Capping Report - NCOA...The data for the Capping Report were drawn from state reports and materials...

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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7

9

10

11

12

15

20

21

22

25

26

28

31

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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29

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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 86,163.*

Additionally, some states offered online CDSME programs, with 826 completers, bringing the total

number of completers in the 22 states to 86,989 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

Chronic Pain Self-Management Program (CPSMP) 17

Programa de Manejo Personal de la Diabetes (Spanish DSMP) 14

Better Choices, Better Health® (Online CDSMP) 12

Better Choices, Better Health® - Diabetes (Online DSMP) 12

Arthritis Self-Management Program (ASMP) 7

Cancer: Thriving and Surviving (CTS) 6

Positive Self-Management program (PSMP) 2

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


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)

11

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


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


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


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


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


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


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


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

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

Arthritis Self-Management 20

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 / 11,811 69.7

Colorado 4,325 / 3,081 69.5

Connecticut 2,098 / 1,522 72.5

Georgia 3,202 / 2,904 81.1

Kentucky 3,191 / 2,524 72.2

Maryland 4,078 / 2,946 72.2

Massachusetts 6,612 / 5,091 77.2

Michigan 7,228 / 5,882 74.1

Missouri 5,191 / 3,708 71.5

New Jersey 8,354 / 6,716 74.4

New Mexico 1,458 / 1,223 83.9

New York 9,299 / 7,464 80.3

Oklahoma 4,454 / 3,587 78.5

Oregon 6,012 / 4,056 67.5

Rhode Island 1,639 / 1,274 77.7

South Carolina 2,239 / 1,743 72.5

Utah 3,709 / 2,847 70.9

Virginia 6,098 / 5,124 76.5

Washington 4,634 / 3,660 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 11,811 51.3

CO 4,325 1,054 3,081 192.3

CT 2,098 1,109 1,522 37.2

GA 3,202

2,170 2,904 33.8

KY 3,191 1,995 2,524 26.5

MA 6,612 4,350 5,091 17.0

MD 4,078 2,762 2,946 6.7

MI** 7,228 5,849 5,882 0.6

MO 5,155 3,153 3,708 17.6

NJ 8,354 5,536 6,716 21.3

NM 1,458 1,000 1,223 22.3

NY 9,299

6,540 7,464 14.1

OK 4,454 1,224 3,587 193.0

OR 6,012 3,844 4,056 5.5

RI 1,647 2,210 1,274 -42.3

SC** 2,239

2,499 1,743 -30.3

UT 3,709 2,343 2,847 21.5

VA 6,098 3,522 5,124 45.4

WA 4,634 2,781 3,660 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 having contracts in place with insurance

companies, such as Blue Shield or large public employee health insurance programs. Other

partnerships in place and funding sources being explored include 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 started to recognize that

chronic diseases can pose barriers to recovery from substance abuse; therefore, CDSME can be

included as part of substance abuse recovery services.

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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

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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

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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, 86,163 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.

http://www.hhs.gov/ash/initiatives/mcc/

http://www.healthypeople.gov/2020/topicsobjectives2020/overview.aspx?topicid=31

https://www.ncoa.org/wp-content/uploads/Health-Outcomes-Evaluation-FINAL-DRAFT-022515.pdf

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XII. Appendix - State Data Extraction Template

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])

Capping Report - NCOA...The data for the Capping Report were drawn from state reports and materials...

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