Improvement Networks-Quality Improvement
Organizations (QINs-QIOs) was evident during this grant cycle. With the emphases on expanding CDSME
programs and developing reimbursement opportunities, all states identified working with one or more
types of health care partners.
Arizona’s success in working with 12 hospitals and health care systems and three Veterans
Administration health care systems is just one example of the progress that was made to integrate
CDSME programs into the health care sector. Alabama was successful in partnering with the Jefferson,
Blount, St. Clair Mental Health Authority (JBS) and the Alabama Department of Mental Health’s
Consumer Division to provide Lay Leader training for their peer support group to serve mental health
consumers in several counties of the state. Also in Alabama, the Healthy Gulf Coast Care Transition
Coalition (HGCCTC) has quarterly team meetings attended by hospital administrators, nurses, and social
workers to identify and overcome barriers that can reduce hospital readmissions. These meetings led to
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the development of effective partnerships with the University of South Alabama and Providence
Hospital to offer the Chronic Disease Self-Management Program (CDSMP).
As shown in Table 5, 17 states are working with Federally Qualified Health Centers (FQHCs) and/or
hospitals and health care systems. Sixteen are working with provider groups at the local level, and 15
have partnered with mental and/or behavioral health. In particular, the role of chronic disease self-
management in the recovery process is gaining momentum in many states and these opportunities are
expanding. For example, Rhode Island shared that “The Opioid Treatment Programs is interested in
gaining resources for chronic disease self-management as it aligns with the Medicaid Health Home
Model. The programs fit in the health and wellness domain of the home health model, as chronic
disease has been identified as a potential barrier to one’s recovery. There is an existing workforce of
Peer Recovery Coaches who provide counseling and support to those in recovery.”
Table 5. Number of States Partnering with Health Care
Partner Number of States Working
with Partner
Federally Qualified Health Centers 17
Hospitals/health care systems 17
Primary care practice/local health organizations 16
Mental/behavioral health care providers/clinics 15
Health insurers/health plans 14
Veteran’s Administration 14
Quality Improvement Organizations/Networks 14
Substance abuse prevention/treatment facilities 8
Source: Sustainability Assessment Survey, August 2015
Partnerships that were established often had exponential benefits for the states. As Connecticut
shared, the partnership with the Connecticut Community Care, Inc. (CCCI) has been a key factor in
bringing together foundation support and introducing regional community partners to the concept of a
statewide collaborative. This partnership played an instrumental role in guiding the program leadership
in the development of linkages with Medicaid funded programs, as well as working with health system
partners such as hospitals and the Connecticut Home Care Program for Elders (CHCPE). In addition, the
growth of the DSMP program also established the current partnership between the Department of
Public Health and Qualidigm, the QIO for the State of Connecticut.
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C. Infrastructure Development
1. Building Workforce Capacity
States provided training to expand the workforce capacity of Master Trainers and Lay Leaders, as
appropriate, to support their program expansion. As Table 6 shows, the total numbers of both
Master Trainers and Lay Leaders increased during the grant period.
Table 6. Number of Master Trainers and Leaders, by State
States Master Trainers Leaders
2013 2015 2013 2015
Alabama 21 15 60 60
Arizona 54 41 434 370
California 167 134 300 450
Colorado 20 17 275 175
Connecticut 9 11 74 136
Georgia 30 50 120 126
Kentucky 12 6 100 95
Maryland 50 46 105 253
Massachusetts 61 77 430 494
Michigan 300 325 1575 2060
Missouri 47 23 125 122
New Jersey 60 84 200 300
New Mexico 9 11 50 100
New York 120 130 250 1548
Oklahoma 12 9 124 150
Oregon 24 13 197 188
Rhode Island 14 13 77 70
South Carolina 9 4 92 97
Utah 8 12 70 122
Virginia 42 64 197 396
Washington 60 443 99 96
Wisconsin 20 20 225 350
Totals 1,149 1,548 5,179 7,758
Source: Sustainability Assessment Survey, August 2015
13
In some states, the number of Lay Leaders and/or Master Trainers decreased over time, as the state
may have discovered they had excess capacity, or adjusted their numbers to reflect only active
Master Trainers and Lay Leaders. At the conclusion of the grant period, states had a greater work
force to deliver and sustain CDSME. As will be presented in the Program Outcomes section of the
report, the number and coverage area of host sites expanded, and the number of implementation
sites increased, with greater access to CDSME programs in all states.
2. Referral Systems and Processes
Arizona, Colorado, Massachusetts, and New York have developed centralized referral systems for
use in promoting health care referrals. Arizona’s Living Well Institute has developed a web-based
Community Referral Network that furthers the data exchange between organizations and allows
health care providers to easily refer patients, track referrals, and receive data on the participation
and progress of their patients. Colorado has developed a web-based, HIPAA-compliant registration
and referral site for CDSME programs. The referral site now also posts leader trainings, conference
call summaries, webinars, and other materials and scripts for ADRC staff. Referrals are received
from a variety of organizations, including ADRCs, tobacco cessation programs/quit lines, health care
systems, local public health agencies, cross-referrals from other evidence-based programs, and
Medicaid Managed Care. Massachusetts has established a statewide referral system through the
Tufts Health Plan Medicare Advantage program. This referral system includes centralized program
intake and registration. After receiving the referral or registration form online, a staff member calls
the potential participant to explain the program options and to review the registration process. The
referrals are tracked, and the referral source is notified when the patient completes the workshop.
The New York statewide system is similar in that patients are engaged to enroll them in workshops,
referrals are tracked, and feedback is provided to the referral source. Their data portal is fully
operational, and provides up-to-date information about where workshops are located.
3. Fidelity/Quality Assurance
To ensure effective, quality programs and efficient delivery and distribution systems, states should
develop quality assurance (QA) plans and have ongoing data systems and procedures in place that
address both continuous quality improvement (CQI) and program fidelity.
CQI is a cyclical process that includes setting performance objectives, monitoring and evaluating
what is or is not working, problem-solving, and making corrective changes as needed. Program
fidelity is one aspect of quality assurance that focuses on monitoring the extent to which an
evidence-based program is delivered consistently by all personnel across sites, according to program
developers’ intent and design.
Data from the 2015 Integrated Services Delivery System Assessment indicated that 33% of states
had a QA plan and ongoing mechanisms in place to monitor fidelity to a large extent, an increase of
more than 10% from 2013. Eighty-one percent of states reported that “to a large extent” or “to a
moderate extent” they have QA and fidelity mechanisms in place.
14
Connecticut has an exemplary fidelity management system. CQI procedures that are utilized include
careful screening of potential workshop Lay Leaders and support of trained Leaders after their
training, including connecting all of them to a Regional Coordinator (RC). The RC works with the Lay
Leaders to organize a workshop, answer questions, and provide materials and support. The RC
completes a fidelity check of all workshops that are facilitated by first-time Leaders, and additional
random fidelity checks are completed as warranted. All participants complete a workshop
evaluation at week six, as well as a pre-post participant survey (completed at week one and week
six). A carefully defined data collection procedure is in place, and all Leaders are trained on proper
data collection. The RE-AIM framework is also used to support quality assurance.
New Jersey developed a Lay Leader Guidance Manual and a DSMP Fidelity Tool, which are posted on
the state website for use by the network of partners. The state holds conference calls with each
grantee and requires an agreement to be signed, which outlines and requires grantee acceptance of
HIPPA policies. Through regular fidelity monitoring visits, the state identifies trends to develop
training updates and tools for program development. Oregon also has an extensive fidelity
monitoring and quality assurance plan. Statewide, Lay Leaders are monitored for fidelity, and each
leader is observed annually. Oregon’s quality improvement coaching system provides valuable
feedback on program implementation barriers and insights to inform future refinement of quality
improvement tools and processes. Training in English and Spanish on Privacy and Information
Security is offered for Leaders, fidelity tools are made available on the website, and regional or state
mentors provide regular fidelity observations. A new requirement is the use of the leader script and
non-disclosure agreement.
15
V. Program Outcomes and Participant Demographics In 2015, fewer than half of states were conducting evaluation work, compared to 82% of states in 2014.
States that were conducting evaluation work reported conducting pre-post assessments, satisfaction
surveys, outcome studies, and studies of special population groups. Additionally, South Carolina
conducted a study to explore the barriers and facilitators to participation in CDSME programs. A
number of states completed separate evaluation studies of participant outcomes during this grant cycle.
A summary of their findings is provided in Table 7 below.
Table 7. State Participant Outcome Evaluation Studies of CDSMP4
Brief Description Population Surveyed Outcomes
Alabama
To evaluate the effectiveness of the Living Well Alabama Program in improving overall health and decrease health care costs of employees with chronic disease
38 city employees of the Public City Works and Fire Departments
Significant cost savings were seen in the Public City Works Department
Reduction in the number of visits to the emergency department
Reduction in the number of health care provider visits
Reduction in the number of days in the hospital
Nine participants stopped smoking
Connecticut
To evaluate the effectiveness of the Live Well program in Connecticut
CDSMP participants who completed pre- and post- participant questionnaires
Increased ability to do chores and participate in social activities
Lower levels of tiredness, pain, and sadness or hopelessness
16
Brief Description Population Surveyed Outcomes
New Jersey
Learn whether CDSMP participants show improvements in health indicators
269 CDSMP participants representing racially and ethnically diverse populations with chronic conditions and/or their caregivers; 150 participants responded to post-workshop survey
Improvement in general health
Reduced social/role activities limitation
Increased self-efficacy
Increased physical activity
Improved communication with physicians
Reduced health care utilization
Oklahoma
Evaluate self-rated health, disability, health distress, social/role activities limitation, and other health-related measures
104 community-based CDSMP participants who completed both a pre- survey and post-survey
Decreased health distress
Improvement in self-rated health
Increase in amount of time spent on exercise and use of cognitive symptom management
Oklahoma
Determine the impact of CDSMP on residential care participants’ health behavior, health status, and health care utilization
43 residents in
independent living, assisted living, and skilled nursing care who participated in a CDSMP workshop
Decrease in perception of self as disabled
Increase in self-rated health
Decline in hospitalization at skilled nursing facility
17
Brief Description Population Surveyed Outcomes
Oklahoma
Evaluate the impact of CDSMP on inmates’ health behavior, self-efficacy, health status, diet, medical services utilization, and social behavior
231 inmates who attended workshops in three Oklahoma Department of Corrections minimum security sites
Improvements in health distress, hopefulness, overall happiness
Better communication with physicians
Improved cognitive symptom management
Better self-rated health
Increase in exercise
Improvements in social tolerance and institutional misconduct
Virginia
Analyze health variables for nursing home eligible participants: blood pressure, number of hospitalizations, medications, depression score, and others
29 nursing home eligible PACE (Program of All- Inclusive Care for the Elderly) participants
Depression scores declined significantly
Overall decreases in number of medications for the largest percentage of participants
Virginia
Determine if participants experience improvements in health status, health-related distress, pain, and other indicators
1,068 adult CDSMP participants Decreased health
related mental stress (distress)
Reduced levels of pain, fatigue, and shortness of breath
More frequent use of cognitive techniques for coping with emotional and physical symptoms and mental relaxation techniques to manage stress
Increase in amount of aerobic and non-aerobic physical activity
18
Brief Description Population Surveyed Outcomes
Rhode Island
Identification of factors associated with non-completion of CDSME workshops offered from 2012 – 2014, a time of economic insecurity for Rhode Islanders.
Participants in CDSMP and DSMP (English and Spanish) and Chronic Pain Self-Management Program (English)
Non-completers were more likely to be non-Hispanic white, African-American or other racial minority; to have yearly household incomes above the poverty threshold; and to be living alone.
In addition, Massachusetts reported on an informal study of the impact of Tomando Control de Su Salud
and Programa de Manejo Personal de la Diabetes implementation on program completers by the Latino
Health Insurance Program. The body mass index (BMI) of 200 program participants (average age 60)
was checked before and after workshops offered between September 2012 and November 2014.
Positive BMI changes were documented after the completion of the six-week workshop. In addition, the
study revealed that 100% of workshop participants incorporated more fruit and vegetables in their
diets; 85% increased physical activity; and 10% replaced sugary drinks with water.
A. Program Outcomes The national database contains observations regarding a number of program measures, including
participant reach and completion, participant demographics, host organization, implementation site,
and number of workshops. These observations are available for all CDSME programs or by program type
for seven different programs developed by Stanford University: (1) Arthritis Self-Management Program
(ASMP), (2) Cancer: Thriving and Surviving, (3) Chronic Disease Self-Management (CDSMP), (4) Chronic
Pain Self-Management (CPSMP), (5) Diabetes Self-Management (DSMP), (6) Programa de Manejo
Personal de la Diabetes (Spanish DSMP), and (7) Tomando Control de su Salud (Spanish CDSMP). Data
were used to answer two specific questions regarding project success: (1) how successful were grantee
states in meeting their proposed targets for completion, and (2) what are the major demographic
characteristics of program participants.
The information presented in this report is based on data that were extracted from the grantee
performance reports and from other data sources and were then inserted into applicable sections on
the capping report template. Analyses include descriptive statistics (sums, frequencies, and
proportions) and qualitative content analyses to develop thematic groupings that identify common
patterns and practices, exemplary processes and outcomes, and the creation of inventory lists. The RE-
AIM framework is utilized to capture challenges, solutions, and grantee key learnings.
Calculations for workshop attendance and completion rates are based on information from the 22
grantees. However, calculations for demographic characteristics and host/implementation site
characteristics are based on “all states,” which reflects information entered by the 22 state grantees
19
awarded in 2012, as well as 16 other states that actively entered data during this time period. Findings
for demographic characteristics are based on those participants who reported relevant data. It is
important to note that virtually across all program measures, information was not available (not
reported, not useable, etc.) for some participants. It is not uncommon in projects of this kind for data to
be incomplete for a variety of reasons. For instance, individuals may choose not to divulge specific
personal information or may have difficulty filling out the forms. It is also important to note that several
data elements (including caregiver status and educational attainment) were added after the start of the
grant period, which accounts for some of the missing data.
1. Participant Reach and Completers
Under the funding agreement with ACL/AoA, all grantees offered one or more CDSME programs. All
states were required to offer, at a minimum, the Stanford Chronic Disease Self-Management
Program (CDSMP). Although the number of CDSME programs offered varied among grantees, all
offered at least two types of programs. Many states offered both CDSMP and the Diabetes Self-
Management Program, as well as the Spanish versions of these programs, Tomando Control de su
Salud and Programa de Manejo Personal de la Diabetes. Some also offered the online version of
CDSMP and/or DSMP (Better Choices, Better Health®). Data for online programs were not entered
into the national database (this information is housed in a separate system); therefore, this report
does not include those findings. Table 8 provides a listing of the specific CDSME programs offered
by each state, by program.
20
Table 8. Program Type, by State
Program Type State
Community-Based Programs
Arthritis Self-Management AZ, CA, KY, MA, MI, SC, WI
Cancer: Thriving and Surviving CO, MA, MD, MI, NM, VA
Chronic Disease Self-Management AL, AZ, CA, CO, CT, GA, KY, MA, MD, MI, MS,
NJ, NM, NY, OK, OR, RI, SC, UT, VA, WA, WI
Chronic Pain Self-Management AL, AZ, CA, CO, GA, KY, MA, MD, MI, MO, NJ, NY, OR, RI, SC, WA, WI
Diabetes Self-Management AZ, CA, CO, CT, GA, KY, MA, MD, MI, MO, NJ, NM, NY, OK, OR, RI, SC, UT, VA, WA, WI
Positive Self-Management NY, OR
Programa de Manejo Personal de la Diabetes
AZ, CA, CO, CT, MA, NJ, NM, NY, OR, RI, UT, VA, WA, WI
Tomando Control de su Salud AL, AZ, CA, CO, CT, MA, MI, MO, NJ, NM, NY, OK, OR, RI, SC, UT, VA, WA, WI
Online Programs
Better Choices, Better Health® AZ, MA, MO, CA, CO, GA, NJ, OR, UT, VA, WA, WI
Better Choices, Better Health® - Diabetes
AZ, MA, MO, CA, CO, GA, NJ, OR, UT, VA, WA, WI
2. Program Type and Frequency; Enrollment/Completion Rates
During this reporting period, a total of 136,452 individuals across all 22 grantee states attended one or
more CDSME program sessions. A total of 100,834 of these individuals, or 73.9%, were completers
(i.e., they attended at least four of the six sessions, the minimum dose required to likely accrue the
benefits of the respective program). Across all programs and all grantee states, a total of 12,431
workshops were implemented during the reporting period. The overwhelming majority of these were
CDSMP workshops. Table 9 presents a listing of total number of workshops, by CDSME program type.
21
Table 9. Total Number of CDSME Workshops, by Program Type
Workshop Type Frequency
Arthritis Self-Management 20
Chronic Disease Self-Management 8,567
Diabetes Self-Management 2,443
Tomando Control de su Salud 820
Chronic Pain Self-Management 345
Programa de Manejo Personal de la Diabetes 209
Cancer: Thriving and Surviving 10
Positive Self-Management 9
Other 8
Completion rates varied greatly between grantees and by CDSME program type. Of the 22 states,
14 had completion rates below 75%, while three had completion rates of 80% or higher. Table 10
provides a listing of total number of participants who attended and who completed workshops, as
well as the completion rate, by state.
22
Table 10. Total Number of Community-Based Workshop Participants and
Completers, by State*
Grantee # Enrolled /
Completed
Completer
Rate
Alabama 2,808 / 2169 77.2
Arizona 4,874 / 3,544 72.7
California 16,262 / 11,333 69.7
Colorado 4,325 / 3,004 69.5
Connecticut 2,098 / 1,522 72.5
Georgia 3,202 / 2,957 81.1
Kentucky 2,191 / 2,305 72.2
Maryland 4,078 / 2,946 72.2
Massachusetts 6,612 / 5,091 77.2
Michigan 7,228 / 5,356 74.1
Missouri 5,155 / 3,686 71.5
New Jersey 8,354 / 6,212 74.4
New Mexico 1,458 / 1,223 83.9
New York 9,299 / 7,464 80.3
Oklahoma 4,494 / 3,495 78.5
Oregon 6,012 / 4,055 67.4
Rhode Island 1,647 / 1,283 77.9
South Carolina 2,239 / 1,623 72.5
Utah 3,709 / 2,631 70.9
Virginia 6,098 / 4,667 76.5
Washington 4,634 / 3,457 74.6
Wisconsin 4,611 / 3,287 71.3
* Does not include online programs
A summary of actual versus proposed completer targets for all states as of the reporting period end
date of 8/31/2015 is shown in Figure 1. All but three states (MI, RI, SC) reached or exceeded their
proposed completer targets (NOTE: for one state [MI], the differential between proposed and actual
23
completer target was less than 10% and even slightly exceeded its proposed target by the NCE end-
date of 12/31/2015). The actual completers for one state (AZ) was almost double the proposed
target, and that of two others (CO, OK) was almost triple.
Table 11 provides a complete listing of reach, proposed completer targets, and actual numbers of
completers for all 22 states. For the nine states that completed their projects on time, the project
end date August 31, 2015 will be used. For the 13 NCE grantee states, the reporting period end date
December 31, 2015 will be used, as it reflects complete data for Michigan and South Carolina, both
of which completed their grant projects on this date, and more accurately reflects the number of
completers for the other 11 states. However, it is important to emphasize that data are still
forthcoming for these 11 NCE states.
24
0
2000
4000
6000
8000
10000
AL AZ CA CO CT GA KY MA MD MI MO NJ NM NY OK OR RI SC UT VA WA WI
Actual Completers Proposed Completers
Figure 1. Actual and Proposed Completer Targets, by State, by 8/31/2015
25
Table 11. Reach, Proposed Completer Targets, Actual Completers, by State
and Reporting Period End Date
State Reach Proposed
Completers
Actual
Completers
%
Difference
Proposed
Completers
Actual
Completers
%
Difference
Reporting Period End Date: 8/31/15 Reporting Period End Date: 12/31/15*
AL 2,808 1,590 2,169 36.4
AZ 4,874 1,774 3,544 99.8
CA 16,262
7,804 11,804 51.3
CO 4,325 3,081 1,054 192.3
CT 2,098 1,109 1,522 37.2
GA 3,202
2,892 2,170 33.3
KY 3,191 2,454 1,995 22.9
MA 6,612 4,350 5,091 17.0
MD 4,078 2,762 2,946 6.7
MI** 7,228 5,882 5,849 0.6
MO 5,155 3,153 3,686 16.9
NJ 8,354 6,716 5,536 21.3
NM 1,458 1,000 1,223 22.3
NY 9,299
7,464 6,540 14.1
OK 4,454 3,550 1,224 190.0
OR 6,012 4,056 3,844 5.5
RI 1,647 2,210 1,238 -41.9
SC** 2,239
1,743 2,499 -30.3
UT 3,709 2,848 2,343 21.6
VA 6,098 5,124 3,522 45.4
WA 4,634 3,660 2,782 31.6
WI 4,611 2,700 3,287 21.7
*Information listed in italics indicates NCE grantee states.
**Both Michigan and South Carolina completed their grant projects by 12/31/2015, and the data shown here for these two states are final. Data reporting for the other no-cost extension grantee states is ongoing.
26
3. Prevalence of Chronic Conditions
Although 31,754 participants (23.3%) reported having no chronic conditions, 78,514 (57.5%)
reported having multiple chronic conditions. The three most frequently reported conditions were
hypertension (39.4%), arthritis (33.9%), and diabetes (32.2%). Table 12 provides a full listing of
chronic conditions, ranked from most to least commonly reported. Least commonly reported were
Alzheimer’s disease/other dementias (0.9%) and multiple sclerosis (0.6%). Depression was reported
by one-fifth (21.2%) of all program workshop participants, showing the strong link between
behavioral and physical health.
Table 12. List of Chronic Condition and Percentage of Participants Reporting
Condition % Reported
Hypertension 39.4
Arthritis 33.9
Diabetes 32.2
Depression 21.2
Other 17.4
High Cholesterol 17.3
Lung Disease 15.2
Heart Disease 12.9
Chronic Pain 10.9
Osteoporosis 10.2
Cancer 9.2
Stroke 4.3
Alzheimer’s or Dementia 0.9
Multiple Sclerosis 0.6
Multiple 57.4
None 23.3
A. Participant Demographics
1. Age and Sex
Information about age was available for 116,542 participants (85.4%), and 80,161 of them (68.8%)
were at least 60 years of age, demonstrating that the target population for this project was reached.
27
Those considered “young old” (i.e., below age 75) made up the largest number (47,888), while those
considered “old” (i.e., age 85 and older) made up the smallest (8,215). The oldest average
participant age was 71 (in CT), while the youngest was 47 (in OK).
Information about sex was available for 120,760 participants (88.5%). Quite typical for the “usual’
gender make-up of CDSME program participants, the majority of all participants (76.4%) were
female.
2. Race/Ethnicity
A total of 105,421 (77.3%) participants provided useable race information. For those participants,
differences in CDSME program attendance varied across racial and ethnic subgroups. More than
two-thirds (67.8%) of participants identified as White; 22.3% identified as Black; and 14.5%
identified as Hispanic. The lowest participation occurred among those who identified as Pacific
Islander (08%). These findings suggest that there is still more work to do to recruit racial and ethnic
minority subgroups, as they can be expected to have greater health disparities and greater need for
CDSME programs.
3. Educational Level
The most significant differences in participation were observed across subgroups of varying
educational levels. However, it is important to note that useable data were available for only 70,999
(52.0%) of the total number of participants (this data element was added after the grant period had
started). Therefore, data must be interpreted with caution. The most frequently reported
educational level was “some college or tech school,” with 22,279 individuals (31.4%) selecting this
response. The second most frequently reported educational level was “some elementary, middle,
or high school,” with 11,899 (16.8 %) of those who provided relevant data selecting this response.
Almost one-third of the participants (27.4%) who answered this time reported having a High School
Diploma or a GED.
4. Living Arrangement and Caregiver Status
A total of 104,685 participants (76.7%) provided useable data. Of those, 42.7% reported that they
live alone, while 57.3% reported that they live with someone.
Of the 136,452 participants who provided information about their caregiver status, data were
useable for only 64,125 (46.9%) of them. This data element was added after the grant period had
already started, which explains the low response rate. Of the individuals who provided relevant
data, more than one quarter (27.2%) indicated that they are caregivers.
5. Disability Status
Similar to caregiver status, only 62,696 (45.9%) gave useable information for this data element. This
data element was also added after the start of the grant period, which explains the low response
rate. A total of 28,341 participants (45.2%) reported having a disability, demonstrating that the
grantees were successful in reaching people with disabilities, a target population for this project.
28
C. Host Organization/Implementation Site Characteristics Host organizations are situated in every grantee state and are those organizations or agencies that
sponsor CDSME programs. In most cases, host organizations are responsible for training CDSME
program Master Trainers and Lay Leaders and for planning, implementing, and monitoring the delivery
of program workshops. Often (but not always), these organizations hold the license, where applicable,
to train and offer CDSME programs in their states. Host organizations may also serve as implementation
sites.
Implementation sites are the physical locations where CDSME program workshops are offered in a local
community. As mentioned above, an implementation site may in fact be the host organization, or it may
be an organization (such as a community center, health care facility, church, etc.) within which the host
organization has arranged to hold one or more program workshops.
During this reporting period, there were a total of 520 active host organizations across all 22 states. A
total of four of the 22 states (CT, NM, RI, and WI) had fewer than 10 host organizations, while four states
(CA, MA, NJ, NY) had 50 or more. A complete break-down of number of host organizations for each
state is shown in Table 13.
Table 13. Number of Host Organizations, by State
# of Host
Organizations State
< 10 CT, NM, RI, WI
10 – 24 AL, CT, GA, KY, MD, MI, MS, OK, UT, VA
25 – 49 AZ, OR, SC, WA
> 50 CA, MS, NJ, NY
Proportionally, the most common type – with almost two-fifths of the host organizations – was “health
care organization” (38.8%). The least common types were “library,” “parks and recreation center/other
recreation organization,” and “tribal center.” These were combined with “other” for ease of calculation.
A complete break-down of host organization types is shown in Figure 2.
29
Figure 2. Host Organizations, by Type
Implementation site characteristics were also examined. Program workshops were offered in a total of
4,404 implementation sites across all 22 grantee states. In contrast to most common host organization
type, implementation sites were most likely to be “senior center” (22.7%). The second most common
type was shared between “health care organization” and “residential facility” (20.7% and 20.0%,
respectively). There also was a wide variety of “other” types, implementation sites that varied from
“faith-based organization” to “library” to “tribal center.” For ease of calculation, these were combined
with “other” and “other community center.” And although the numbers for each of these types were
relatively small, together they made up the almost one-third of implementation sites (27.2%).
The above finding suggests that although some types of organizations, such as a health care
organization, might be more readily thought of as a good fit for and lend themselves more easily to be a
CDSME implementation site, these programs can be implemented with success almost anywhere in a
community, even if the more “obvious” choice of organization is not available. A complete break-down
of implementation site types is shown in Figure 3.
20.1%
10.7%
38.8%
5.6%
5.7%
19.1%
Area Agency on Aging
County Health Department
Health Care Organization
Senior Center
Other Community Center
Other
30
Figure 3. Implementation Sites, by Type
27.2%
20.7%
20.0%
22.7%
9.4%
Other
Health Care Organization
Residential Facility
Senior Center
Faith-Based Organization
31
VI. Sustainability Strategies
A. Business and Sustainability Planning Eight of the nine grantees who completed their grant cycle by August 15, 2015, had developed a
business plan, a sustainability plan, or both. One grantee did not finish the plan by the end of the grant
cycle but has sustainability strategies in place and a written plan under development. Nine of the 13
NCE grantees have completed a business and/or sustainability plan; three are working on their plans and
have indicated that they will complete them by the end of the grant cycle; and one recently finished the
grant cycle with specific sustainability strategies identified but no formal, written plan in place.
Altogether, 17 of the 22 grantees (77%) now have either a business or sustainability plan in place, as
shown in Table 14 below.
Table 14. States with Sustainability and/or Business Plans
States With Completed Plans
Alabama New Mexico
Colorado New York
Connecticut Oregon
Georgia Rhode Island
Kentucky South Carolina
Maryland Utah
Massachusetts Virginia
Missouri Wisconsin
New Jersey
Based on results from the 2015 Integrated Services Delivery System Assessment, states demonstrated
considerable progress toward creating sustainable systems for ongoing CDSME programs. Highlights
from this report include:
Twenty-one states reported that they had partnerships with health care organizations to
provide CDSME;
Sixteen states (73%) reported that they had calculated accurate operating costs and established
per participant costs for CDSME programs;
Program partners who have embedded CDSME increased by nearly 15% from 2013 to 2015;
Partners providing a statewide delivery system nearly doubled from 2013 to 2015;
The percentage of states charging a fee for participation in CDSME increased from 45% in 2013
to 50% in 2015;
32
In 2015, more than 70% of states reported that they have a good working knowledge about how
their state Medicaid system works, and half of them indicated that they are working on
reimbursement but had not yet received it. In fact only one state was receiving reimbursement
for program participation through the state Medicaid plan or waiver at the time the survey was
completed in August, 2015; and
Nine states (41%) were partnering on Affordable Care Act (ACA) initiatives, triple the number
that selected this option in 2013.
B. Sustainability Successes and Innovations A more up-to-date description of sustainability processes and plans was provided in the states’ final reports (submitted for 10 states as of the date of this Capping Report). Information was also sought on sustainability in state performance reports and other NCOA administrative materials for the NCE states that had not yet submitted their final reports. Sustainability strategies were identified and grouped into five categories: 1) sustainability planning tools and training; 2) use of Older Americans Act (OAA) Title III funds; 3) embedding of programs for continuation and expansion; 4) acquisition of external funds; and 5) reimbursement contracts and opportunities. Within each of these categories, exemplary sustainability successes and innovations are provided in the discussion below.
1. Sustainability Planning Tools and Training
Several states provided partner training modules or sponsored conferences to assist partners in
sustainability planning (MD, MI, MO, and SC). Planning processes often supported sustainability
efforts from the beginning of the project. For example, Missouri did not use grant funds to hire
program management staff but relied on building these functions into the job duties of existing
staff. New Jersey and South Carolina required partners to each develop a sustainability plan, and
the plans were discussed during regular meetings. Colorado and Massachusetts provided partial
funding to support partners, while partners were also expected to contribute a portion of their own
resources to offer CDSME. Utah offered mini-grants to partners to prepare sustainability plans, and
set up payment through a reimbursement structure that was dependent on the number of
participants and completers. Investments during the grant cycle were made to position states to
have the needed ingredients to fuel sustained activity. For example, New York developed an
innovative centralized bidirectional referral system to assure health care referrals into CDSME.
Missouri developed a detailed Sustainability Toolkit to guide providers of CDSME programs in
creating sustainable services at the local level. The Toolkit included ten key planning areas to help
local providers in establishing community-specific growth action plans. The toolkit was introduced
at state regional meetings in 2012, and the state expects all partners with contractual agreements to
continue to submit growth action plan worksheets to demonstrate plans for program sustainability.
2. OAA Title III Funds
Most, but not all, states mentioned the plan to continue offering CDSME programs through OAA
Title IIID funds. Two states said that not all their AAAs planned to use Title III funds, or that they
would be working with local AAAs to enable them to more fully utilize both Title IIID and IIIB funds.
A number of states shared that funding levels available through Title IIID were not sufficient to fully
support CDSME programs.
33
3. Embedding Programs
States used many methods and diverse funding sources to embed CDSME into their organizational
networks. Massachusetts explained, “CDSME is becoming highly integrated into … Long Term
Services and Support (LTSS) system through cross-training of aging network, healthcare system and
public health staff and sustainable partnerships with hospitals, health departments and state
agencies. Community Health Workers have been trained in multiple CDSME programs, and there
are several coalitions of health departments, AAAs and hospitals implementing (and paying for)
CDSME. The tobacco quit-line provides ongoing referral to our local programs for persons indicating
they have a chronic condition.”
Alabama described strategies to sustain programs in work release facilities, jails, churches, senior
community centers, as well as through partnerships with the Veterans Administration. The Wellness
Coalition has maintained a CDSMP license, delivered CDSMP according to fidelity standards, and
utilized a Centers for Disease Control and Prevention (CDC) grant to train members at three
churches to deliver workshops.
States, for the most part, indicated that partnering organizations had found a way to keep the
programs going as part of their organizational operations. Agencies are able to continue offering
and expanding programs because they are supported by centralized operations and the purchase of
new CDSME licenses; they have made investments in trainers and leaders for program capacity; they
have relied on coalitions to share delivery costs; and they have continued efforts to partner with
health care and insurance plans to secure contracts for reimbursement. Some states mentioned
that program continuance may be short term and others took the “long view.” Rhode Island has
been developing core competencies for peer health educators, hoping that once there is a standard
of care provided by peer educators, third party payers will be more confident in agreeing to
reimbursement contracts.
4. External Support
External support, typically in the form of grants from a variety of sources, was identified by every
state that had completed their grant and by all but three states operating under the NCE. Common
grant sources were the CDC, Health Resources and Services Administration (especially related to
health disparities), Tufts Health Foundation, and Medicaid and Medicare for pilot programs and
demonstration projects. Other sources of external funds were state budget allocations; state health
programs, such as cancer control; Lifetime Respite; AmeriCorps; National Kidney Foundation;
mental health associations; health care coalitions, such as the Appalachia Diabetes Coalition; and
hospital and community funds. Several states mentioned charging for programs and getting support
for program materials from health care and other community organizations to offset costs.
Interestingly, New Mexico and Rhode Island mentioned securing CDSME program support through
maternal and child health funds, school health programs to assist families with high need children,
and state programs to promote school children’s health.
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5. Reimbursement Contracts
Every state reported either working to develop reimbursement contracts or having already secured
them to support sustainability of CDSME programs. States that mentioned having reimbursement
contracts or demonstration projects with Medicaid include California, Colorado, Connecticut,
Kentucky, Massachusetts, Missouri, New York, Oregon, Rhode Island, Virginia, and Washington. A
number of states reported working with FQHCs and training community health workers that provide
care to Medicaid recipients, including Colorado, Missouri, New Mexico, Rhode Island, South
Carolina, Virginia, and Wisconsin.
A number of states were successful in securing Medicare contracts or entering into funded
exploratory projects for Medicare coverage of DSMP, including California, Connecticut,
Massachusetts, Michigan, New York, Oregon, Rhode Island, Virginia and Washington. Medicare
reimbursement through QIN-QIO projects was also noted by Colorado, Maryland, New Mexico,
Virginia, and Washington. Several states mentioned working with Accountable Care Organizations
(ACOs), and a number mentioned having contracts with insurance companies such as Blue Shield or
large public employee health insurance programs. Other reimbursement contracts were in place
with the state Department of Corrections, fee-for-service medical groups, and behavioral health
programs, such as the Opioid Treatment Program in Rhode Island. Behavioral health programs have
begun identifying having a chronic illness as a barrier to recovery from substance abuse; therefore,
CDSME can be supported as part of substance abuse recovery services.
35
VII. Challenges In spite of the many successes and accomplishments of the states during the grant cycle, they
experienced a number of challenges while reaching their goals. States were encouraged to identify their
challenges in the semi-annual and final reports. For those states that provided a final report, challenges
identified in their reports were assembled for this section of the report. For the NCE states, a number of
semi-annual reports and other administrative data were used as the source of information about
identified challenges.
The types of challenges were organized, for reporting purposes, into the RE-AIM framework. For the
states that had completed their projects, most of the challenges were identified within the
Implementation category, followed by the Reach category, then the Maintenance component. The NCE
states reported challenges within the categories of Implementation, Reach, and Maintenance Adoption.
No challenges were identified in the Effectiveness category.
A. Reach Within the Reach category, by far the most commonly reported challenge was cancellation of workshops
due to low participation or low retention rates for workshop participants. Another common challenge
mentioned by states was inadequate transportation within rural areas. Other Reach challenges included
engaging diverse populations, including Tribal members, and obtaining referrals from health care
organizations.
B. Adoption Adoption challenges were centered on organizational commitment and embedding CDSME programs
into the organizational operations. One state noted resistance within a hospital partner to offer DSMP.
Originally, the hospital’s Certified Diabetes Educators (CDEs) saw DSMP as competitive and were not
supportive. Over time, program staff worked with the CDEs to help them see DSMP as supplemental to
their efforts, and the program slowly gained their support. Especially in the health care arena, several
states noted that it was the well-documented effectiveness of the CDSME programs that were the
tipping point in gaining acceptance.
C. Implementation Implementation challenges were mentioned frequently. The most commonly stated implementation
challenge by far was staff turnover and staff shortages within the leadership and/or partner
organizations. Additionally, program delivery infrastructure changes, agency reorganizations,
communication issues among partners, and recruitment and maintenance of Lay Leaders and Master
Trainers often slowed the states’ ability to deliver the programs. One state mentioned that, rather than
increasing the number of programs being offered by adding DSMP, agencies opted to shift from CDSMP
to the DSMP, resulting in no net gain in the numbers of programs being offered. A number of states
identified challenges around the data collection and reporting, including staff shortages that made it
difficult to enter the data and manage fidelity and the demands on organizations to maintain the
database. Several states mentioned that changes made in the CDSMP program curriculum in 2012 were
36
costly due to the need to retrain leaders and trainers and to purchase the revised program participant
book.
States surmounted many of these implementation challenges, surpassing their target goals for programs
offered and completers achieved. When faced with staff shortages, New Mexico reported a renewed
involvement with their network, “Leadership within the Chronic Disease Prevention and Control Bureau
(CDPCB) initiated a strategic focus to support the integration of its programs to enhance operations,
provide opportunities to use limited resources more efficiently, and allow for more effective and
coordinated efforts.”
D. Maintenance Maintenance challenges often centered on building partnerships with heath care organizations and
health plans to establish reimbursement opportunities as a funding stream for the continuation of
programs. States mentioned the slow and cumbersome process of gaining approval for reimbursement.
It was difficult to connect to the “right people;” it was hard to convince leadership to agree; and it was
challenging to put into place the billing codes and reimbursement agreements. The process is complex,
requires a great deal of staff time, and may take years to accomplish. New Mexico shared that, “There
are a number of complex factors and mechanisms that need to be considered, planned for, and
implemented before the program can be transferred and adopted by health insurance plans. These
include: eligibility criteria, assessment, intervention and education plan documentation requirements,
billing (e.g. providers who submit for reimbursement must have a National Provider Indicator), and
coding.”
States agreed that transitioning from offering programs at no charge to charging for them was a difficult
“sell”; and that embedding programs into organizations was hard, due to stretched budgets. The
implementation challenge of staff time and workload was echoed in the issues around program
maintenance, specifically the lack of time to develop the needed organizational relationships, to write
grants, or to develop the business plan. One state mentioned that, as they built their network and
expanded their partners and delivery sites, demands on staff coordination tasks, especially data
management, increased.
Because the states were building on previous efforts, the focus of this grant cycle was to venture into
new areas, not only new geographical areas of unmet need but also new areas in programming, funding,
policy, and partnerships. States expanded programs into harder to reach areas and target populations,
ramping up their programs and working with health care organizations and health insurance plans to
create reimbursement structures and policies. It is not surprising that many challenges were identified.
Addressing the mutable challenges created much new learning and states freely shared lessons learned,
summarized in the following section.
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VIII. Lessons Learned The many lessons learned described in the states’ reports were also organized using the RE-AIM
framework for discussion in this report. Lessons learned within the Reach category included tips to
attract diverse and underserved populations, ways to fill workshops and increase participant retention,
and advice on securing referrals from health care organizations.
A. Reach To attract diverse and underserved populations, states suggested geocoding workshop locations
overlaid with population information, to show the relationship between workshops and areas with
higher concentrations of low income and underserved populations. In addition, a number of states
were successful in reaching diverse populations by engaging non-traditional partners who were already
serving these groups and were able to bring the programs to the people.
Winter weather challenges were minimized by hosting programs in senior housing facilities, retirement
communities, and mental health group homes. In addition to many innovative marketing efforts, some
states found “word-of-mouth” from previous participants or endorsement of a trusted community
leader a great help in recruitment. Retention was definitely improved by screening participants (i.e.,
ensuring potential participants understood the structure and goals of the workshop, time commitment,
etc.), and the sharing of positive program outcomes helped with recruitment. At least one state
mentioned using motivational interviewing techniques when recruiting and screening potential
participants.
The states reached out to people with disabilities as one of the expectations of the grant. They
developed partnerships with a wide variety of disability service and advocacy organizations. All 22
grantees partnered with their Centers for Independent Living. Partnerships were also formed with
Easter Seals, State Departments of Mental Health, behavioral health organizations, State Departments
of Disability, group homes and other housing sites for people with disabilities, and disability rights
coalitions. They engaged participants with low vision, intellectual/developmental disabilities,
behavioral/mental health conditions, physical disabilities, brain injury, and those with hearing loss.
Connecticut, New York, Oregon, and Utah developed marketing materials that targeted people with
disabilities and advertised through disability newsletters. Alabama, Arizona, and Utah successfully
trained individuals with disabilities as Lay Leaders to offer workshops to others with similar disabilities.
California developed a tip sheet for offering DSMP to individuals with low vision; and Michigan offered
CDSMP in sign language to deaf and hearing impaired individuals. New York obtained a research license
from Stanford University to determine if making modifications to CDSME would permit greater
participation by people with developmental disabilities. Some states encouraged caregivers of
participants with disabilities to participate. They were able to support their family member with a
disability, while also benefiting personally from participation in the workshops.
One state found that by focusing on populations who resided in medically underserved areas, they not
only reached new participants with complex needs, but also formed partnerships with health care
organizations and other groups who serve these communities. Understanding the work flow of health
care organizations was helpful in developing referral processes. For example, referrals from a health
38
care provider require consent from patients; therefore, the process for obtaining patient consent was a
feature in the process that had to be considered. Some states found that participant letters to their
health care provider at the end of the workshop session increased awareness and subsequent referrals
to the programs by health care providers. In addition, linking CDSME to quality standards and health
care metrics was critical to expansion into health care organizations. As Rhode Island shared, “There is a
demand for these [DSMP] services on the provider side, as diabetes outcomes are of importance to the
providers [because they align] … with requirements for patient centered medical homes, NCQA quality
measures, Meaningful Use Measures and HRSA measures for FQHCs. These measures impact incentive
payments to practices.”
B. Effectiveness For the Effectiveness category, not many lessons were mentioned. The reasons for this may be two-
fold. First of all, because the CDSME programs already have strong evidence of their effectiveness, it
was not a major area of focus for this grant initiative. Rather, it was decided that limited resources were
better spent on expanding program reach and coverage and seeking new and innovative funding
opportunities to sustain the programs. Second, the states had already developed fidelity plans and put
fidelity monitoring processes in place during previous grant cycles. Therefore, the knowledge gained in
this area may not have been as great as in some of the other areas of the RE-AIM framework. Even so,
states were expected to and did continue to implement fidelity management processes to assure that
quality programs were provided. Missouri shared a very important learning, “An important takeaway
identified by Leaders was that the class is not just about the material taught, but participants learning
they are not alone and knowing that others can identify with what they are feeling and experiencing.”
C. Adoption Lessons within the Adoption category focused on many successful approaches to involving health care
organizations and embedding the programs within all types of organizations. Often infrastructure
facilitators were mentioned as critical to agency adoption. Several suggestions were made about the
best ways to approach new organizations. These included using visuals or other interesting methods of
presentation to get the leaders’ attention when describing the value of the program. A number of
states found that persistence worked and learned to make “the ask” more than once. Virginia
explained, “Persistence has brought ‘brand recognition’, respect and interest.” Several states
mentioned the need to identify a champion to drive adoption and the importance of senior leadership
buy-in to secure ongoing organizational commitment.
States have identified the value of working with large organizations that have existing infrastructures
that can support system-wide changes within the organization. However, it is important to do some
homework and ask questions about the organization and its programs, so that it will be easier to identify
where CDSME can fit in, especially within health care practices. It is essential to promote programs to
large organizations in ways that show how CDSME meets their needs or provides added value. As
Virginia noted, “… Look for organizations where CDSME gives added value to programs, for example a
Nursing and Rehabilitation facility that can say they offer CDSME to increase self-efficacy and potentially
lower return to hospital rates.” Another state explained that identifying the programs as a part of their
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“practice without walls” was the key to show how self-management resources are a support to their
clinical work. Ongoing communication is critical, and one state found value involving patient navigators
from the partner organization to help close the communication loop with busy referral providers. One
state worked with their medical school to set up a rotation for medical students in CDSME and led a
focus group with them at the end of their rotation. The state reported that the medical students
provided a great deal of insight into how CDSME can fit into care plans, which was helpful in engaging
health care organizations.
Finally, the infrastructure that the states created to support the CDSME programs played a huge part in
program adoption, and therefore expansion. Virginia provided a standout quote, “AAAs are at the heart
of the network,” and went on to say that by working together and sharing resources, they are able to
expand the regional model that works very well. Massachusetts mentioned that the decision to utilize
one statewide license was critical to their success because it allowed them to create the infrastructure,
memorandums of agreement, and reimbursement protocol centrally to service the state. Missouri
pointed out that CDSME supported increased impact of a statewide partner, which in turn increased
receptivity of health care partners who subsequently provided referrals, program space, and had their
own staff trained as Lay Leaders.
D. Implementation The effort of setting up centralized systems was seen as very important to states’ progress and success,
even though it was time consuming. These systems included a centralized leadership structure; a
centralized database and/or referral system; and centralized program support functions, such as leader
recruitment and training, participant attendance tracking, and fidelity management. In addition, it was
recommended to establish formal agreements with partners, so that expectations and processes are
clear to all.
One state mentioned that they attributed their success to leveraging the expertise of key partners and
organizational leaders. A number of states utilized regional collaboratives or networks to expand the
programs across their states. Wisconsin set up a network of Health Promotion Coordinators within
ADRCs and other organizations and found that agencies with this type of coordination function “have
proven to have a higher success rate in scheduling and conducting these workshops and boosting older
adult participation, were more successful in leveraging resources from multiple agencies in the same
community, had more volunteers to offer the workshops, and are better positioned to continue the
partnerships when current funding ceases.” For the network model to work optimally, it was suggested
that regular communication and meetings be planned between coordinators and partners, and not to
rely on an “as needed” approach.
E. Maintenance What, from the states’ perspectives, are the key learnings for sustainability? States offered many
lessons for ongoing maintenance of the programs, centering on key partners, processes, resources, and
essential organizational elements. Philosophically, as Michigan shared, “To sustain and expand the EBP
self-management footprint … the … program must be viewed as an ongoing, predictable, and self-
sustaining patient education partner. This will enable health providers to view [CDSME] … as an integral
40
part of the health services array that improves patient outcomes and quality of life through cost-
effective interventions.”
Many states agreed that future sustainability rests on health care systems’ involvement and support, as
they have great potential for contributing by making referrals and by sponsoring programs themselves.
New Mexico expanded on this viewpoint, “Strategies to support further expansion need to include: 1)
effective targeted marketing and promotional strategies for healthcare providers and consumers; 2) a
comprehensive referral system to increase access, identification and referral of eligible individuals; and
3) health plan reimbursement and worksite policy.”
Additional maintenance lessons focused on infrastructure components and innovative models that were
developed during the project period. The centralized model promoted partner support and embedding
of programs. Maintenance encompasses collaborative leadership, policy issues at the state and local
levels, and includes sustainability planning, cross-departmental collaborations, regional alliances, and
the value of professional development. Cross-training in CDSME and cross-program referrals are seen as
important for sustainability, along with the support and expansion of a volunteer leader base. A new
health screening model developed with the National Kidney Foundation includes providing CDSME as
the final component in the health screening process. This type of model developed in Arizona may be
able to be expanded to other states. It is very important to share these, and all, successes widely. One
state noted that by sharing the success of their accomplishments, they were able to gain additional
resources to sustain their efforts.
Finally, states believe that continued leadership at the national level is essential to ensure that policy
changes continue to support and promote health insurance coverage and reimbursement by Medicare
and Medicaid for CDSME programming.
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IX. Recommendations for Future Effort
In November 2015, NCOA identified a number of recommendations in the 2015 Chronic Disease Self-
Management Education (CDSME) Integrated Services Delivery System Assessment Report. Given the
richness of the information provided since then by the states, a number of these recommendations are
still highly relevant. These are summarized and expanded upon below.
1. Technical assistance is needed to help grantees learn more about developing formal, written
agreements, such as memoranda of agreement, memoranda of understanding, and contracts.
2. There is more work to do in terms of engaging AAAs, especially with regard to embedding programs.
Adequate staffing and availability of funding are the key barriers. Potential solutions may be found
within states with a higher AAA involvement.
3. States should be encouraged to expand their relationships with ADRCs beyond serving as referral
sources to take advantage of untapped opportunities, such as the Options Counseling or Care
Transitions programs.
4. To increase program funding, there is a need for more technical assistance and information sharing of
successful practices to secure Medicare and Medicaid reimbursement and to have CDSME recognized as
a covered benefit. There are specific Medicare benefits that can be accessed to achieve reimbursement
(e.g., Diabetes Self-Management Training and Health and Behavior Assessment and Intervention), but
the processes are unfamiliar and complex. Medicaid Health Homes offer potential, especially for dual
eligibles. Several states are receiving support from their QIO/QIN. This should be the case for all states,
as this is one way to build partnerships with Medicare and is mutually beneficial for both the QIO/QIN
and the state.
5. States would benefit from continued technical assistance to support the development of centralized
and coordinated processes, including a centralized website, toll-free number, tracking of leaders and
trainers, a standard referral system, consistent fidelity management protocols, and a centralized
programs calendar. States repeatedly mentioned the benefit of a centralized network hub to support
program implementation and structure expansion efforts.
6. Finally, a continued focus on supporting grantees to complete their sustainability or business plans
and to increase their knowledge, skills, and competence with regard to business acumen and community
health care integration are important next steps.
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X. Conclusions Grantees, as a whole, met or exceeded their goals. All states set in place plans and processes to meet or
exceed the goals of this funding initiative, which were to 1) Significantly increase the number of older
adults and/or adults with disabilities who complete evidence-based CDSME programs to maintain or
improve their health status; and 2) Strengthen and expand integrated, sustainable service systems
within states to provide evidence-based CDSME programs.
Exemplars and highlights throughout the Capping Report describe the innovative and difficult work
undertaken by the states to meet these goals. Altogether, during this grant cycle, 86,080 participants
completed a CDSME community-based program and 826 more completed an online program. New
partnerships and models were developed that others can take advantage of in their own program
expansion. Sustainability plans and processes are described that paint the picture of diversified funding
sources, stronger linkages with health care systems, innovative avenues for program reimbursement,
sophisticated centralized logistical processes, and new and expanded partnerships to provide more
widespread access to CDSME programs among older adults and adults with disabilities, especially those
who are most in need.
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XI. References 1. U.S. Administration on Aging PPHF – 2012 - Empowering Older Adults and Adults with Disabilities through Chronic Disease Self-Management Education Programs financed by 2012 Prevention and Public Health Funds, (PPHF-2012), Program Announcement and Grant Application Instructions. 2. US Department of Health and Human Services, Multiple Chronic Conditions: A Strategic Framework. http://www.hhs.gov/ash/initiatives/mcc/. 3. Healthy People 2020. http://www.healthypeople.gov/2020/topicsobjectives2020/overview.aspx?topicid=31. 4. NCOA. Chronic Disease Self-Management Program Summary of National and State Translational Research Findings. https://www.ncoa.org/wp-content/uploads/Health-Outcomes-Evaluation-FINAL-DRAFT-022515.pdf.
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XII. Appendix
State Data Extraction Template Performance Summary: How well did the State reach its planned outcomes? (Use words like Exceeded, Met, Did not meet) Note NCE States
Receipt of Previous AoA grants?
CDSME Programs
Pre-Grant # Trainers and Leaders in State
Trainers:
Leaders:
List Types of Partners
State Aging & PH
Other State Agencies
Health Care Provider Groups/ HC Orgs/FQHCs
Medicaid/ other Funded Programs
AAA’s/Aging Services
Mental/Behav Health
Orgs for the Disabled
Coalitions/Collaboratives
Other Community Orgs
Other: Academic
Other:
Other:
Project Outcomes
Target Goal
Total Reach (during grant)
Trainings Offered T-Trainers:
Master Trainers:
Leaders:
Fidelity/QA:
Refresher:
Other:
Participant Outcomes
Exemplars (reaching diverse pops or high MCC %)
Other:
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State Data Extraction Template Other:
Other:
Describe Leadership Structure and Processes
Aging & PH
Hub/Centralized Model
Coordinated Model
Advisory Council
Innovative Partners
Other:
Other:
Describe Successes/Innovations
Sustainability Strategies
Use of Partnerships
Infrastructure Dev
Marketing
Referral/Logistical Processes
Disabled Reach
Fidelity/QA Training/Processes
Receipt of other grants
Other:
Other:
Types* Describe Challenges Describe Solutions/How Addressed
Types* List Lessons Learned
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State Data Extraction Template Sustainability Plan
Business Acumen
Maintenance level (reduced activities)
Continuation thru Org Adoption/Embedding
Continuation thru External Support
Continuation thru Reimbursement contracts
Continuation with AoA Title III Funds
Other:
Other:
Types* List Recommendations
Types* Provide Quotes, Other Exemplars, Other Information
* Types: Use RE-AIM framework (Reach, Effectiveness, Adoption, Implementation and Maintenance
[Sustainability])