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Page 1: National Council on Aging (NCOA) Empowering Older People ...activities were consistent with the funding guidance and intent of the funding. The 24 states reported supporting 21 total

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National Council on Aging (NCOA)

Empowering Older People to Take More Control of Their Health Through

Evidence-Based Prevention Programs: A Capping Report

Administered: September 2011 – December 2012

Prepared by:

Janet C. Frank and Christy Ann Lau

UCLA Multicampus Program in Geriatric Medicine and Gerontology

Submitted to: National Council on Aging

Revised Submission

March 26, 2013

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TABLE OF CONTENTS

I. EXECUTIVE SUMMARY ..................................................................................................... 4

II. INTRODUCTION ............................................................................................................... 7

A. Background .................................................................................................................... 7

1. Program Purpose and Goals ........................................................................................ 7

2. Program Evolution Over Time .................................................................................... 7

a. The Early Years ...................................................................................................... 7

b. National Expansion and Systems Integration ........................................................ 8

c. Empowering Older People to Take More Control of Their Health Through

Evidence-Based Prevention Programs .................................................................. 8

d. Empowering Communities to Sustain Evidence-Based Disease and Disability

Prevention Programs (Empowering Communities) ............................................... 9

3. Approach to the Study ................................................................................................ 9

a. Study Limitations ................................................................................................... 10

4. Description of EBHP Programs Supported ................................................................. 10

5. States Implementing Evidence-Based Health Promotion and Disease Management

Programs (EBPs) ......................................................................................................... 12

6. Types of Partners and Their Roles .............................................................................. 12

B. Program Outcomes ....................................................................................................... 14

1. Persons Served ............................................................................................................ 14

2. Outcomes of Interventions on Program Participants .................................................. 16

3. National Program Impacts .......................................................................................... 18

4. Program Fidelity and Quality Assurance .................................................................... 20

5. Best Practices .............................................................................................................. 20

a. Marketing/Outreach ............................................................................................... 20

b. Worker Training ..................................................................................................... 21

c. Infrastructure Development ................................................................................... 22

d. Fidelity and Quality Assurance ............................................................................. 23

e. Evaluation .............................................................................................................. 23

C. Challenges ...................................................................................................................... 24

1. Marketing/Outreach .................................................................................................... 24

a. Rural Issues ............................................................................................................ 24

b. Transportation ....................................................................................................... 24

c. Program Characteristics and Requirements .......................................................... 25

d. Outreach to Minority and Underserved Populations ............................................ 25

2. Worker Training .......................................................................................................... 26

a. Trainer and Leader Recruitment ........................................................................... 26

b. Trainer and Leader Engagement and Retention .................................................... 27

3. Infrastructure Development ........................................................................................ 28

4. Fidelity and Quality Assurance ................................................................................... 29

5. Evaluation ................................................................................................................... 30

D. Sustainability ................................................................................................................. 31

1. Embedding Programs into Systems of Services ......................................................... 31

2. Establishment of New Systems, Positions, Units or Programs ................................... 32

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3. New Policy Development ........................................................................................... 33

4. Sustainability as a Project Theme ............................................................................... 34

5. Sustainability Plan Documentation ............................................................................. 35

6. New Funding ............................................................................................................... 36

E. Lessons Learned ............................................................................................................ 37

1. Reach ........................................................................................................................... 37

2. Effectiveness ............................................................................................................... 39

3. Adoption ..................................................................................................................... 39

4. Implementation ........................................................................................................... 40

5. Maintenance and Sustainability .................................................................................. 41

F. Products Developed ....................................................................................................... 43

G. Conclusion ..................................................................................................................... 45

APPENDICES .................................................................................................................... 47

Appendix A: Data Extraction Tools and Scoring Rubrics ............................................. 47

Appendix B: Case Studies of Five Grants ....................................................................... 56

Appendix C: Products/Resources Developed .................................................................. 80

Appendix D: Lessons Learned .......................................................................................... 100

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I. EXECUTIVE SUMMARY

In 2006 and 2007, the Administration on Aging made a major investment in the national

expansion of evidence-based (EB) health promotion and disease management programs in the

Empowering Older People to Take More Control of Their Health Through Evidence-Based

Prevention Programs that provided funding to 24 states. This initiative was followed in 2010

with additional funding from the American Recovery and Reinvestment (ARRA) entitled

Empowering Communities to Sustain Evidence-Based Disease and Disability Prevention

Programs, to expand the capacity and delivery of the EB programs in these states. These grants

began in 2006, 2007 and all state grant projects under these two initiatives were completed in

2012.

Through the National Council on Aging, the Administration on Aging commissioned an

evaluation to document the successes, challenges, accomplishments, lessons learned, and

products produced through these two major grant initiatives. This report is based on data derived

from the states’ Final Reports, and agency (AoA) and resource center (NCOA) administrative

materials. The evaluation employed both quantitative (descriptive) and qualitative (content

analyses) methods. The report is organized to answer the key questions of interest to the agency

as outlined above.

The states, in general, exceeded the grant goals they had set for themselves. All states goals and

activities were consistent with the funding guidance and intent of the funding. The 24 states

reported supporting 21 total evidence-based health promotion and disease management programs

during the grant period. All states were expected to support the expansion of CDSMP program

capacity and offerings, and all states also provided more than just the CDSMP programs. The

most prevalent programs provided, besides the general CDSMP, included A Matter of Balance

(MoB) offered by 14 states and EnhanceFitness (EF) offered by 10 states. Almost all states

exceeded their goals for numbers of participants recruited into programs, and established

important infrastructure protocols and partnerships. All 24 states involved a working partnership

at the state level of aging services and public health departments for project leadership. Ten

states identified their state’s Medicaid program and six included their Aging and Disability

Resource Centers as key project partners. Four states identified their states’ Department of

Corrections as a key partner. Four states engaged Tribal Entities as key partners and eleven

states partnered with universities, primarily to provide evaluation expertise. The states excelled

at building partnerships across many community sectors to impact policy, provide programs,

provide referrals to programs, assure fidelity, and document outcomes.

Program outcomes examined in this report included, but were not limited to, number of program

completers and trainers/leaders, key partnerships developed, geographic coverage, the

development of a quality improvement/fidelity plan and a sustainable infrastructure. Across all

24 state grantees and 21 evidence-based programs offered, a total of 136,441 people were

reached. About 25% of states were “exemplary” in reaching their target population goal, 17%

“exceed” their goals for reaching their target population, 37% “met” their goals, 13% “fell short”

of their goals, and 8% did not provide information or did not specify a goal. The majority of

people reached were over the age of 65, female, about half lived alone and 68% were Caucasian,

13% African-American and 11% Hispanic/Latino. Seventeen states went beyond grant

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expectations to provide participant level program outcome and health improvements post

programs, although typically follow up response rates were problematic. The most common

program interventions that produced participant outcomes were EnhanceFitness, CDSMP and A

Matter of Balance.

Notable impact was made in creating aging service and health partnerships, as 21% of grantees

proved “exemplary” in their accomplishments, Additionally, many states made significant

progress toward sustainability either by finding new funding, leveraging existing funding, or

developing or maintaining an infrastructure for offering programs and training leaders.

Additionally, 51% of state grantees made substantial progress in creating an infrastructure for

program delivery, referrals and registration. Eighty-eight percent of the States met or exceeded

their goals for maintaining fidelity within the programs they were offering and assuring quality

in all program implementation processes.

All states identified challenges, with the predominance of them in the areas of implementation

and sustainability. Because these programs are so highly relevant to addressing minority

populations’ health needs, states made this a priority focus. States found that their ability to

successfully recruit minority groups required a multifaceted approach: they needed to engage

peer group champions and local community leaders to support program marketing, they needed

to recruit leaders who are members of the participant groups they are trying to recruit into the

programs, they sometimes had to adapt the programs to make them more relevant, and also

needed to work with trusted agencies already serving these populations as partners and referral

agencies. The evaluation report also documents best practices, solutions, lessons learned and

exemplary case study states.

We used the RE-AIM framework to capture and categorize some 120 key lessons learned. From

the lessons learned, we identified a number of key recommendations for states to use in the

future. Within the “Reach” category, states suggested that its best to pick partners already

serving your target audience(s) to reach ethnic and underserved populations and to use GIS

mapping tools for expansion planning to identify current program locations and trainer

availability to indicate uncovered areas for development and expansion. Many states struggled

with rural transportation problems, and recommendations emerged to try ride sharing programs,

scheduling classes after other activities at times when people would already be at the site, and in

some cases, consider whether program leaders can pick up participants on their way to the site.

To assure “Effectiveness”, states recommended to get input and buy in for the scope and

requirements of any planned evaluation with the agencies you expect to participate in advance

and to assure the highest quality of leaders, set up a screening and/or interview protocol for

potential leaders before enrolling them in a leader training program.

In “Adoption”, it is best, when possible, to have a dedicated employee who specifically is in

charge of heath promotion programs within the AAAs; to use an organizational readiness tool

and spend time meeting with potential agencies before partnering; and to make sure staff at all

levels in organization understand the commitment they are making in offering the programs.

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For “Implementation”, a key role at the state level continues to be the development and oversight

of protocols to foster fidelity monitoring and quality at all levels of program implementation.

Another recommendation is to use the Cost Calculator not only to identify program costs but to

also identify cost variations across programs and delivery sites/regions.

In the “Maintenance and Sustainability” category, key recommendations included the use of

business planning principles to approach sustainability and to diversify funding sources in

sustainability planning and to have a paid program coordinator to manage program logistics –

this is the best investment that can be made according to a number of states. Another innovative

recommendation was to structure partner contracts that are based on the number of completers by

grantee. In that way, there is a measurable outcome while incentivizing providers to engage

participants and yield a high number of completers per workshop. Two final recommendations

were to make sure that EBP is in the state plan for both aging and public health; and that having

good outcome data on participant health improvement and costs provides the basis for state

budget support and makes the business case for proposals for additional funding. The

commitment of state leadership and local coordinators is evident and a critical ingredient to

program success and sustainability.

The evaluation report includes a number of tables with detailed specific information and a series

of Appendices that provide the evaluation rubric tools, and complete lists of recommendations

and products and resources produced by the states.

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II. INTRODUCTION

A. Background

1. PROGRAM PURPOSE AND GOALS

AoA funding support to states under the Evidence-Based Disease and Disability Prevention

programs has been provided to empower older adults to take control of their health. In these

programs, older adults learn to maintain a healthy lifestyle through increased self-efficacy and

self-management behaviors (www.aoa.gov).

A major expectation of the Empowering Older People initiative was to deliver high quality

evidence-based programs that maintain fidelity to both the original design and to the research

outcomes associated with the evidence-based models that are being deployed and to reach the

maximum number of older adults that are at risk who can benefit from the programs. The AoA

expectation reflected both the design and implementation of efficient and well-managed

programs, and the need to find and commit funds from other public and private sources to these

programs (as has occurred at the national level). By making these programs available in their

communities, older adults were being empowered to take control of their health. Programs

included:

Physical activity programs, such as EnhanceFitness or Healthy Moves for Aging Well,

which provide safe and effective low-impact aerobic exercise, strength training, and

stretching.

Falls management programs such as A Matter of Balance, which addresses fear of falling,

and Stepping On and Tai Chi: Moving for Better Balance, which build muscle strength

and improve balance to prevent falls.

Nutrition programs, such as Healthy Eating for Successful Living among Older Adults,

which teaches older adults the value of choosing and eating healthy foods, and

maintaining an active lifestyle.

Depression and/or Substance Abuse Programs, such as PEARLS and Healthy IDEAS,

which teach older adults how to manage their mild to moderate depression.

Medication Management Programs, such as HomeMeds.

Stanford University Chronic Disease Self-Management Programs (CDSMP), which are

effective in helping people with chronic conditions change their behaviors, improve their

health status, and reduce their use of hospital services.

2. PROGRAM EVOLUTION OVER TIME

a. The Early Years

The programs funded in 2006-7 that are the focus of this report represent a major expansion of

the building blocks that had been put into place beginning in 2001. The programs began

modestly in 2001 with John A. Hartford Foundation support of four demonstration projects led

by the National Council on Aging to test the ability and interest of aging service organizations to

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actually lead and sponsor evidence-based health promotion (EBHP) programs. Making EBHP

programs more accessible by placing them into community agencies was a major step, since

previously the programs were based in a small number of research-oriented universities and a

limited number of partnering organizations. In 2003 AoA funded 14 model projects that were

primed by community agencies and included a major evaluation component, typically provided

by a university partner. These model projects carefully documented the planning and

implementation process of offering the programs in aging service community agencies and

organizations while protecting the fidelity of the core components that made the programs

effective.

b. National Expansion and Systems Integration

Since 2003, AoA has supported states as they have developed infrastructure, workforce, and

capacity to deliver EBHPs through the aging services network and local partners (see Table 1).

The Empowering Older People initiative, described below, was by far the largest program

sponsored by AoA in support of the expansion of evidence-based programs and the integration of

them into the fabric of community program delivery to support the health improvements of older

people. From 2003 – 2012, AoA provided $23 million in funding for the Evidence-based

Disease and Disability Prevention Program (EBDDP) to support programs aimed at keeping

older adults healthy and engaged in their communities.

Table 1: Evolution of AoA-Funded EBHP Programs in the United States

• 2003: AoA model projects (14) served 5,000 people

– Programs included CDSMP, falls management,

depression, physical activity, medication management,

and nutrition

– Documented fidelity and focus on evaluation

– Produced replication reports

• 2006: AoA “Empowering Older People” funded in 16 states

• 2007: “Empowering Older People” expands to 8 more states

• 2010: AoA ARRA Projects: 47 states/territories

c. Empowering Older People to Take More Control of Their Health through Evidence-Based

Prevention Programs (Empowering Older People)

In FY 2006, the Administration on Aging awarded cooperative agreement funding to 24 states to

support dissemination of evidence-based programs. These grants were designed to mobilize the

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aging, public health, and non-profit networks at the State and local level to accelerate the

translation of HHS funded research into practice through the deployment of low-cost evidence-

based disease and disability prevention programs at the community level. An AoA goal for the

projects was for state units on aging and state health departments to collaborate on the provision

of policy leadership and on-going support for local partnerships involving non-profit aging

services providers, area agencies on aging, health organizations, the business sector, and other

potential partners from the private and public sectors.

d. Empowering Communities to Sustain Evidence-Based Disease and Disability Prevention

Programs (Empowering Communities)

In 2010, AoA issued a limited competition for one additional year of funding to the 24 states that

had been funded under the 2006 program. The new initiative was to support the continued

growth of partnership activities at both the state and community level. This opportunity allowed

further advancement of collaborations with state units on aging and state health departments on

the provision of health policy leadership, and the on-going strengthening of local partnerships

involving area agencies on aging, local departments of public health, non-profit aging services

providers, health and health insurance organizations, and other partners from the private and

public sectors.

3. APPROACH TO THE STUDY

This report will present information and data provided through the 24 funded states’ Final

Reports and related AoA and NCOA administrative and programmatic data. The state funded

programs were scheduled to end in May 2011, but most states (75%) received no-cost

extensions. The evaluators reviewed the original grant applications, final reports with their

extensive appendices, state profiles, and grant management reports as the primary data sources

for data extraction. Data extraction tools and evaluation rubrics were developed in six general

areas of inquiry listed below. The tools and rubrics are provided in Appendix A.

1. How well were project outcomes achieved?

2. What major challenges were encountered and what solutions for these challenges worked

best?

3. Taken together (across grantees) what was the major impact of the program and what

lessons were identified that will assist future efforts by AoA in this program area?

4. What features supported states in their own formal program evaluation efforts?

5. What evidence is there that programs will be sustained or replicated? What program

features and/or partners support embedding the program into systems?

6. What types of resources and products were developed by the projects?

The data was available on a rolling basis as grantees completed their projects and subsequently

provided their final reports. One evaluator reviewed state materials for 10 states (Frank) and the

other evaluator reviewed the remaining 14 states (Lau). The two evaluators worked closely

together in completing the data extraction and met weekly to review the evaluation matrices and

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discuss any issues that were identified. The two evaluators also completed four state data

extractions from each other’s state assignments to assure inter-rater reliability in score

assignment and use of the tools.

The data was then entered into an Excel database and included both rubric scores (quantitative)

and extensive qualitative notes within the six areas of inquiry. Analyses included descriptive

statistics (frequencies, means, and standard deviations), bivariate analyses and qualitative content

analyses that included both conceptual groupings, frequency counts, and the creation of

inventory lists (e.g. products list).

a. Study Limitations

The data presented in this report is derived from the written materials provided to the

Administration of Aging by the states and other AoA and NCOA administrative materials (e.g.

AoA grant monitoring reports, original state grant proposals). There is the potential that if the

final reports did not include all relevant information sought during the data extraction, this

missing information would result in an incomplete accounting of states’ accomplishments or

incorrect scores assigned within the rubrics. The quality and validity of the evaluation data was

dependent on the completeness and quality of the final reports and appendices provided to AoA

by the states.

4. DESCRIPTION OF EBHP PROGRAMS SUPPORTED

The 24 states reported supporting 21 total evidence-based health promotion and disease

management programs (Table 2 below) during the grant period. These programs can be

organized into several general categories: Stanford University chronic disease self-management

programs (CDSMP) (English and Spanish) both general and specialized (diabetes, pain,

arthritis); falls management programs; physical activity programs; behavioral health, medication

management and lifestyle improvement programs. All states were expected to support the

expansion of CDSMP program capacity and offerings, and all states also provided more than just

the CDSMP programs. The most prevalent programs provided besides the general CDSMP

included A Matter of Balance (MoB) offered by 14 states and EnhanceFitness (EF) offered by 10

states (see Table 2).

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Table 2: EB Programs Offered by States During Grant Period

EB Program Number of States Offering Number of Participants

Trained by Program

Stanford Chronic Disease Self-Management Programs

Chronic Disease Self-Management Program 24 80,386*

Diabetes Self-Management Program 10 35,278*

Tomando Control de su Salud 5 9,889* **

Programa de Manejo Personal de la

Diabetes 1 0000

Arthritis Self-Management Program 1 3,177*

Chronic Pain Self-Management Program 1 0000

Falls Management

A Matter of Balance (MOB) 14 21,072

Tai Chi: Moving for Better Balance 4 1,937

Asunto de Equilibrio (Spanish MOB) 1 3,585

Step-by-Step 1 172

Stepping On 1 2,755

Physical Activity Programs

EnhanceFitness 10 11,320

Active Living Every Day 2 623

Fit & Strong! 2 94

Active Choices 1 24

Strong for Life 1 483

Healthy Moves for Aging Well 1 345

Behavioral Health Program

Healthy IDEAS 4 5,288

Medication Management

HomeMeds 3 5,672

Life Style Improvement Programs

Healthy Eating for Successful Living among

Older Adults 2 1,754**

EnhanceWellness 1 131

*States reported training numbers across multiple programs (e.g., CDSMP/Tomando/DSMP); exact numbers by

individual program undeterminable/may be duplicative

**Figure includes missing data, as some states omitted training numbers from reported programs

0000 = state(s) did not report training numbers for specified program

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5. STATES IMPLEMENTING EVIDENCE-BASED HEALTH PROMOTION AND DISEASE

MANAGEMENT PROGRAMS (EBPS)

The 24 states that were funded in this initiative are identified in Figure 1 below. Each state

identified the geographic target areas (by region or county) in their grant proposal that they

planned to focus their expansion efforts within. The planned expansion coverage is depicted by

the blue color designation in the map. At the conclusion of the project, 50% of states (n = 12)

had exceeded planned geographic coverage, 29% (n = 7) met their geographic coverage goals,

and 21% (n = 5) of states fell short of meeting their geographic expansion plans.

Figure 1: State grantee reach by county

NOTE: Twenty-four grantee states’ targeted counties are shown in blue; unmarked states were not covered by this

grant

6. TYPES OF PARTNERS AND THEIR ROLES

Within the grant guidance, states were required to demonstrate that the projects would involve a

partnership between the state level aging services (e.g. State Unit on Aging) and the state level

health department (e.g. State Department of Public Health). There was also encouragement in

the grant guidance to include public health services funders (e.g. Medicaid) as a key partner. All

24 states involved a working partnership at the state level of aging services and public health

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departments for project leadership. Ten states identified their state’s Medicaid program and six

included their Aging and Disability Resource Centers as key project partners. As shown in

Figure 2, all states relied on local AAA’s as key partners and developed community

organizations and local agencies as partners. The local organizations included health

departments, parks and recreation departments, senior housing, faith based communities, and

county and city service programs. Health care services providers (hospitals, clinics), health

districts, physician groups, and health plans were all included in the “health care” category

shown in Figure 2. Four states (Ohio, Oklahoma, Oregon, and South Carolina) identified their

states’ Department of Corrections as a key partner. Four states engaged Tribal Entities (Arizona,

Oklahoma, Oregon and Minnesota) as key partners and eleven states partnered with universities,

primarily to provide evaluation expertise. Three states (Florida, Massachusetts, and Michigan)

noted local foundations as key partners for their projects.

Figure 2: Key Project Partners

In almost all states, agencies and departments formed statewide collaborative networks for

oversight and to serve as steering committees for the projects. Several states established formal

statewide collaborative organizations. For example, Colorado formed the public-private

Consortium for Older Adult Wellness; Hawaii developed the Hawaii Healthy Aging Partnership;

and Massachusetts established the Massachusetts Disease Management Coalition. Texas

developed the Texas Strategic Health Partnership, whereas Arkansas established the CDSMP

Partners & Stakeholders’ Group. Wisconsin developed the Community-Academic Aging

Research Network and the Evidence-based Coordinating Community. Wisconsin was the only

state to establish a not-for-profit organization during the project, the Wisconsin Institute for

Healthy Aging (WIHA). The WIHA’s steering committee provided project oversight and also

applied for grant funding that was not available to governmental agencies. The states excelled

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at building partnerships across many community sectors to impact policy, provide programs,

provide referrals to programs, assure fidelity, and document outcomes.

B. Program Outcomes

The evaluation assessed how well state grantees achieved the goals they set forth in their original

grant proposals. It also documents how well the programs retained their original design and

were aligned with AoA’s overall goals for the initiative. Program outcomes examined in this

grant included, but were not limited to, number of program completers and trainers/leaders, key

partnerships developed, geographic coverage, the development of a quality improvement/fidelity

plan and a sustainable infrastructure. For a complete list of the constructs that were assessed, see

Appendix A, Tables 1 and 3.

1. PERSONS SERVED

Across all 24 state grantees and 21 evidence-based programs offered, a total of 136,441 people

were reached. Among the most popular programs offered were the Chronic Disease Self-

Management Program (CDSMP), A Matter of Balance (MOB), the Diabetes Self-Management

Program, and EnhanceFitness, the four of which, combined, served 113,877 people in total. For

each of the programs offered, grantees usually set goals for their targeted number of program

participants. As noted in Table 3, 42% of grants were “exemplary” in achieving their participant

goals, 29% “exceeded” their goals, 4% “met” their goals, 8% “fell short” of their goals, and 17%

did not provide outcome information or did not designate a goal.

Table 3: How Well Did the State Achieve Its Program Outcomes?

Did not

provide

information

or no goal (Score = 0)

FELL

SHORT of

achieving

outcome

goals (Score = 1)

MET

outcome

goals (Score = 2)

EXCEEDED

outcome

goals (Score = 3)

EXEMPLARY

in achieving

outcome goals

(Score = 4)

TOTAL (N = 24)

Program Completers 17% (n=4) 8% (n=2) 4% (n=1) 29% (n=7) 42% (n=10) 24

# of Trainers/Leaders 42% (n=10) 4% (n=1) 17% (n=4) 25% (n=6) 13% (n=3) 24

Key Partnerships 0% (n=0) 0% (n=0) 42% (n=10) 42% (n=10) 17% (n=4) 24

Geographic

Coverage/Target

Population 8% (n=2) 8% (n=2) 37% (n=9) 17% (n=4) 25% (n=6) 24

Aging/Public Health

Leadership 4% (n=1) 0% (n=0) 58% (n=14) 21% (n=5) 17% (n=4) 24

Quality

Improvement/Fidelity

Plan 8% (n=2) 4% (n=1) 50% (n=12) 4% (n=1) 34% (n=8) 24

Sustainable

Infrastructure 4% (n=1) 4% (n=1) 29% (n=7) 34% (n=8) 29% (n=7) 24

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Table 3 also indicates that 25% of states were “exemplary” in reaching their target population,

17% “exceed” their goals for reaching their target population, 37% “met” their goals, 8% “fell

short” of their goals, and 8% did not provide information or did not specify a goal. State

grantees that fell short of reaching their target population were Maryland and Oklahoma. The

Maryland grant noted that delays in contracting processes resulted in no workshops being offered

in one area. Finally, Oklahoma’s report stated a goal of establishing 100+ permanent program

sites. However, their state profile showed that they fell a little short of that goal with only 90

workshop sites (which is still a substantial accomplishment). Those that did not provide

information or did not specify a goal were Arkansas and Oregon.

Table 4 below presents demographic data of program participants across all 24 states through

five grant years. Note that completion of the demographic data form was not mandatory, so data

is only provided for the 80,067 participants who provided this information.

Table 4: Participant Demographics (N = 80,067)

Demographic Construct 5-Year Total % of Known Statistics

Age

Under 60 5,328 9%

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60-64 3,796 7%

65-69 6,589 12%

70-74 8,405 15%

75-79 9,166 16%

80-84 9,766 17%

85-89 8,122 14%

90 and Over 5,078 9%

Unknown 23,817 30% (% of total)

Gender

Female 46,465 79%

Male 12,097 21%

Unknown 21,505 27% (% of total)

Living Arrangement

Living Alone 26,455 50%

Living With Someone 26,166 50%

Unknown 27,446 34% (% of total)

Race/Ethnicity

Native American 928 2%

Asian 1,747 3%

Black 7,027 13%

Pacific Islander 194 0%

Hispanic/Latino 6,232 11%

White 38,109 68%

Other Race 585 1%

Multi-Racial 1,291 2%

Unknown 24,040 30% (% of total)

Source of data: The National Council on Aging (NCOA)

2. OUTCOMES OF INTERVENTIONS ON PROGRAM PARTICIPANTS

Seventeen grants conducted extensive evaluations of participant level outcomes in the programs

they offered. While the majority of these efforts centered on measurements such as health

outcomes, physical activity, and hospital readmissions, a few states chose to focus on program

satisfaction and fidelity. These states included: Illinois, which focused on participant and leader

satisfaction; Michigan, which conducted an extensive fidelity study in partnership with Michigan

State University; and Texas, which performed an evaluation of program implementation

processes across sites using the RE-AIM framework. This section, however, will focus on those

state grantees that provided participant level health and wellness outcomes as a product of

participating in the evidence-based program interventions. These states included: Arizona,

Connecticut, Hawaii, Idaho, Iowa, Maine, Massachusetts, New Jersey, New York, Ohio,

Oklahoma, Oregon, South Carolina, and Wisconsin. States with exemplar evaluation efforts are

discussed below.

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The most common program interventions that produced participant outcomes were

EnhanceFitness, CDSMP and A Matter of Balance. States offering EnhanceFitness used tools

such as the chair stand (lower body strength), arm curl (upper body strength), and timed Up and

Go (transfer ability and risk of falls) tests to quantify participants’ health improvements while

enrolled in the program. Both Arizona and Hawaii reported that participants improved at an

average rate of 18% for the number of chair stands they could perform in 30 seconds, 22% for

the number of arm curls they could do in 30 seconds, and 11% for the length of time in seconds

it took to complete the Up and Go assessment.

States that reported evaluation data for participants of CDSMP utilized survey instruments to

measure constructs pre- and post-program such as:

Participant self-rated health

Number of times participants discussed health conditions with their doctors

Health care utilization (e.g., physician visits, emergency department visits, nights of

hospitalization)

Fatigue, and

Pain

Iowa, as a key example, reported results at baseline, six months, and one year post-program for

all constructs measured except pain and fatigue, which were reported at baseline and one year

post-program. See Table 5 below.

Table 5: Changes in Health Outcomes for Participants of Iowa’s CDSMP

Baseline 6 Months Post- 1 Year Post-

Self-Rated Health 3.08 3.01 3.21

Chronic Disease Self-

Efficacy 5.70 6.40 6.60

Pain 4.80 -- 4.60

Fatigue 5.03 -- 4.78

Emergency Room

Visits 1.44 0.72 0.35

Nights of

Hospitalization 7.62 4.56 1.88

These outcomes were instrumental in estimating the average health care cost savings for

participating in CDSMP. For example, Iowa estimated a one-year savings of $76,204 based on

the average charge per visit of $506.

Oregon reported similar results, with reduced emergency department visits from 0.8 to 0.7 visits

per year, hospitalizations from 0.4 to 0.3 visits per year, and hospital days from 2.4 to 1.9 days

per year. For the participants who have completed Oregon’s Living Well (CDSMP) program to

date, this translates to 557 fewer emergency department (ED) visits, 557 fewer hospitalizations,

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2,783 fewer hospital days, and a savings of $634,980 in ED visits, and $6,501,088 in hospital

stays.

Finally, Massachusetts served as a prime example of a state that assessed the effectiveness of A

Matter of Balance. Survey tools were administered at the first (week one) and last (week eight)

classes. The survey tool measured outcomes in three key areas: 1) fall management; 2) fall

efficacy; and 3) fall control. Key findings showed that, as a result of completing the A Matter of

Balance class, 95% of participant responders noted they are more comfortable talking about their

fear of falling, 96% feel more comfortable increasing activity, 90% plan to continue exercising,

and 92% would recommend the program to other older adults.

3. NATIONAL PROGRAM IMPACTS

To examine the impacts of the programs on both the state and national levels, a rubric was

developed to score state successes as they “engaged state leadership in systems level strategic

planning,” “created aging service and health partnerships,” “reached rural, minority, or

underserved populations,” “increased capacity of local agencies to deliver EB programs,” “made

progress toward sustainability/funding,” “expanded geographic reach,” “created infrastructure

for program delivery, referrals and registration,” “aligned their goals, achievements and

successes with AoA,” “offered more programs than CDSMP,” and “measured outcomes.” Table

6 below provides a snapshot of the national impact made across the 10 abovementioned factors.

Table 6: What Impact Did the State’s Project Achieve?

No

information

Limited

(Score = 1) Moderate

(Score = 2) Major

(Score = 3) Exemplary

(Score = 4) TOTAL (N = 24)

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provided or

not done

(Score = 0)

Engaged state leadership

in systems level strategic

planning 4% (n=1) 13% (n=3) 33% (n=8) 25% (n=6) 25% (n=6) 24

Created aging service +

health partnerships 0% (n=0) 0% (n=0) 8% (n=2) 71% (n=17) 21% (n=5) 24

Reached rural, minority

or underserved

populations 13% (n=3) 38% (n=9) 25% (n=6) 16% (n=4) 8% (n=2) 24

Increased capacity of local

agencies to deliver EB

programs 0% (n=0) 4% (n=1) 38% (n=9) 50% (n=12) 8% (n=2) 24

Progress toward

sustainability/funding 0% (n=0) 0% (n=0) 33% (n=8) 38% (n=9) 29% (n=7) 24

Expanded geographic

reach 8% (n=2) 13% (n=3) 29% (n=7) 29% (n=7) 21% (n=5) 24

Created infrastructure for

program delivery,

referrals and registration 0% (n=0) 8% (n=2) 41% (n=10) 38% (n=9) 13% (n=3) 24

Goals, achievements and

successes aligned with

AoA 0% (n=0) 0% (n=0) 13% (n=3) 62% (n=15) 25% (n=6) 24

Offered more programs

than CDSMP 0% (n=0) 17% (n=4) 29% (n=7) 33% (n=8) 21% (n=5) 24

Notable impact was made in creating aging service and health partnerships, as 21% of grantees

proved “exemplary” in their accomplishments, 71% made a “major” impact and 8% made a

“moderate” impact. Key examples of partnerships are given in Figure 2 under the section,

“Types of Partners and their Roles.” Additionally, many states made significant progress toward

sustainability either by finding new funding, leveraging existing funding, or developing or

maintaining an infrastructure for offering programs and training leaders. 29 percent of states

were “exemplary” in their progress toward sustainability/funding, 38% made “major” progress,

and 33% made “moderate” progress.

Additionally, Table 6 shows that 13% of state grantees were “exemplary” in creating an

infrastructure for program delivery, referrals and registration, 38% made a “major” impact, 41%

made a “moderate” impact and 8% made a “limited” impact. Those scoring “exemplary” in this

category included: California (as mentioned above), Colorado and Hawaii.

4. PROGRAM FIDELITY AND QUALITY ASSURANCE

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To evaluate the degree to which states maintained fidelity within the programs they were

offering and assured quality in all program implementation processes, raters focused on how well

states developed and carried out a quality improvement/fidelity plan and created an infrastructure

for program delivery, referrals and registration. Stellar state examples mentioned fidelity

monitoring processes embedded into their infrastructure to ensure that fidelity was kept

throughout the duration of the program. California, for example, created a Program Office and a

Steering Committee to facilitate program offerings across California and to ensure fidelity and

data collection.

Table 3 above shows 34% of state grantees were “exemplary” in developing and implementing a

quality improvement/fidelity plan, 4% “exceeded” their outcome goals in doing so, 50% “met”

their outcome goals, 4% “fell short,” and 8% did not provide information or did not specify a

goal. States that received “exemplary” marks included: Colorado, Hawaii, Massachusetts,

Michigan, New York, Oregon, South Carolina, and Texas. Colorado, for example, established

the Healthy Aging Service System for training, technical assistance, and evaluation/fidelity

checks. Using this system, they conducted 227 fidelity visits during the grant period. In Oregon,

grantees developed a statewide Living Well Quality Assurance and Fidelity workgroup, provided

fidelity tools, and observed 70% of all Living Well workshops over the course of a year.

5. BEST PRACTICES

Through analysis using the aforementioned scoring rubrics, best practices for implementing the

evidence-based programs emerged as state grantees received “exemplary” scores in project

outcome achievement and program impact. Specific attention was paid to best practices in the

areas of marketing/outreach, worker training, infrastructure development, fidelity, and quality

assurance and evaluation.

a. Marketing/Outreach

In order to determine best practices relating to marketing/outreach, states were scored on their

accomplishments in developing key partnerships, reaching rural populations and expanding their

geographic reach.

Four states (California, Colorado, Connecticut, and Ohio) received “exemplary” marks in key

partnerships. In California, over 70 health care organizations have invested in CDSMP and are

offering it internally, including 22 Kaiser sites, 17 physician groups and clinics, 12 Dignity

Health (formerly Catholic Healthcare West) hospitals and medical centers, five health care

districts, and three health plans. The grant has also contributed to a new collaboration between

the California Department of Aging and the California Department of Public Health, and at the

local level between sixteen local health departments and AAAs serving those counties.

The Connecticut Department of Social Services, Aging Services Division (DSS) and the

Connecticut Department of Public Health (DPH) served as the key partnership for implementing

all of the state’s programs. To implement CDSMP, they spearheaded an advisory council

comprised of their technical assistance consultant, project evaluator from the UCONN Center on

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Aging, local partners from the Hartford Community including the City of Hartford Health and

Human Services and the City of Hartford Elderly Services, and the North Central AAA.

Two states (Massachusetts and Texas) were “exemplary” in reaching rural populations. Hebrew

Senior Life, a key partner in the state of Massachusetts, made focused efforts to reach diverse

populations, starting with a presentation at the Harvard Multicultural Coalition Annual Aging

Well Together Conference in 2008. At that conference, abbreviated workshops were presented

in several languages: English, Spanish, Portuguese, Chinese, Vietnamese, Haitian Creole, and

Cape Verdean Creole. A grant from the Tufts Health Plan Foundation in 2009 allowed for the

translation and piloting of the program into Spanish and Vietnamese. Translations of the

program into Haitian Creole and Portuguese are currently being conducted in collaboration with

the Cambridge Health Alliance (Haitian Creole) and the Visiting Nurse Association

(Portuguese).

Lastly, five states (California, Colorado, Florida, New Jersey, and Texas) were “exemplary” in

expanding their geographic reach. In Florida and New Jersey, programs are now being offered

in 100% of their counties, and in Texas program offerings increased from 10 counties to 58

counties over the course of this grant.

b. Worker Training

In order to increase capacity to deliver the programs, a number of states identified goals of

increasing their numbers of master trainers and lay leaders available to offer the programs. For

those states with this type of stated goal, we rated them using the rubric that ranged from “fell

short” in meeting goal, met goal, exceeded goal and exemplary in meeting their goal. It is

possible that for states who far exceeded their goal that they were creating excess capacity in

trainer availability, but we could not discern this from available data. What seemed to be

happening was that states needed two major things to increase the spread and number of

programs being offered. First, they needed the trained personnel to lead the classes; and second,

they needed the agencies being ready and willing to sponsor the programs. Sometimes it

appeared that one of these factors lagged behind the other, but oftentimes they were in sync.

For best practices in worker training, states were assigned scores for their achievements in the

number of trainers/leaders trained, and their ability to increase the capacity of local agencies to

deliver the evidence-based programs. Three states were “exemplary” in their number of

trainers/leaders by the end of the grant. These states were Colorado, Maryland, and

Massachusetts. Colorado stood out with two T-Trainers, 62 Master Trainers and 363 Lay

Leaders, and Massachusetts boasted stellar results by increasing their numbers of Master

Trainers and Lay Leaders in CDSMP, Healthy Eating, and A Matter of Balance. In 2011 alone,

the number of CDMSP Master Trainers in Massachusetts grew from 76 to 152, Lay Leaders

from 101 to 350, Healthy Eating Master Trainers from 5 to 86, Lay Leaders from 17 to 221, and

A Matter of Balance Master Trainers from 74 to 116 and Lay Leaders from 143 to 450.

Additionally, two states were “exemplary” in their ability to increase the capacity of their local

agencies to offer EB programs: California and Colorado. In Colorado, 23 partners provided

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programs in 17 counties, and a Colorado Health Foundation grant supported program

implementation and infrastructure development.

c. Infrastructure Development

Development of a strong infrastructure was a key element to ensuring that agencies were able to

systematically recruit participants, deliver programs, and monitor fidelity through the provision

of technical assistance and data collection. The strength of this infrastructure was also telling in

state grantees’ ability to sustain their efforts beyond the duration of the grant. To look at best

practices in this area, raters assigned states scores focused on their achievement in building a

sustainable infrastructure, the aging service and health partnerships they created, and their

engagement of state leadership in systems level planning.

Seven states were “exemplary” in achieving a sustainable infrastructure: California, Colorado,

Connecticut, Hawaii, Massachusetts, New Jersey, and Ohio. All of these states made significant

headway in building and sustaining an infrastructure for offering EB programs. A few of them

are discussed below.

California’s development of a project office and statewide steering committee provided a

central hub for guiding program implementation and facilitating relationships with

various organizations/entities.

In Colorado, a partnership was built with three health care systems and a state ADRC for

referrals. Emphasis was placed on embedding programs into systems where they could

be sustained, and using Older American’s Act funding to support AAA programming.

In Connecticut, the Yale Connecticut Collaboration for Fall Prevention and the State

Commission on Aging secured funding through the Connecticut State Legislature to

provide fall prevention training sessions to a larger network of home care and hospital

based clinicians in both regions and other parts of the state that were not covered by the

grant. In a September 2009 special legislative session, this statewide falls prevention

initiative became Public Act 09-5 and continues to receive yearly funding from the state

legislature.

In New Jersey, the statewide infrastructure for CDSMP is based on shared

administration/oversight by state government and local implementation by community

partners. State level personnel costs will continue to be paid through other federal and

state funding streams.

Five states were “exemplary” in creating quality aging service and health partnerships to aid in

the process of developing a strong infrastructure. These states included: California, Connecticut,

Hawaii, Massachusetts, and Ohio. California and Connecticut’s stellar partnerships were

discussed in the “Marketing/Outreach” section above. Additionally, Hawaii created the Hawaii

Healthy Aging Partnership (HHAP), comprised of 63 partner organizations and 27 volunteers.

In Massachusetts, implementation of EBDPs is the top program and policy initiative for the

Councils on Aging and is actively being promoted by the Massachusetts Association of Councils

on Aging. A coalition of leaders from the Tufts Health Plan Foundation and the Massachusetts

Health Policy Forum formed the Healthy Aging Steering Committee to examine community-

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based, environmental, and systematic approaches to promote healthy living and healthy aging.

Key partners in Ohio included their 12 AAAs, senior centers, behavior health organizations,

local/county health departments, meal providers, senior housing, neighborhood health centers,

health care providers, faith-based organizations, PASSPORT, hospitals, corrections facilities,

regional Alzheimer’s Association chapters, and many more.

d. Fidelity and Quality Assurance

The importance of maintaining fidelity to the programs as designed and incorporating quality

assurance measures was discussed in the “Program Fidelity and Quality Assurance” section

above. As mentioned, states received scores around their achievement of developing and

implementing a quality improvement/fidelity plan. Eight states received “exemplary” marks:

Colorado, Hawaii, Massachusetts, Michigan, New York, Oregon, South Carolina, and Texas.

For Massachusetts, in addition to recruiting and coordinating leader trainings in their three EBDP

programs, the lead community partners have provided mentoring, technical assistance (including

the development of websites for all programs), and support to newly trained program facilitators.

In addition, opportunities for continuing education and sharing of best practices have also been

available to leaders. Texas A&M, the university evaluators for the state’s grant, offered training

and technical support continuously, troubleshot programs for concerns or issues, and provided

remedial training and support to address challenges.

e. Evaluation

Finally, as discussed in the “Outcomes of Interventions on Program Participants” section above,

17 states provided extensive data on the effectiveness of the programs for participant health and

physical activity outcomes. Scoring to determine “exemplary” states was not done for this

construct since it was not an expectation of the funding initiative. Instead, qualitative data was

pulled to examine each of the 17 states’ efforts and individual outcomes. Premier examples of

evaluation efforts by those states are discussed above. It should be noted that the majority of the

states that provided these extensive evaluation studies included a university partner in their

project that managed the participant level evaluation studies.

In addition to those 17 states, two others emerged as key examples of strong evaluation efforts as

an analysis of solutions to remedy challenges was done. Towson University, the evaluation

partner in the Maryland grant, performed key evaluations in 2009 and 2010 to monitor the

fidelity of the program. Maryland implemented a fidelity consultant training in 2010-2011 with

each grantee, requiring the completion of a written fidelity plan. In Illinois, a robust evaluation

and fidelity monitoring of the CDSMP and Strong for Life programs was completed. The

evaluation monitored class participants, class leaders, and key informants (four agency

directors).

C. Challenges

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In their final reports, States identified a number of challenges that they faced in executing their

plans and accomplishing activities to reach their goals. These challenges included marketing and

outreach, worker training, infrastructure development, fidelity and quality assurance, evaluation,

and other issues such as personnel changes, delays in hiring, and contract execution with

partners.

1. MARKETING/OUTREACH

Challenges in outreach and recruitment of both program participants and leaders/trainers were

common, being reported by over 70% of the states. This category of challenges represented

about 25% of types of all challenges reported.

a. Rural Issues

Many states’ challenges in this area were related to the rural nature of the state. Rural program

delivery was challenged because the scarcity of population made it difficult to recruit enough

people to be trained as leaders and also to recruit enough people to fill the classes. Arkansas

found that rural program delivery challenges made it difficult to accomplish their goal of “30-30”

– having a class available within 30 days and within 30 miles of any participant who desired to

enroll in a class. They employed an innovative GIS mapping tool to identify the geographic

distribution of leaders and implementation sites, thus revealing the areas of need for further site

development. They blanketed small rural communities’ senior centers, faith-based communities,

and other strategic locations with information on the evidence-based programs through radio,

free television spots, flyers, newsletters, and local newspapers. Through partnering with the

AAAs and the Arkansas Aging Initiative they were able to recruit local leaders and provide

programs in the geographic areas that represented locations for almost 90% of older adults in the

state. Michigan also used a GIS mapping tool effectively to document available leader locations

in order to target leader training programs in needed areas. Other states focused on developing

local champions to be trained as leaders and to help recruit members of their community to

classes.

b. Transportation

Transportation was also noted as a challenge, especially in rural areas, and frequently was the

reason for the difficulty in recruiting leaders and recruiting and retaining program participants.

Leaders were typically clustered in more densely populated areas and a number of states found it

difficult to address the challenge of leaders traveling to the more rural areas to deliver programs.

Participant travel to the programs was also an issue. Some older adults no longer drove or had

limited personal transportation access. Those residing in rural areas often had limited public

transportation options to travel to the program locations. Local agencies were very imaginative

in addressing transportation issues: they found funding to provide a transportation stipend to

leaders, they scheduled programs at leaders’ convenience, they assisted with carpooling, van

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pickup of participants; and in some cases, dedicated leaders picked up participants on their way

to the programs.

c. Program Characteristics and Requirements

Other challenges in marketing and outreach had more to do with the programs themselves.

States reported that the falls management programs (e.g. A Matter of Balance) and physical

activity programs (like EnhanceFitness) seemed easier to recruit people to because participants

understood the goals of the programs and could identify how participating would address a

perceived risk or prevent a problem, whereas the Chronic Disease Self-Management programs

(CDSMP) were often a “harder sell.” On the face of it, participants often felt they were

managing just fine, and did not really understand the potential program benefits. States typically

changed the name of the CDSMP to one that was more upbeat and attractive: in California, the

program is called Healthier Living; whereas in Oregon and several other states it was known as

Living Well.

Participant retention problems for CDSMP were often addressed by adding a “class zero” for

orientation so that participants would understand more about the goals, benefits, and structure of

the program (six meetings) prior to signing up. Several states also addressed retaining

participants with an incentive such as Maryland did, by providing a book of county ride tickets

valued at $15. A very common problem in participant retention related to the characteristics of

the target audience for CDSMP – those with chronic illnesses. Participants’ health problems

often interfered with their ability to attend programs. The CDSMP curricula itself discusses

these issues and helps its participants to anticipate this potential problem in program attendance.

The expectation of a “completer” being a person who attends at least four of the six sessions also

recognizes the issue. It is an expectation that both the “buddy system” the program employs and

the expectation that leaders call participants after a missed session also addresses this challenge.

d. Outreach to Minority and Underserved Populations

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The evidence-based health promotion and disease management programs are especially relevant

for ethnic, racial minorities and low-income populations due their high chronic disease

prevalence. States sought to specifically target these underserved groups for their programs and

often faced challenges in their efforts to do so. Often recruitment was a concern – these groups

have many life challenges and becoming involved in programs such as these may not be a

priority. They may question the relevance of the programs to their own life situations. States

found that their ability to successfully recruit these groups required a multifaceted approach:

they needed to engage peer group champions and local community leaders to support program

marketing, they needed to recruit leaders who are members of the participant groups they are

trying to recruit into the programs, they sometimes had to adapt the programs to make them more

relevant, and also needed to work with trusted agencies already serving these populations as

partners and referral agencies. Recruiting Native Americans by working with Tribal entities

typically took longer for the Tribal permission process and to engage agency personnel to be

recruited as leaders so they could provide the programs to their constituencies.

Many states selected key partners specifically to assist in recruiting participants for programs,

especially those from minority and underserved low-income populations. States who partnered

with Medicaid programs found these to be very effective referral sources. Several states,

including Colorado, Maine, Maryland, and New Jersey, noted how well their state’s Aging and

Disability Resource Center worked with them in making participant referrals. Minnesota

changed partners to work with Wisdom Steps, a preventive health organization that provides

services to all tribes in the state. By doing so, they were able to recruit and train Tribal leaders in

both A Matter of Balance and CDSMP and offer multiple sessions in both programs. By taking

the extra time to find the best partner and invest in the Tribes’ own capacity to provide its

members with programs, Minnesota has established the foundation to expand programs to

address the Tribal community needs.

2. WORKER TRAINING

State grantees in the Empowering People and Communities initiatives were tasked to expand the

capacity, geographic reach, and sustainability of evidence-based health promotion and disease

management programs. To accomplish this, adequate workforce capacity for trainers, leaders,

and program coordination staff was essential. Because the Empowering People and

Communities initiatives were building on previous years of program support in many states,

existing trainer and leader capacity varied. Thus the individual state goals and activities

regarding worker training were consistent with identified needs and expansion plan

requirements.

a. Trainer and Leader Recruitment

About 75% of all states experienced a common set of challenges centered around recruiting

enough of the “right people” as trainers and leaders and getting them started in leading the

programs. The issue of having enough people to be trained as leaders was often related to small

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numbers of people living in rural regions (discussed above) and also related to having sufficient

numbers of people from underserved communities to model, lead, and relate to the target

audience of minority and low income populations. The “right people” to lead programs and train

others are those dedicated to the work, who believe in the mission and benefits of these

programs, and make the time to continue leading programs over time.

A number of states set up application and screening processes to make sure that people recruited

as potential leaders were suitable, committed, and available prior to making the investment in

their training. California was one of the states to identify these problems and they found that

selecting committed people was enhanced through two tools that the California Department of

Aging developed: 1) a website survey (SurveyMonkey) to assess prospective leaders’ readiness

and commitment level, and 2) a Leader Agreement stating that leaders would facilitate a

minimum of two workshops per year. In Illinois, staff employed multiple strategies for leader

recruitment. Strategies developed included on-site presentations at locations where potential lay

leaders work, and to volunteer organizations and community groups. A list of leader

responsibilities was developed so potential leaders understood the commitment. Peer leader

pairing was also established, and class leaders continued to identify former class participants as

potential class leaders as well.

Partnership selection also was identified as important to provide sufficient numbers from

minority affiliated organizations and communities. For example, in Oklahoma a key state level

partner is the Health Equity Resource Opportunity Network, an organization dedicated to

addressing issues of health disparities and providing services to underserved minority

populations. Other states recruited personnel from federally qualified community health centers

as leaders to serve their populations at the centers. In the four states actively targeting Native

Americans (Arizona, Minnesota, Oklahoma, and Oregon), Tribal entities were important partners

for both leader and participant recruitment.

For some programs, such as EnhanceFitness, the requirements to become a program leader were

more stringent. The more qualifications required to be a leader/trainer, the more challenging it

was to secure an adequate number of leaders. States addressed this particular challenge in

several ways. Some states, such as Arizona, had to limit program availability and expansion

opportunities due to the cost and availability of the certified fitness instructors who are required

to lead EnhanceFitness. Other states, such as Hawaii, utilized their agency networks to identify

and recruit people to become certified instructors to lead the program. Texas developed their

own fitness instructor training program to pipeline trainers into EnhanceFitness. Unfortunately,

Oregon noted that it replaced the program with an arthritis physical activity program because it

was less expensive and had less stringent leader qualification requirements.

b. Trainer and Leader Engagement and Retention

All states discussed the challenge of having a number of people trained to lead programs who

were not actively leading programs. A tremendous amount of effort was expended in getting

leaders scheduled to do the programs, and continuing to do the programs over time. States found

that leaders needed to be engaged immediately after being trained. California coordinators try to

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schedule workshops within three weeks after leader trainings and pair new leaders with

experienced ones to increase the leaders’ comfort level and dedication. Centralized scheduling

systems like the ones developed by Colorado were very helpful in keeping the available leaders

actively leading programs.

Depending on whether the majority of leaders were volunteers or paid agency staff, different

challenges presented themselves. For volunteers, keeping people active and engaged was related

to the benefits they perceived from these activities. Recognition events, such as the luncheons

sponsored by Illinois to thank and honor volunteers, were very important in volunteer leader

retention. Travel reimbursements or small stipends provided to volunteers helped them to

continue their work.

North Carolina reported that leader turnover continued to be a challenge in EBHP development

with turnover averaging approximately 25-40% depending upon the program. They found it

incredibly time consuming to recruit and train leaders and also reported that it was a costly drain

of financial resources for programs with limited funding. They addressed this issue by having

the EBHP coordinator modify, develop, and increase screening tools for new leaders and spend

more time interviewing and discussing EBHP with prospective new leaders so that they knew

what to expect prior to certification. Other tools such as a memorandum of agreement with both

the leader and the organization they worked for (if not a volunteer from the community) were

helpful in communicating guidelines, designating resources, and defining expectations.

For paid agency personnel who were trained as leaders, often this was one more job to do for an

already busy person. As Title III-D funding began to be used to support programs and these

activities continue to become an expected part of the job, agency personnel will be more

effective in providing programs. The expansion and integration goals of the Empowering People

and Communities initiatives were nothing short of an organizational culture change mandate for

many community-based organizations. Embedding the programs into the fabric of the

organizations by having their personnel trained to lead and manage the programs was a goal in

almost every state. However, when state budget cuts or program budget redirection occurred,

this jeopardized the availability of paid staff to continue to do the programs (discussed in more

detail below under sustainability). Systems transformation is a slow process, but having a

qualified work force that sees this work as an important part of their job is essential. Integrating

the value and need for the programs into the agency’s protocols enhances staff buy-in and

solidifies role expectations. In Connecticut, when agency personnel found it difficult to

incorporate falls prevention activities into their work, the agency’s intake and follow-up tools

were modified to include falls prevention automatically, cross cutting agency fall prevention

committees were developed, and fall prevention was included as a part of orientation for all new

staff.

3. INFRASTRUCTURE DEVELOPMENT

There were two major challenges identified by the states regarding effective infrastructure

development. The biggest one was leveraging funding and helping to expand systems and

agencies to provide and manage the programs. A second challenge was identifying the partners

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and getting them engaged in the mission. As noted in the introduction section of this report, the

current grant projects were building on previously funded projects that also focused on

programmatic infrastructure development. In addition, all states were required to mount their

projects using an aging services + public health partnership. By design, this identified the two

key partners who would anchor the infrastructure and lead the development efforts.

Due to previous funded projects that initiated the beginning steps of building the infrastructure,

almost all states began the grant period with some form of centralized coordination by staff at

state level agencies. A number of states were able to develop centralized resources to support

further infrastructure development. North Carolina utilized a centralized coordination approach

so that all regions of the state have access to consistent templates for various resources and

materials, as well as a database and leader tracking system. Maine state partners provided

financial resources, technical assistance, and a state business plan draft to serve as a framework

for local plans. Larger local and regional organizations obtained licenses to deliver CDSMP and

the state secured a multi-site, multi-program license to assist partners with licensure costs.

As local adoption and capacity was expanded, states often retained a centralized technical

assistance and data collection role, and made statewide resources available through their website.

Program coordination, fidelity monitoring, and program delivery was slowly transferred to the

local AAA’s and other community partners. New Jersey is a prime example, with their statewide

infrastructure for CDSMP based on shared administration/oversight within state government and

local implementation by community partners. State level personnel costs were covered by other

funding, with the bulk of New Jersey’s grant dedicated to providing seed money to local

agencies to establish local infrastructure for program delivery. Texas created the Texas Strategic

Health Partnership and reported that the state health department’s role was that of technical

advisor and referral agent to local programs.

The states’ infrastructure to deliver the programs slowly expanded like a social network through

partnership building and seed funding. Bringing needed partners onboard was very time

consuming and required many meetings, strategic alliances, memorandums of understanding,

policy incentives, and tremendous state leadership. Reluctant partners were won over through

education about the programs’ value, demonstration of return on investment, and state funding

policies to provide public funding for programs. Most states started with small geographic

regions that grew over time to programs being available in the majority of the state. In Texas,

they expanded programs in three regions from 10 counties to 58, reaching older Hispanic and

rural populations with low-incomes and high diabetes rates. In Oregon, 29 of 36 counties have

Living Well or Tomando classes available now. The Ohio Department of Aging partners with all

12 of their AAAs to disseminate EB programs. Their initial goal was to offer programs in six

AAA regions, but with additional ARRA funding they were able to expand into the remaining

six so all are now involved. California’s infrastructure grew from an initial target of seven

counties to 32 counties; and New Jersey, Florida, and Maine report full state coverage engaging

all AAA’s and all counties. State partnerships, as shown in Table 2, represent all community

sectors: public and private service organizations, housing, faith-based communities, education,

health care, business, civic groups, and others.

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4. FIDELITY AND QUALITY ASSURANCE

Protecting the fidelity of the EB programs is paramount in assuring that the potential beneficial

outcomes are protected. Fidelity monitoring and quality assurance activities are an essential

project activity for EB program delivery. For CDSMP, there are extensive fidelity tools (e.g.

check lists), and fidelity manuals and tool kits have been produced by Stanford and several states

including New York, Idaho, Colorado, Maine, Michigan, Oregon, Texas, and Wisconsin. A

number of states reported well thought out protocols and activities to protect fidelity. For

example, Massachusetts reported that in addition to recruiting and coordinating leader trainings

in all programs, the lead community partners provided mentoring, technical assistance (including

the development of websites for all programs), and support to newly trained leaders/coaches and

trainers. In addition, opportunities for continuing education and sharing of best practices have

also been available to leaders. Colorado established the Healthy Aging Service System for

training, technical assistance, and evaluation/fidelity checks. They conducted 227 fidelity visits

during the grant period and established Senior Assistant and Management System (SAMS).

During this grant period, very few states reported challenges in completing needed fidelity

activities. South Carolina noted the problem of not have enough well-trained staff at new

agencies to do fidelity monitoring. They addressed this problem by developing standardized

forms, as well as providing training, checklists, and technical assistance to the agencies.

Oklahoma reported a concern that it was difficult for them to assure that participants completed

necessary forms, but did not discuss a solution. More challenges in this area were possibly

averted due to the awareness of the necessity of fidelity monitoring and assuring program

quality, the wealth of tools and training materials available to states and organizations, and the

technical assistance provided at the national level on fidelity.

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5. EVALUATION

There are several aspects of evaluation in the Empowering People and Communities initiatives.

Agencies offering programs were required to collect attendance and demographic information

from participants in order to enter the data into the national databases. State CDSMP programs

also collect pre- and post-program evaluation forms, monitor and report drop outs, and report

those who complete at least four of the six program sessions. Fidelity monitoring activities are

critical, and are addressed above. Challenges reported included the timely reporting of data from

partner organizations. California addressed this issue by adding a component to their leader

training on the data process. The lead state coordinating organization (Partners in Care) also

works with all licensed organizations in California on a quarterly basis to ensure CDSMP

activity and evaluation data are recorded. Massachusetts reported that partner organizations had

difficulty in conducting the six-month follow-up evaluations. This problem was managed by

suggesting that partner organizations use interns and volunteers to make the six-month follow up

phone calls. They also responded to this challenge by streamlining the survey tool and by using

foundation grants to provide stipends to organizations submitting data forms. New Jersey

revised the initial data collection protocol for CDSMP to eliminate the four-month follow-up

after it was determined that the data being collected was invalid.

While not required, states also implemented more rigorous evaluation studies, usually with the

help of a university research partner. Figure 2 shows that 11 states had university partners.

Typically, the evaluation studies measured the same participant outcome measures as were used

in the original EBP efficacy studies. In one state (South Carolina), the participant outcome

evaluation protocols were so rigorous that local agencies felt they were too burdensome and the

effort was discontinued because it was not practical for the agencies to collect.

D. Sustainability

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The states approached their projects with the idea that they were building statewide partnerships

and delivery systems that would continue after Empowering People and Communities grants

ended. Sustaining the EB projects post-grant was a common goal identified in the original grant

applications. To assess how well the states’ efforts and approaches could be sustained, the

evaluators created an overall rubric that categorized a number of key features and assigned a

score ranging from 0 (not done or no information provided) to a 4 (exemplary efforts towards

sustaining the programs). These key features included a number of characteristics that identified

the approaches to sustainability and the activities undertaken to maximize funding for the

programs when the current grants ended. The features included how well states embedded the

programs into existing public health, aging and/or community based service systems; whether

new systems, units, or positions to support programs were established; whether new policies

were put in place to support programs; whether addressing sustainability was central in the

project’s design; how well documented plans for sustainability were described; and whether

additional funding was obtained during the grant period to sustain the programs.

Table 7: What evidence is there that the state’s programs will be sustained or replicated?

No info or

not done

(Score = 0)

Limited

(Score = 1) Moderate

(Score = 2) Major

(Score = 3) Exemplary

(Score = 4) Mean

Programs were

embedded into systems 0% (n=0) 8% (n=2) 21% (n=5) 50% (n=12) 21% (n=5) 2.83

Established new systems,

units or positions to

support programs 12% (n=3) 17% (n=4) 25% (n=6) 29% (n=7) 17% (n=4) 2.21

New policies were put in

place to support

programs 33% (n=8) 8% (n=2) 29% (n=7) 25% (n=6) 5% (n=1) 1.58

Addressing sustainability

was central in the

project’s design 0% (n=0) 8% (n=2) 21% (n=5) 38% (n=9) 33% (n=8) 2.96

Sustainability plans were

documented 0% (n=0) 5% (n=1) 33% (n=8) 29% (n=7) 33% (n=8) 2.92

Additional funding was

obtained 8% (n=2) 12% (n=3) 21% (n=5) 38% (n=9) 21% (n=5) 2.50

1. EMBEDDING PROGRAMS INTO SYSTEMS OF SERVICES

As shown in Table 7, all states embedded programs into existing systems, with over 70% of the

states doing so to a major or exemplary extent (mean for all 24 states is 2.83).

In Maine, the project leadership team provided support and technical assistance to partner

organizations as they sought other sources of funding to maintain the level of staff needed for

program coordination. In addition, the on-going leadership team conference calls and meetings

provided support to new lead community partners’ staff.

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EB programming was embedded into the Arizona State Plan on Aging for 2011-2014, which

included strategies and objectives that created partnerships and collaborations with community

resources to deliver the most appropriate wellness and EB programs designed to assure actives

lifestyles and independence.

Arkansas reported working with the Aging and Disability Resource Centers (ADRC), the State

Health Insurance Assistance Programs (SHIP), Centers for Independent Living (CIL), and found

the Medicaid program to be a good source for referrals.

Idaho embedded their program into Health West Inc., who plans to continue training multiple

staff as trainers or lay leaders and will continue to look for funding. The HDSP program will

support CDSMP until all resources are exhausted, and mini-grants were awarded to five of eight

sites to offer workshops through March 2012.

Maine developed partnerships between AAAs and Quality Counts and MaineHealth and Eastern

Maine Medical to integrate this work into the health care delivery system with the Patient-

Centered Medical Home pilots and Medicaid Health Home model. Maine received ARRA

funding to sustain CDSMP efforts. The Healthy IDEAS program was embedded into the current

statewide screening for waiver programs for the long term.

A Matter of Balance and CDSMP were embedded into each of Minnesota’s six AAAs and

Wisdom Steps programs. New Jersey worked with local public health departments, Chronic

Disease Prevention and Control, and Minority and Multicultural Health to integrate CDSMP into

their service delivery models and each dedicated funding and staff to the program. The two

agencies that piloted Healthy IDEAS continue to offer it through care management protocols.

Other agencies obtained foundation funding (Grotta Fund) to replicate Healthy IDEAS. Nine

agencies have integrated A Matter of Balance into their agency operations without any additional

funding. DHSS will continue to coordinate and support program delivery through these local

agencies.

Texas reported offering programs in all community sectors – AAAs, federally qualified health

centers, medical organizations, faith-based housing, recreation organizations, and nutrition sites.

2. ESTABLISHMENT OF NEW SYSTEMS, POSITIONS, UNITS OR PROGRAMS

Fewer states established new systems, units, or programs in support of sustaining the programs.

About one-quarter did so to a moderate extent, while not quite half reported development in a

major or exemplary manner. Eleven states (29%) either did not establish new systems, units, or

positions, or did so to a limited extent.

New staff positions were created by several states. In Maine, regional coordinator staff positions

have been developed within implementation partner organizations for Healthy IDEAS and

Hawaii established a sustainability consultant position. North Carolina implemented the EBHPs

Infrastructure Task Force to convene quarterly meetings/conference calls and maintain an email

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listserv of members and send regular updates. They also developed a regional infrastructure

coordinator position in Centralina and established a regional EBHPs committee.

For outreach purposes, Illinois established a referral system with the Department’s Tobacco

Quitline and WiseWoman Program, as well as the Illinois Department of Health and Family

Services’ Illinois Health Connect program to reach Medicaid clients. Other states brought

project stakeholders together into networks to support the programs. In Massachusetts, they

established the Action for Boston Community Development, Inc. (ABCD) to work with state and

community partners on falls prevention programs and explore funding to create Healthy Aging

and Wellness Clubs at its Neighborhood Service Center sites throughout Boston. These clubs

would offer professional supports and EBDPs.

A number of states established centralized systems to provide technical assistance and support

for program expansion and sustainability. Wisconsin was one such state that created centralized

systems to train leaders, organize and promote workshops, provide leader materials, and provide

fidelity and quality improvement oversight. CDSMP and Stepping On are embedded in 75% of

the state. Texas established a nutrition and physical activity workgroup called “Texercise” – a

collaborative program with health and aging services to promote physical activity which

involved the Government Council on Physical Fitness. Minnesota created a “start-up” package

to get AAAs equipped to offer programs and provided training on data collection and cost

analysis. Wisconsin established the Wisconsin Institute for Healthy Aging and Community

Academic Aging Research Network, and Michigan created a new AAA program outcome

assessment to monitor EBHP objectives and evaluate programs using the RE-AIM model. Ohio

stated that their key emphasis was placed on sustaining programs by forming partnerships and

ensuring that the state was dedicated to the cause by embedding the initiative into the State Plan

of Aging.

3. NEW POLICY DEVELOPMENT

Even fewer states were able to enact new policies to support program sustainability. Eleven

states did so in a major or exemplary way, and 10 either did not or did so in a limited way. Of all

the features assessed to support sustainability, new policy development was the least frequently

reported (mean for all 24 states = 1.58 on a scale of 0 to 4).

A number of states reported that policies were put in place to direct AAA’s to use Title III funds

to support local programs. For example, Colorado reported that their SUA put in policy

language so AAAs could use Title IIIB, C1, C2, D, and E. North Carolina, South Carolina, and

Oregon each detailed the development policy mandates for Title III.

Some states were successful in creating state legislation that was funded in support of the

programs. In September 2009, the Connecticut special legislative session created a statewide fall

prevention initiative that became Public Act 09-5 and continues to receive yearly funding from

the state legislature. Massachusetts reported that implementation of EBDPs is the top program

and policy initiative for the Councils on Aging and was actively being promoted by the

Massachusetts Association of Councils on Aging. Massachusetts also reported another example

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of the impact on public policy is the three-year collaboration of the Tufts Health Plan Foundation

and the Massachusetts Health Policy Forum on a statewide healthy aging initiative. A coalition

of leaders from these groups formed a Healthy Aging Steering Committee to examine

community-based, environmental, and systematic approaches to promote healthy living and

healthy aging. The Texas EBDP clearinghouse was formalized under Executive Order RP42 in

2005 and legislation was passed to provide grants to local communities to offer physical activity

programs. Texas also formed a falls prevention coalition that received funding.

While still a work in progress, California reported that the Medicaid Section 1115 waiver

(“Bridge to Reform”) may afford CDA the opportunity to offer EB programs as part of the

Department of Health Care Services (DHCS) pilot service delivery system. Partners in Care (the

state resource center) attended meetings of the Right Care Initiative to foster collaboration across

managed care plans in implementing prevention and self-management programs. The California

Department of Aging is in the process of conducting a pilot test to determine whether clients in

the Medi-Cal Home and Community-based Waiver Program for the Elderly are appropriate for

participation in CDSMP.

4. SUSTAINABILITY AS A PROJECT THEME

Addressing sustainability was a central feature in states’ project design for all states. All but two

states focused on sustainability in a moderate or more extensive level (92%). By focusing on

sustainability from the very beginning of project development, states built their projects to

continue after project funding.

Texas began their project with sustainability planning and has continued these efforts with the

awarding of the ARRA grant. While these funds have assisted with maintaining current efforts

and aiding in programmatic expansion, they recognized that federal grants might not be a long-

term solution. Plans for sustainability therefore were outlined on several levels, including

replicating EBDPs in other organizations such as additional AAAs and the Veterans

Administration; embedding the programs in hospital systems, health care organizations and

through other health care providers; entrenching the programs into the local and regional public

health entities and federally qualified health centers; developing a program referral system for

managed care organizations; and working to achieve Medicare and Medicaid reimbursement.

A number of states, including California, Illinois, and Colorado, selected partner organizations

with capacity to sustain programs. In California, partnerships were formed from the beginning to

ensure sustainability and energies were channeled throughout the duration of the project to reach

the highest number of participants in the most sustainable communities. Illinois also selected

partners who were likely to be able to sustain programs. Emphasis was placed on embedding

programs into sustainable systems and delivering gap-free service to PSAs. Where partners fell

off, other active partners stepped up to take responsibility for training so no PSA suffered.

In Florida, all AAAs were required to offer at least three EB workshops per year using their Title

III-D funds, and EB programs were embedded into two large organizations: Visionary Vanguard

and the Health Foundation of South Florida. Several states discussed how they used their early

grant periods to do extensive planning for sustainability. In South Carolina, they recognized

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early on that relying on continuous grants from AoA and CDC to award mini-grants to local

agencies to do programs would not be sustainable. Maryland used part of their ARRA CDSMP

grant to fund a sustainability assessment for each local program to clarify the status of their

programs’ sustainability. Because North Carolina wanted to ensure sustainability, they first pilot

tested their infrastructure roll out in one region to form a protocol replicable in all AAAs.

Minnesota’s business planning efforts identified cost analyses in efforts to engage Medicaid and

health care partners.

5. SUSTAINABILITY PLAN DOCUMENTATION

States also documented their sustainability plans and activities very well in their final reports,

with only one state failing to do so. Fifteen states provided major or exemplary evidence of their

sustainability efforts (62%).

Colorado reported that their project would continue but with stronger local and regional support

and less centralized support. Local partners had all developed sustainability plans to provide

workshops (on a more limited basis) without state funds. Ohio’s prevention goal was included in

the 2008-2011 State Plan of Aging – “Develop a statewide training infrastructure to support local

implementation of at least three evidence-based disease prevention and health promotion

programs.” Ohio’s goal in the current state plan (2012-2013) is to “Embed evidence-based

prevention programs into communities and organizations, creating a culture of healthy aging for

Ohioans.”

Texas provided quite a detailed plan for the AAA regions they targeted. The Bexar AAA

reported that classes would continue to be offered at various locations within the community

with the assistance of partner agencies and dedicated leaders. At the Brazos Valley AAA,

programs continue to be sustained through its community partners which have embedded

CDSMP/DSMP and A Matter of Balance within their individual organization’s existing

programs. Active senior residential facilities tend to find that the CDSMP/DSMP and A Matter

of Balance classes are an effective marketing tool to increase their resident numbers. BVAAA

has additional funding available through the ARRA program and Title III-D instruction and

training dollars through the AAA to continue supporting evidence-based programming in the

region. Humana continues to fund the A Matter of Balance program throughout the Texas

Association of Area Agencies on Aging by contributing $100,000.00 each year. By utilizing

students, BVAAA is able to provide workshops in the community at a minimal cost.

New York reported not only embedding of the evidence based programs within program delivery

by partners, but also building a continuation strategy for local master training and leader

capacity. They also noted their work with HMOs, hospitals, senior centers, NORCs, and RSVP

to commit resources and staff time to support sustainability and beginning to explore more

formal reimbursement and funding. They had a commitment of state resources to fund training

and fidelity management at the University of Albany and a plan for coordinating with CDC and

other AoA initiatives to support and expand program efforts.

Massachusetts is piloting the use of nutrition consultations for Healthy Eating participants, which

are reimbursable by Medicare. Opportunities are also being explored for collaboration between

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community-based organizations offering CDSMP and health care providers. Massachusetts was

also planning on Medicare reimbursement for DSMP and incorporation of CDSMP in their Care

Transition models as opportunities for sustainability. Additionally, representatives from Hebrew

Senior Life, Elder Services of the Merrimack Valley, and NCOA were engaged in negotiations

with a major health care plan to purchase both community CDSMP and online CDSMP for plan

members to make both models available to members statewide, particularly those in the top 20%

of the plan’s cost drivers.

6. NEW FUNDING

Eighty percent of states identified successes in securing additional funding to keep the programs

going after the Empowering People and Communities grants ended. A variety of types of

funding were secured and many states sought to have a diversity of funding sources.

Use of Title III funds was common as a continuing program support source as noted above.

Colorado, Hawaii, Massachusetts, Oregon, New Jersey, Michigan, and Ohio all reported having

received philanthropic foundation funding. Additional state or local public funding was reported

by California, in that they used Community Development Block Grant (CDBG) funding to

sustain access to EB programs in Los Angeles through the LA City Dept. of Aging. The Ohio

Department of Aging has included EBDPs as a fundable activity with the new Enhanced

Community Living Medicaid Waiver service. In addition, in the department’s biennium budget

proposal, Senior Volunteer Subsidy funds have been targeted to Senior Corp Programs that

implement and/or support EBDPs. Oregon reported they were exploring the use of Public

Employee and Oregon Educators Benefits Boards funds for reimbursement sources. A few states

reported working with the Veterans Administration integrated networks and also with Title V

Senior Employment. Oklahoma’s state Department of Corrections received grant funding to

continue CDSMP in their prison system.

North Carolina states that even though no additional funding was obtained, existing AAA

funding was being leveraged to support the coordinator position in Centralina, and a mixture of

state and federal funds, as well as a private contract, will be used to provide EBHP services.

North Carolina was continuing to collaborate with Community Care of North Carolina

organizations, public-private partnerships that serve as medical homes and care management

organizations in order to address quality, utilization, and cost issues in Medicare and Medicaid.

The hope is to expand this model and generate financial resources and sustainability.

The Wisconsin Partnership Program provided their new not-for-profit organization, the

Wisconsin Institute of Healthy Aging, a “Bringing Healthy Aging to Scale” grant. In addition,

funds for falls prevention and physical activity programs were also supported by CDC in

Wisconsin and a number of other states.

E. Lessons Learned

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Throughout the states’ final grant reports, they identified a substantial number of lessons learned

during the grant. The more than 120 lessons documented by the states were organized using the

RE-AIM framework for discussion here. The RE-AIM framework is commonly used to describe

health education and other preventive health program activities in the community (see RE-

AIM.org). Table 8 provides the frequency counts of the lessons within each RE-AIM category,

whereas Table 9 shows the numbers of states that identified at least one lesson by RE-AIM

category.

Table 8: Lessons Learned – Number of Lessons by RE-AIM Category

RE-AIM Category Frequency (N=122)*

Reach 17% (n=21)

Effectiveness 15% (=19)

Adoption 22% (n=27)

Implementation 16% (n=19)

Maintenance and Sustainability 29% (n=35)

Other 1% (n=1)

NOTE: States could identify more than one lesson per RE-AIM category

Table 9: Total Number of States That Identified Lessons Broken Down by RE-AIM

Category

RE-AIM Category Total # of States That Identified at Least One

Lesson Learned in This Category (N = 24)

Reach 42% (n=10)

Effectiveness 50% (n=12)

Adoption 75% (n=18)

Implementation 58% (n=14)

Maintenance and Sustainability 67% (n=16)

Other 4% (n=1)

1. REACH

Lessons within the Reach category were reported by over 40% of the states. A number of states

offered lessons learned around program recruitment, which was a common challenge.

Massachusetts described their multifaceted approach to outreach and marketing for the programs.

They reported their best practices that were implemented as: conducting information sessions;

offering programs in places where older adults already congregate; collaborating with medical

providers, insurance companies, corporations, inter-faith organizations, and wellness centers; and

developing a yearly calendar of EBDP offerings. Productive sources for referrals and activities

were also described.

Michigan also described a very comprehensive set of lessons learned in their outreach efforts. To

reach the intended target audiences, they selected regions representing high-ethnic, low-income

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populations to target recruiting into programs. They used GIS maps to identify underserved rural

areas where more trainers and programs needed to be developed. They documented leader

recruitment and retention strategies identified by coordinators and disseminated these among

coordinators and master trainers. They also developed relationships with Geriatric Medicine

Fellowship programs at University of Michigan, Michigan State University, and Wayne State

University to include CDSMP and other evidence-based self-management programs as part of

their community resources segment of fellowship training. Partnering with college medical

schools provided venues for provider training and recruitment via referrals.

Arizona found that EnhanceFitness classes were a good referral source for A Matter of Balance

program classes and CDSMP workshops, as participants were already engaged in their own

health care and were interested in taking a greater role. Texas also found EnhanceFitness was a

good “feeder” program for other EBPs. Oregon used the Oregon Tobacco Quitline as a referral

source and did cross-referral with CDC disease management programs, while New York found

that the RSVP provided a good source for leader volunteers.

South Carolina developed an Ambassador Program for CDSMP completers as an innovative

approach to program recruitment. Oregon relied on the state website, toll free number, statewide

branding, marketing, listserves, and workshop information sessions. Texas found that in rural

areas, the use of local champions was effective, while in high volume areas, they expanded

workshops venues to non-senior specific locations such as libraries, senior apartment complexes,

community centers, and faith-based centers. In urban areas, Wisconsin found success in using

bus shelter and bus advertising effectively to reach urban low-income, inner-city participants and

was also pleased with the response from the 70-radio station ad campaign that they ran. New

York also noted successes in using peer leaders as program champions. They also found that

training more Tomando leaders increased Hispanic participation.

Oklahoma was one of three states to discuss bringing CDSMP into prison systems. They found

that providing programs to inmates in prison reaches a younger, although chronically ill,

population and results in decreased behavioral/disciplinary problems and may reduce health care

costs.

For states serving rural regions, transportation was noted as a major barrier for rural outreach.

Oklahoma suggested that programs would need to provide transportation services in order to

overcome this barrier. They developed ride sharing programs, scheduled classes after other

activities at times when people would already be at the site, and in some cases, their program

leaders picked up participants on their way to the site.

2. EFFECTIVENESS

Program effectiveness lessons comprised about 15% of the total number of lessons identified,

and was reported by about half of the states. Lessons in the Effectiveness category focused on

the effectiveness of the EB programs themselves.

South Carolina had a very extensive program evaluation in place intended to measure

effectiveness, but it proved difficult to implement. They ended up listening to local providers

and changed the scope of evaluation to be more manageable.

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Lessons about effective volunteer recruitment and management were specifically documented.

Massachusetts found that volunteer placements for classes frequently worked best when the

volunteer is paired with an experienced staff person who can ensure that everything is ready for

the class and provide consistent support and follow up to the volunteer leader. They also found

that volunteers worked best if they only have responsibility for teaching classes with the staff

person coordinating all other details. Texas found that employing a formal review and interview

procedure with prospective leaders improved the quality and activity level of lay leaders.

California noted that when facing leader recruitment and retention challenges, it was beneficial

to develop tools to strengthen the screening and orientation process through its online survey and

a leader agreement.

Arizona found that tracking fitness in the EnhanceFitness classes by way of fitness checks

allowed participants to track their progress throughout the duration of the class and that the

buddy system kept the participants coming back to class and recruiting other participants to take

the class.

3. ADOPTION

There were many lessons identified in the realm of program adoption. Seventy-five percent of

the states identified lessons in this category and adoption lessons comprised 22% of all lessons

reported. Working with partners to expand the delivery of programs and embed them into the

agencies was challenging and states gained a great deal of knowledge from their efforts.

Lessons around program coordination and administration were plentiful. A number of states,

such as Arizona, identified the critical importance of having a dedicated employee who was

focused specifically on heath promotion within the AAAs. New Jersey reported that for them it

may have been more effective to delay program delivery until key administrative processes were

in place. For example, little to no screening was done initially for CDSMP leaders. As a result,

many trained leaders never led a workshop. The recruitment and screening tools that were

created in subsequent years of the grant helped to more effectively train only those people who

understood the program and the commitment. It is important to ensure that the leadership of the

partner agencies fully understand and are committed to the concepts of the program, some of

which include changing their business processes. With their buy-in, resistance among care

managers/staff could be more easily addressed.

Connecticut states that champions must be on board from the beginning of the project. Without

a project champion from day one, it is very difficult to make inroads into communities and to

establish buy-in from potential partners. The role of a statewide coordinator was vital, according

to North Carolina, to the success of building an EBHP infrastructure, and this role needs to be

replicated at a regional level as well. Maine stated that clearly defining responsibilities and

outlining commitments at each juncture of the project is important for successful adoption to

ensure a coordinated, planned approach from implementation to sustainability.

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Wisconsin worked with federal programs such as the HRSA Area Health Education Centers

(AHECs) and federally qualified health centers (FQHCs) and found them to be a good vehicle to

attract trainers and offer programs to rural and underserved populations. Florida stated that it

was imperative for program partners (AAAs and other community based organizations) to be

educated about the value of EB programs for older adults. As a result of this grant, the AAAs

are not only maintaining current EB programs, but many are planning to adopt and implement

additional programs.

Wisconsin had a difficult time implementing the HomeMeds program. The lessons they shared

were that introducing the program was challenging for a number of reasons, such as no

perception of need; requirements for new partners (pharmacist); new software; and that the

program took more time than anticipated for outreach and coordination. Agency staff recognized

the need for medication education but are incorporating this component into other programs

rather than continuing HomeMeds.

California provided a number of lessons about adoption. They found that it was important (and

very beneficial) to engage large, well-established networks to adopt and deploy these programs

within their systems. In addition to helping meet performance goals, this also aided with

sustainability once grant funding ended. The rate of return was much higher than making direct

outreach to program staff in local agencies that often needed higher-level approval before they

could become involved in offering/sponsoring the EB programs. This also helped in leveraging

funding, as many host organizations sought and obtained private funding/reimbursement for

workshop participation. This also helped the Department of Aging to set a fee structure in place

that could be used in either supporting program expansion or compensating for resources

provided to develop program capability.

Both Texas and California found that they could be more effective by embedding EBDPs into

AAA activities by partnering with organizations that have similar missions such as health care

providers and managed care organizations.

4. IMPLEMENTATION

There were 19 lessons reported by a little over half of the states (58%) within the Implementation

category. The major lessons were about maintaining program fidelity and quality of the

programs, and best methods of organizing the programs effectively. New Jersey noted that

increased attention was needed to maintain program fidelity and ensure quality. A key role for

the state continues to be the development and oversight of protocols to foster quality at all levels

of program implementation. Wisconsin provided in- person fidelity monitoring for all new

leaders and developed refresher sessions to ensure reinforcement of critical CDSMP

implementation elements. In addition, all leaders will receive updated curriculum training in

early 2013.

Another implementation lesson identified by Wisconsin was that when ADRCs utilized the cost

calculator for CDSMP and Stepping On it helped inform the state about cost variation within

different community settings. They also reported that they developed a monitoring timeline to

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identify potential workshop cancellations and a four-step plan to provide technical assistance to

increase participant recruitment and ensure leader quality. They also found that their approach

of awarding mini-grants to 14 communities enhanced efforts to engage volunteers as leaders,

members of speakers’ bureaus, and recruiting experts.

New York reported their approach to combined leadership was improved because of specific role

delineation. The state level provided centralized resources (training, TA, website, data

management and analysis), while the local agencies built community delivery system and owned

coordination for area programs. Partnership and teamwork were essential to their

accomplishments.

Massachusetts reported that their success in partnership development has been due to the model

of collaboration created to implement EBDPs. Organizations have collaborated in marketing the

programs, bringing leaders from different organizations to co-lead workshops, and sharing

among them other resources like transportation, space, and materials. Connecticut also

mentioned how important team building was to their efforts. Since Connecticut is a small state,

they felt that strong partnerships among state agencies are crucial to project successes and

sustainability. The strong partnership between state partners played a major role in project

development with each agency providing the knowledge and connections that the other lacked.

Texas found that partnering with a university school of nursing provided valuable training for

nursing students and good program leaders after their training (inexpensive, too).

The continued role of the state level agencies appeared critical to assure ongoing program

quality. In South Carolina, they developed a fidelity tool kit and noted that the training and

fidelity manual continues to be important as a centralized resource to assure program quality.

The important state oversight role was reinforced by Oklahoma and Colorado. Oklahoma held

regular partner meetings between state and local agencies to instruct agencies on processes and

expectations in order to reduce initial grants monitoring problems. Colorado felt that providing

state-led centralized resources and functions to local agencies is important to ensure

sustainability and maintenance.

5. MAINTENANCE AND SUSTAINABILITY

The Maintenance and Sustainability category was by far the most frequent category for lessons

learned within the RE-AIM framework. Over two-thirds of all states reported 35 lessons in this

category. This is not surprising since this series of grants was the first to emphasize building and

sustaining statewide systems for the EB programs. States approached their projects with enough

background to understand how to build programs in small areas, but learned a great deal with the

efforts to expand and sustain them. The states understood the need for key stakeholder input,

administrative coordination expertise, and strong partnerships. New York promoted using

business planning principles to approach sustainability and to diversify funding sources in

sustainability planning. Oregon emphasized the need to support staff coordination of programs

and the importance of the stability of leadership.

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Maryland stated that networking and training of coordinators was key, but that much was gained

through feedback from independent focus groups to help them identify the key issues impacting

program delivery. They also cautioned against separate communication and reporting systems if

coordinators were running the same program but with different funding source. They found that

efficiency was highest when they were funding experienced organizations who were motivated

to grow the program, have staff paid for through the grant, and utilize in-kind resources in

addition to grant funds. Program efficiency was lower when there was not staff funds allocated.

Massachusetts also noted that partner organizations have had more luck recruiting younger

volunteers, especially students in the Boston area who have school requirements for volunteering

and/or internships. Ohio found that the use of online websites, such as Craigslist, Idealist, and

Volunteer Match, as well as graduate school volunteer and career fairs were good sources for

volunteer recruitment to maintain programs.

Ohio felt it was important to ensure program sustainability and scalability through buy-in from

the aging network, primarily their 12 AAAs, and a strong array of partners that are committed to

embedding and sustaining EB programs. For Ohio and other states, partnership development

was a large component of this project.

A number of states identified additional federal funding to help sustain the programs developed

during the grant cycle. Colorado recommended involving the state Medicaid office leadership as

part of project planning and advisory committee from the start. Oklahoma reported that the

policy to require AAA’s to use Title III-D funds for EB programs provided a needed source of

funds to enhance sustainability. They were also successful in involving local businesses as a

financial source of support for sustaining programs, as was Wisconsin. Idaho suggested engaging

health districts in sustainability planning from the beginning to ensure their maximized role

capacity during and beyond the duration of the project funding. In Connecticut, even though

there wasn’t great success with Medicaid integration, they felt that CDSMP could begin to

sustain itself by leveraging funding from other state and federal programs and partnering with

initiatives such as the ADRC to build the program base.

The Florida report stated, “Reasonable flexibility is a pillar that holds the project up as much as

the funding does.” They felt that while it was important to standardize contracts, they should

also be based on the number of completers by grantee. In that way, they can have a measurable

outcome while incentivizing providers to engage participants and yield a high number of

completers per workshop. This worked better than initiating contracts based on reimbursement

for lay leader trainings, participants and workshops, incentives, or license fees.

Two states (Hawaii and Oklahoma) noted that EnhanceFitness was costly and due to its

popularity, attrition and turnover are low, which results in the need to add new sites and

programs that require funding to keep up with program demand. Oklahoma noted that there was

potential for program support by businesses that perceive that the programs will benefit their

employees. However, they found that costs and administrative protocols made EnhanceFitness

challenging to sustain and that Tai Chi was more affordable and easier to do.

Wisconsin was unique in establishing the collaborative, non-for-profit Wisconsin Institute for

Healthy Aging (WIHA) so they were able to apply for additional grant funding. They, like many

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other states, recruited diverse stakeholders to help maintain and sustain the programs. HMOs,

medical providers, and universities continue to provide workshop support, referrals, and leaders,

as well as targeted marketing to Parkinson’s and cancer support groups. The Wisconsin’s 2020

state plan includes CDSMP as a key intervention strategy for Chronic Disease Prevention and

Management; the Arthritis, Diabetes, and Heart Disease and Stroke Programs includes CDSMP

in their state plans as well.

Understanding all of the components and costs for program continuation is essential to garnering

more support from a variety of sources. Maine reported that it is not only important to have

adequate capacity in place at the initial stage of program implementation, but it was also critical

to anticipate what resources (including personnel, tools, policies, and practices) would be

required to sustain operations when targets have been met and funding decreases. Hawaii found

that having good outcome data on participant health improvement and costs provided the basis

for state budget support of EnhanceFitness.

F. Products Developed

Throughout the course of the projects, states developed and produced numerous resources for a

variety of purposes. The evaluators sorted over 200 products and resources into five categories,

including publications, tools, protocols and guidelines, branding materials and other, which

included websites and presentations (see detailed list provided as Appendix C). Frequencies for

these five types of publications are listed in Table 10. The publications category included

several types of publications, with the majority being newsletter and newspaper articles

published about the programs. Several states also had manuscripts published in scholarly

journals including New Jersey, Oregon, South Carolina, and Texas.

Of all the types of resources and products developed, 16% were publications. Half (50%) of the

states produced materials that were categorized as publications (see Table 11). Products were

listed in publications only if there was a reference to where the materials were published,

whether in a journal, newsletter, website, or other type of source. If a report was produced for

internal use (e.g. evaluation report) those types of products are listed in the New Tools and

Materials category.

Of note, Hawaii produced a curriculum for EnhanceFitness with Asian Pacific Islanders and New

Jersey produced a Blueprint for Healthy Aging. In addition, the New Jersey CDSMP model was

highlighted in the National Association of Chronic Disease Directors’ publication “Meeting the

Challenges of an Aging Society – The Experience of State Health Departments” and an article on

the Ohio program was published by NASUAD, “Ohio’s Aging and Mental Health Networks

Partner to Strengthen Services to Aging Ohioan,” Volume 3, Issue 6, July 2010. Oregon

published “Healthy Aging: Programs That Make a Difference” (2009) and a Living Well Impact

Report in 2010. South Carolina published a report on “Dissemination of an Evidence-based

Program to Reduce Fear of Falling in Three Geographic Areas in South Carolina” and Texas

published two journal articles on the program and its outcomes.

Table 10: Total Resources and Products Developed

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Resource/Product Frequency

(Total # Developed)

Publication 16% (n=35)

New Tools and Materials 43% (n=92)

New Protocols/Guidelines 5% (n=11)

Branding Materials 22% (n=47)

Other 13% (n=27)

TOTAL OF ALL RESOURCES/PRODUCTS DEVELOPED N = 212

Table 11: Total Number of States that Developed Resources/Product by Type

Resource/Product Total Number of States that

Developed This Resource/Product

(N = 24)

Publication 50% (n=12)

New Tools and Materials 92% (n=22)

New Protocols/Guidelines 33% (n=8)

Branding Materials 83% (n=20)

Other 58% (n=14)

NOTE: Percentages across all resources/products are not meant to equal 100% since states produced multiple

products within and across categories.

During the projects, 92 new tools or materials were developed for use in program design,

implementation and evaluation. Almost all (92%) of the states produced materials in this

category. A number of states produced implementation manuals and toolkits (California,

Maryland, New Jersey, and Wisconsin). Five states (Colorado, Maryland, Michigan, New York,

and South Carolina) produced fidelity manuals; however many states reported producing tools

for fidelity management. Two states (Arkansas and Oklahoma) reported developing mapping

tools to identify locations of leaders and training programs, which helped prioritize geographic

areas for development.

States also produced a number of innovative and useful program materials for outreach,

marketing, and education. North Carolina developed two games, Leader Bingo and Jeopardy, for

use in leader trainings and retreats. Several states, including Massachusetts and Oregon,

produced instructional CDs or DVDs for training and three states (Maryland, North Carolina and

Texas) developed prescription pads for health care provider referrals. Texas developed extensive

patient education materials as well. Two states (Massachusetts and Oregon) produced business

plans that focused on sustainability planning. In addition, Minnesota developed A Matter of

Balance curriculum for people with low vision, which was adopted by MaineHealth; and South

Carolina developed an Ambassador training program for leaders to assist with outreach and

program marketing for CDSMP.

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About one-third of the states developed new protocols or guidelines to assist the implementation

of their projects. In total, eight new protocols or guidelines were produced. These products

provided guidance on leader roles and job descriptions (Connecticut and Illinois), project

organization and system models (Colorado and Hawaii), policies and procedures manuals (North

Carolina), and guidance on using Title III-D funding for program support (Connecticut).

Program promotion, information, and branding materials were frequently produced by the states,

with 83% of all states reporting on almost 50 examples of program promotion and branding

materials overall. These materials included brochures, flyers, press kits, radio public service

announcements, videos, and posters. Maryland designed and produced t-shirts. New York noted

that the brochures and posters they designed were adaptable to other programs.

In addition to the four types of products and resources discussed above, there were additional

materials that were listed in the “other” category. Project websites and PowerPoint presentation

materials were the primary types of resources listed in the “other” category. Please see

Appendix C for a complete list of all products and access information provided in the state

reports.

G. Conclusion

The funding provided by AoA to the 24 states came at a critical time in the building process for

statewide systems to expand programs and establish infrastructure for program delivery and

continuation. Much of the success documented in this report rests on the previous building

blocks of funding provided that launched the states to the capability and capacity to do more.

The commitment of state leadership, local champions, dedicated staff and volunteers, and willing

partners are the critical ingredients that brought about the successes and achievements that have

been documented. The work within the 24 states, especially those with exemplary achievements,

are models for all states to follow. By documenting the challenges – those bumps along the road

of progress and lessons learned – and the tools and materials produced, future efforts will

benefit.

The states were very effective in problem solving and addressing their challenges. Within the

lessons learned, we identified a number of recommendations that may be helpful to others in

future work. We’ve organized these recommendations within the Re-AIM framework and

provide them in list form in Appendix D.

The evidence-based programs have tremendous potential for improving health outcomes and

quality of life for those living with chronic illnesses. These programs may also be important

tools for care transitions, risk reduction, health care cost savings, and healthier communities

through partnership coalitions. The challenge is taking the programs to scale nationwide and

reaching those most in need. The 24 states funded through these initiatives have created the

models to follow. They have documented that systems can be transformed to provide health

promotion and disease prevention programs to help older people one agency, one community,

one region, and one state at a time.

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APPENDIX A: DATA EXTRACTION TOOLS AND SCORING RUBRICS

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Table 1: NCOA/AoA State Reports Analyses Rubric – Outcome Achievement – “How well did the state achieve its project outcomes?”

Variable

Did not provide

information or

no goal

(score = 0)

FELL SHORT

of achieving

outcome goals

(score = 1)

MET

outcome goals

(score = 2)

EXCEEDED

outcome goals

(score = 3)

EXEMPLARY

in achieving

outcome goals

(score = 4)

Notes

Program

Completers

# of

Trainers/Leaders

Key Partnerships

Geographic

Coverage/Target

Population

Aging/Public

Health

Leadership

Quality

Improvement/

Fidelity Plan

Sustainable

Infrastructure

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Table 2: NCOA/AoA State Reports Analyses Rubric – Common Challenges and Solutions

Categorize challenges using RE-AIM framework

Challenges Solutions Solution Codes

REACH. Examples could include: inability to recruit

participants; inability to reach target population; inadequate

geographic coverage; rural challenges (geographic

isolation, transportation)

EFFECTIVENESS. Examples could include: limited

partnerships/capacity building; inability to provide

evaluation results

ADOPTION. Examples could include: lack of

organizational support; limited infrastructure development

(including leader capacity); lack of adequate administrative

staffing; senior center challenges

IMPLEMENTATION. Examples could include: limited

registration and referral systems; challenges with fidelity

monitoring and quality assurance

MAINTENANCE AND SUSTAINABILITY. Examples

could include: lack of adequate funding; limited success in

embedding into existing infrastructure, policies,

procedures; unable to ensure an adequate workforce;

problems in recruiting/retaining trainers and leaders

OTHER

Solution Codes:

1 = Leverage Funding 5 = Develop Strategic Planning Activity

2 = Find New Funding 6 = Enhance Current or Develop New Program Component(s)

3 = Refine Current/Form Additional Partnerships 7 = Enhance Current or Develop New Management Component(s) (Infrastructure Improvements)

4 = Develop Protocols 8 = Other

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Table 3: NCOA/AoA State Reports Analyses Rubric - Impact for State – “What impact did the state’s project achieve?”

Variable

No information

provided or not

done

(score = 0)

Limited

(score = 1)

Moderate

(score = 2)

Major

(score = 3)

Exemplary

(score = 4) Notes

Engaged state leadership

in systems level

strategic planning

Created aging service +

health partnerships

Reached rural, minority

or underserved

populations

[To include a list of underserved

populations reached]

Increased capacity of

local agencies to deliver

EB programs

Progress toward

sustainability/funding

Expanded geographic

reach

Created infrastructure

for program delivery,

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Variable

No information

provided or not

done

(score = 0)

Limited

(score = 1)

Moderate

(score = 2)

Major

(score = 3)

Exemplary

(score = 4) Notes

referrals and registration

Goals, achievements and

successes aligned with

AoA

Offered more programs

than CDSMP

Measured outcomes

[Outcomes or evaluation efforts

only]

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Table 4: NCOA/AoA State Reports Analyses Rubric – Lessons Learned

Categorize lessons learned using RE-AIM framework

Lessons Learned

REACH. Examples might include: marketing

successes; participant engagement strategies; outreach

to diverse populations; outreach to target populations;

referral strategies; addressing rural issues

EFFECTIVENESS. Examples might include: types

of partners, models for collaboration (formal or

informal); shared leadership (aging and public health);

national, regional and/or multi-state partnerships;

evaluation efforts

ADOPTION. Examples might include: inter- or intra-

agency efforts; organizational champions; staff

training and buy-in; established advisory councils;

written protocols for referring; embedding in

electronic medical records

IMPLEMENTATION. Examples might include:

internet-based calendaring; rolling admission; cross-

referral of multiple evidence-based programs; fidelity

monitoring protocols; continuous quality improvement

planning

MAINTENANCE AND SUSTAINABILITY. Examples might include: leveraging funding/new

funding; policies and procedures at the agency and/or

state level; developing a business plan; formal

partnerships with Medicaid and/or other healthcare

entities; workforce capacity; workforce tracking;

workforce engagement strategies; use of incentives

OTHER

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Table 5: NCOA/AOA State Reports Analyses Rubric – Number of Older Adults Reported by Individual Programs

Program Stated Goal # Served Completed

# and %

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Table 6: NCOA/AOA State Reports Analyses Rubric – Sustainability – “What evidence is there that the state’s programs will be sustained

or replicated?”

Variable

NO

information

provided or not

done

(score = 0)

LIMITED

evidence

(score = 1)

MODERATE

evidence

(score = 2)

MAJOR

evidence

(score = 3)

EXEMPLARY

evidence

(score = 4)

Notes

Programs were

embedded into

systems

[to include the list of organizations]

Established new

systems, units or

positions to

support programs

New policies

were put in place

to support

programs

Addressing

sustainability was

central in the

project’s design

Sustainability

plans were

documented

Additional

funding was

obtained

[list or describe funding]

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Table 7: NCOA/AOA State Reports Analyses Rubric – Resources and Products Developed

Name and Describe

Resources/Products/Innovations Point of Access

Check all that apply

Publication

New tool

(evaluation,

media, etc.)

New

protocols/

guidelines

Branding

materials Other

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APPENDIX B: CASE STUDIES OF FIVE GRANTS

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California Initiative to Empower Older Adults to Better Manage Their Health

Grant Award: 90AM3122

B.1 Introduction

California’s Initiative to Empower Older Adults to Better Manage Their Health grant was

awarded to the California Department of Aging (CDA) in October 2006. The overall goal of this

grant was to develop an infrastructure of state and local partners capable of implementing

sustainable evidence-based programs for older adults. In order to build this infrastructure, seed

funding was given to Area Agencies on Aging serving the counties of Fresno, Los Angeles,

Madera, San Diego, and Sonoma. In each of these five counties, the aim was to support

implementation of at least one of the following evidence-based programs: A Matter of Balance

(MOB), CDMSP, Healthy Moves, or HomeMeds. The target population for the grant was low

income, ethnically diverse and/or limited non-English speaking older adults who have had less

access to evidence-based program and have a higher incidence of chronic disease.

In 2009, CDA received a one-year supplemental grant from AoA, which they used to continue

building the infrastructure and partnerships needed to expand the evidence-based programs.

With this funding, CDA focused on the expansion of CDSMP and MOB. Targeted expansion

strategies included: involving physician groups in patient referrals, retention of workshop

leaders, creating an infrastructure for web access to class scheduling, and developing new

strategies for participant recruitment.

In 2010, CDA received another one-year supplemental grant to further expand CDSMP through

the American Recovery and Reinvestment Act (ARRA). Funding from this grant was used to

provide technical assistance and boost fidelity monitoring in the seven ARRA-funded counties

offering CDSMP: Los Angeles, Napa, Orange, Solano, Sonoma, San Diego, and San Francisco.

By the end of the five years, California had trained 21,417 participants in CDSMP, MOB,

HomeMeds, and Healthy Moves. Of those trained, 14,925 provided demographic data (See

Table B-1).

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Table B-1: Demographic Data on Participants in California’s Initiative to Empower Older

Adults to Better Manage Their Health (N = 14,925)

Characteristics 5-Year Total % of Known Statistics

Age

Under 60 926 16%

60-64 345 6%

65-69 547 9%

70-74 739 13%

75-79 921 16%

80-84 951 17%

85-89 834 15%

90 and Over 478 8%

Unknown 9,184 62% (% of total)

Gender

Female 4,302 77%

Male 1,302 23%

Unknown 9,321 62% (% of total)

Living Arrangement

Living Alone 1,956 38%

Living With Someone 3,216 62%

Unknown 9,753 65% (% of total)

Race/Ethnicity

Native American 53 1%

Asian 554 10%

Black 454 8%

Pacific Islander 18 0%

Hispanic/Latino 1,381 25%

White 3,003 53%

Other Race 91 2%

Multi-Racial 51 1%

Unknown 9,320 62% (% of total)

B.1.1 Infrastructure Development

In order to implement the evidence-based programs, initial grant funding was used to establish a

Project Office, housed at the Partners in Care Foundation (PICF). PICF’s role was to provide

technical assistance to organizations offering programs, collect and report data to the

Administration on Aging (AoA), and collaborate with CDA to see the project through

successfully. Concurrently, CDA established a Statewide Steering Committee with the aim of

providing a forum for coordination of grant activities across partners. The Steering Committee

was comprised of the California Department of Public Health, PICF, and representatives from

the five aforementioned counties and organizations sponsoring evidence-based programs.

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B.1.2 Program Outcomes

With the expansion of CDSMP and MOB, other organizations like Kaiser Permanente of

Southern California became aware of the need for fall prevention programs in the community

and adopted MOB. As a result, Kaiser provides free trainings and materials for the program.

With the help of such collaborations among state, local, and regional partners, CDSMP became

available in over 32 counties in California. Additionally, technical assistance was provided to

over 346 implementation sites and 76 host organizations throughout the state. Currently, over 70

health care organizations in California have invested in CDSMP and are offering it internally,

including 22 Kaiser Permanente sites, 17 physician groups and clinics, 12 Dignity Health

(formerly Catholic Healthcare West) hospitals and medical centers, five health care districts, and

three health plans.

HomeMeds and Healthy Moves continue to expand throughout California. By the end of the

grant, HomeMeds had served 5,316 participants and Healthy Moves served 345. Healthy Moves

is currently offered in four California communities.

B.1.3 Challenges

Challenges that surfaced during program implementation included timely reporting of data from

all project partners. Partners in Care sought to remedy this by providing training on the data

process. They also worked with all licensed organizations in California on a quarterly basis to

ensure CDSMP activity and evaluation data were recorded.

Additionally, California struggled with recruitment and retention of quality workshop leaders.

One solution proposed was to schedule workshops within three weeks after leader trainings and

pair new leaders with experienced ones. This appeared to increase the leaders’ comfort level and

dedication. At the same time, CDA also developed two tools: 1) a SurveyMonkey to assess

prospective leaders’ readiness and commitment level, and 2) a Leader Agreement stating that

leaders must facilitate a minimum of two workshops per year.

Finally, limited funding and budget cuts hampered the overall implementation of programs in

targeted systems. To address this, CDA focused their energies on systems with sufficient

resources in the near term to help ensure the sustainability of efforts in the long term.

B.1.4 Sustainability

To date, California has expanded their network to AAAs, local hospitals, and public health

departments to offer evidence-based programs to patients/members. Partners in Care has been

attending meetings of the Right Care Initiative to foster collaboration among managed care plans

in implementing prevention and self-management programs. CDA is also in the process of

conducting a pilot test to determine whether clients in the Medi-Cal Home and Community-

Based Waiver program for the elderly are appropriate for participation in CDSMP. This would

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mean waiver funds could pay for their participation. CDA also plans to maintain the Project

Office to have staff resources specifically focused on this program.

B.1.5 Lessons Learned and Recommendations for Future Efforts

California’s lessons learned for this grant pertained to Adoption and Implementation in the RE-

AIM framework. Under Adoption, CDA learned that it was important to engage large, well-

established networks to adopt and deploy evidence-based programs within their systems. In

addition to helping meet performance goals, this also aided with sustainability once grant

funding ended. The rate of return was much higher than making direct outreach to program staff

in local agencies that often needed higher-level approval before they could become involved in

offering/sponsoring the evidence-based programs. This also helped in leveraging funding, as

many host organizations sought and obtained private funding/reimbursement for workshop

participation. This also helped CDA to set a fee structure in place that could be used in either

supporting program expansion or compensating for resources provided to develop program

capability.

Under Implementation, facing leader recruitment and retention challenges, California learned

that it was beneficial to develop tools to strengthen the screening and orientation processes.

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Colorado Empowering Older People to Take More Control of Their Health: Evidence-

Based Prevention

Grant Award: 90AM3130

B.2 Introduction

Colorado’s Empowering Older People to Take More Control of Their Health grant was awarded

to the Colorado Department of Public Health and Environment (CDPHE) in September 2006.

The overall goal of the grant was to develop an infrastructure capable of implementing and

sustaining evidence-based prevention programs. The main implementers of these programs

would be community aging service providers. The Chronic Disease Self-Management Program

(CDSMP) was the main focus of Colorado’s program implementation targeting older adults age

60+.

Prior to Colorado receiving this grant funding, there was a very limited infrastructure in place to

deliver CDSMP in the state. At the time, four health care organizations were offering CDSMP to

individuals within their systems, with workshops offered at their clinics and hospitals. However,

these four organizations focused only on the metropolitan area. Therefore, the aim of this grant

was focused on broadening the geographic reach of CDSMP using community aging service

providers. In addition to community aging service providers, key partners identified to see this

grant through included: the State Unit on Aging (SUA), local public health departments and Area

Agencies on Aging (AAAs).

Table B-2 below provides a snapshot of the reach this grant was able to accomplish with

demographic data for 1,459 of Colorado’s program participants who provided this information.

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Table B-2: Demographic Data on Participants in Colorado’s Empowering Older People to

Take More Control of Their Health (N = 1,459)

Characteristics 5-Year Total % of Known Statistics

Age

Under 60 329 26%

60-64 133 10%

65-69 184 15%

70-74 187 15%

75-79 168 13%

80-84 135 11%

85-89 77 6%

90 and Over 49 4%

Unknown 197 14% (% of total)

Gender

Female 972 77%

Male 286 23%

Unknown 201 14% (% of total)

Living Arrangement

Living Alone 435 39%

Living With Someone 689 61%

Unknown 335 23% (% of total)

Race/Ethnicity

Native American 8 0%

Asian 57 5%

Black 36 3%

Pacific Islander 3 0%

Hispanic/Latino 228 19%

White 842 69%

Other Race 12 1%

Multi-Racial 37 3%

Unknown 236 16% (% of total)

B.2.1 Infrastructure Development

From the outset of this grant, the Consortium of Older Adult Wellness (COAW) was identified

as the primary implementation agency. However, the Central Colorado Area Health Education

Center (CCAHEC) took over as the implementation agency in July 2010 as the result of

competitive procurement process. This change allowed for a broader program reach into

additional communities’ new partners to deliver CDSMP, including five local lead agencies and

18 host sites.

When building the remainder of their infrastructure, Colorado identified sustainability as their

top priority. Toward this goal, they made sure to partner with health care systems that had the

ability to sustain the evidence-based programs beyond the grant funding. Three health care

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systems embedded the evidence-based programs into service delivery for their clients: Kaiser

Permanente, Centura Health, and Poudre Valley Heath System. Two of these systems (Kaiser

Permanente and Centura Health) are currently able to sustain the programs with their own

funding.

By the end of 2007, 23 new community sites in three regional areas had conducted CDSMP

workshops. By the end of 2008, 28 of the state’s 64 counties offered CDSMP workshops, and

four new partnerships were formed: Centura Health (mentioned above), the University of

Colorado Family Practice Residency Program, the state Medicaid agency, and the Colorado

Clinical Guidelines Collaborative. In 2009, seven of Colorado’s 16 AAAs had implemented

CDSMP workshops, two of which created dedicated staff positions to grow the evidence-based

programs at the AAA level. In order to manage the implementation of programs across the 16

AAAs, they were divided into three regions managed by three regional coordinators: the

Volunteers of America (VOA) (Denver metro), Pueblo SetUp (changed to the Southeastern

Colorado AHEC in 2009) (Eastern Plans), and the Northwest Visiting Nurses Association

(NWVNA) (Western Slope).

The Colorado Health Foundation (TCHF) has also been instrumental in ensuring sustainability,

as they gave funding to CDPHE for data collection, infrastructure development, and program

implementation. To date, funding continues to expand CDSMP into additional communities, and

32 counties continue to provide CDSMP through AoA or other grant funding.

Finally, in partnership with Metropolitan State College of Denver, students pursuing a certificate

in “Wellness for Active Aging” can take the CDSMP leader training for credit toward that

certificate, and students can also receive general college credit.

B.2.2 Program Outcomes

By the end of the five-year period, Colorado had trained 363 Lay Leaders, 62 Master Trainers,

and two T-Trainers were certified in CDSMP, DSMP or Tomando. Additionally, the Master

Trainers and T-Trainers conducted 227+ site visits to monitor fidelity. To provide a central

location for class schedules, trainings, and registration, a website, managed by COAW, was

developed for Leaders and Master Trainers.

In terms of program participants, Colorado enrolled over 2,353 individuals in one of the CDSMP

programs, of whom 76% (n = 1,788) completed the programs.

B.2.3 Challenges

Challenges encountered during this project period included the switch in the implementation

agency from the Consortium of Older Adult Wellness (COAW) to the Central Colorado Area

Health Education Center (CCAHEC) in 2010. This caused an initial delay in implementation

because of contractual issues and state fiscal rules in place. However, Colorado met this

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challenge by holding multiple meetings with partners, identifying new partners, and devising

what they called the Adult Resources for Care and Help (ARCH) referral tree.

Furthermore, Colorado struggled to have AAAs fund the evidence-based programs, as those

funds were already allocated to support core services. The State Unit on Aging (SUA) and AoA,

however, trained the AAAs about the importance of the evidence-based programs and their

direction moving forward. SUA also drafted policy guidance that showed the AAAs that they

could use Title III-D funds, and parts of B, C1, C2 and E to support the programs. Through

these efforts the AAAs dedicated additional funds to implementation of the programs.

Lastly, Colorado experienced difficulty in maintaining active support from the state Medicaid

office due to organizational changes and instability of staff participation on the state CDSMP

Advisory Board. The solution to this challenge came with Colorado’s collaboration with CMS

on a different grant opportunity, which helped CMS to understand the importance of CDSMP.

Through this, Colorado gained the support of CMS.

B.2.4 Sustainability

To support the aforementioned efforts, Colorado secured ARRA funding to offer programs

through March 2012. Funds were leveraged from the Diabetes Prevention and Control Program

grant. This funding, however, cannot be relied upon in the long term. Additionally, local

partners have each developed sustainability plans to offer programs beyond this grant funding,

though program offerings may be less frequent. SUA will continue to provide technical

assistance, as they are doing for the AAAs. COAW, the first implementation agency, gathered

financial support through foundation grants and by charging fees for trainings and workshops,

and COAW plans to continue their support of CDSMP. Primary state funders are also being

asked to statewide sustainability meetings to discuss future directions.

B.2.5 Lessons Learned and Recommendations for Future Efforts

Colorado noted learning lessons in the following RE-AIM categories: Effectiveness, Adoption,

Implementation, and Maintenance and Sustainability.

Under Effectiveness, Colorado learned that branding through a trademarked name (Healthier

Living Colorado™) should be done by a state agency as opposed to a contract agency that could

change over time.

The Adoption lesson learned was to encourage Master Trainers to complete the necessary

workshops required for certification as quickly as possible by tripling up on leaders, joining

already scheduled workshops, and/or getting workshops done for one certification before starting

a second certification.

For Implementation, they learned that providing state-led centralized resources and functions to

local agencies is important to ensure sustainability and maintenance.

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Finally, for Maintenance and Sustainability, Colorado learned to involve the state Medicaid

office leadership as part of the project planning and advisory committee from the start.

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Hawaii Empowering Communities to Sustain Evidence-Based Disease and Disability

Prevention Programs

Grant Award: 90AM3117/05

B.3 Introduction

The Executive Office on Aging in Hawaii was awarded this grant in June 2010. With this

funding, the overall goal was to maintain and enhance the evidence-based program

EnhanceFitness by preserving its infrastructure to expand program delivery capacity and to

deliver high quality, high fidelity programs to at-risk older adults.

The measurable goals outlined by Hawaii were to maintain and enhance the infrastructure of

three sites on the island of Kauai, develop two new sites on the island of Oahu, train six new

EnhanceFitness instructors, and train 128 new participants.

For an overview of the demographic of participants reached in Hawaii, see Table B-3.

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Table B-3: Demographic Data on Participants in Hawaii’s Empowering Communities to

Sustain Evidence-Based Disease and Disability Prevention Programs (N = 842)

Characteristics 5-Year Total % of Known Statistics

Age

Under 60 37 5%

60-64 40 5%

65-69 117 14%

70-74 138 17%

75-79 158 20%

80-84 169 21%

85-89 98 12%

90 and Over 51 6%

Unknown 34 4% (% of total)

Gender

Female 716 88%

Male 96 12%

Unknown 30 4% (% of total)

Living Arrangement

Living Alone 266 33%

Living With Someone 535 67%

Unknown 41 5% (% of total)

Race/Ethnicity

Native American 1 0%

Asian 400 49%

Black 2 0%

Pacific Islander 136 17%

Hispanic/Latino 3 0%

White 135 17%

Other Race 16 2%

Multi-Racial 116 14%

Unknown 33 4% (% of total)

B.3.1 Infrastructure Development

At the state level, the Executive Office on Aging worked with the Hawaii Healthy Aging

Partnership (HHAP) Steering Committee to identify and invite new partners, develop

knowledgeable, ready instructors on Kauai, increase program visibility, collect provider training

data, monitor fidelity, collect participant outcome data, and disseminate key findings. The

HHAP is a coalition of 60+ partners devoted to embedding evidence-based programs into

Hawaii’s Aging Network.

In Honolulu, on the island of Oahu, two service providers were contracted to support the

development of two sites to offer EnhanceFitness: Child and Family Service and Kokua Kalihi

Valley (KKV), a community health center located in an underserved, at-risk community.

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Additionally, the University of Hawaii was brought on as a key partner to conduct grant

evaluation activities (data collection and quality improvement).

B.3.2 Program Outcomes

By the end of the grant period, Hawaii trained a total of 1,833 participants in EnhanceFitness

(EF) and CDSMP. Additionally, participant outcome data from the implementation of EF

showed that, upon completion of the 16-week program, participants reported 39% fewer falls,

reported a 29% increase in the number of days spent doing physical activity per week, and were

confident that they would be able to continue exercising regularly. Using the arm curl, chair

stand, and Up and Go tests, participants also showed improvements of 18% more, 22% more,

and 11% faster, respectively.

B.3.3 Challenges

Hawaii encountered challenges in the areas of Effectiveness and Adoption during this grant

period. With regard to Effectiveness, contracting with the City and County of Honolulu’s

Elderly Affairs Division was delayed due to a change in administration. However, once this

change was stabilized, the contract went through. For Adoption, it was difficult to recruit

qualified fitness instructors interested in obtaining more training to run EnhanceFitness

programs. To remedy this, Honolulu received guidance from the County of Kauai, as they had

expertise from successfully offering the program since 2007. The University of Hawaii also

aided in providing assistance with regard to data collection and fidelity monitoring.

B.3.4 Sustainability

In order to sustain their efforts with regard to EnhanceFitness, Hawaii, with key assistance from

the University of Hawaii, conducted a cost analysis for programs previously offered in order to

determine the amount needed to continue offering programs in the future. This data was

presented at the 2012 Hawaii Legislative Session and, as a result, the state was able to secure

funding for the 2013 fiscal year. This funding will be used to sustain programs on Kauai, and

programs on Oahu will be sustained using Title III-D funding. Additionally, due to the

popularity of EnhanceFitness, the County of Maui has decided to offer the program using their

own county funds.

A hybrid delivery model has been developed to mirror the structure, effectiveness, and decision-

making capacity of the HHAP. This model is spearheaded by the Executive Office on Aging and

the Hawaii Department of Health (DOH), responsible for coordination of programs and AAAs as

well as provision of technical assistance. A sustainability consultant was also brought onboard

to map out a future sustainability plan, and the University of Hawaii continues to support

evaluation activities. Finally, the AAAs support county-level coalitions for HHAP, which are

comprised of county offices, eldercare providers, group leaders, older adults, volunteers, etc.

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B.3.5 Lessons Learned and Recommendations for Future Efforts

Looking back on this grant, Hawaii identified lessons in Adoption, Implementation, and

Maintenance and Sustainability.

For Adoption, the lesson was the importance of ensuring participant safety in EnhanceFitness by

adhering to protocols.

For Implementation, they needed to have a clear understanding of expectations of the

EnhanceFitness program and how to adhere to fidelity (e.g., utilizing properly trained leaders).

For Maintenance and Sustainability, two lessons were noted. First, EnhanceFitness is costly and

due to its popularity, participant attrition and turnover are low. Therefore, there is an increased

need to add new sites and programs, requiring funding to keep up with program demand.

Second, it is important to have good outcome data on participant health improvement and cost

savings in order to garner state budget support for EnhanceFitness.

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Massachusetts Empowering Older People to Take More Control of Their Health Through

Evidence-Based Prevention Programs

Grant Award: 90AM3137

B.4 Introduction

The Massachusetts Executive Office of Elder Affairs (EOEA) was awarded this grant funding in

June 2007. Prior to this grant funding, in partnership with the Massachusetts Department of

Public Health – Healthy Aging and Disability Unit (DPH-HADU), the EOEA established a

foundation for offering evidence-based programs by building relationships with community

based organizations. To expand upon these efforts, the EOEA designated this grant funding

toward implementing the following three evidence-based programs: CDSMP, Healthy Eating,

and A Matter of Balance.

The overall goal of the grant was to develop a sustainable infrastructure in Massachusetts to

implement high quality evidence-based disability and disease prevention programs to the

maximum number of older adults and people with disabilities.

Across all three of these programs over the four-year grant, Massachusetts reached 6,862

participants. Demographic data for 2,977 of these participants was submitted. See Table B-4

below for statistics broken down by demographic characteristics.

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Table B-4: Demographic Data on Participants in Massachusetts’ Empowering Older

People to Take More Control of Their Health Through Evidence-Based Prevention

Programs (N = 2,977)

Characteristics 5-Year Total % of Known Statistics

Age

Under 60 114 5%

60-64 87 3%

65-69 201 8%

70-74 324 13%

75-79 429 17%

80-84 571 23%

85-89 483 19%

90 and Over 312 12%

Unknown 456 15% (% of total)

Gender

Female 2,263 85%

Male 407 15%

Unknown 307 10% (% of total)

Living Arrangement

Living Alone 1,850 71%

Living With Someone 739 29%

Unknown 388 13% (% of total)

Race/Ethnicity

Native American 55 2%

Asian 74 3%

Black 280 11%

Pacific Islander 0 0%

Hispanic/Latino 171 6%

White 1,965 74%

Other Race 53 2%

Multi-Racial 40 2%

Unknown 339 11% (% of total)

B.4.1 Infrastructure Development

Implementation of CDSMP, Healthy Eating, and A Matter of Balance was built upon three pre-

existing partnerships. The Traumatic Brain Injury Taskforce, formed in 2006 by the Department

of Public Health, recommended the implementation of A Matter of Balance to prevent falls.

Action for Boston Community Development (ABCD) and the Boston Public Health Commission

took responsibility for developing implementation strategies.

The Massachusetts Disease Management Coalition (DMC) initiated the implementation of

CDSMP. Elder Services of the Merrimack Valley (ESMV) started this coalition, comprised of

60+ agencies, in 2005. A sample of agencies that made up this coalition included: the

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Merrimack Valley and North Shore Aging and Disability Resource Centers, the Lifetime

Partners (a consortium of six Aging Services Access Point agencies in Northeast

Massachusetts), the Multicultural Coalition on Aging, the Northeast Massachusetts

Regional Department of Public Health, and the Senior Medicare Patrol Integration

Project.

Finally, under the leadership of Hebrew Senior Life, the south suburban area of Massachusetts

established a partnership to deliver Healthy Eating.

A leadership team, made up to state agency leaders, program coordinators from the Traumatic

Brain Injury Taskforce, the Massachusetts DMC, Hebrew Senior Life, and a set of community

champions was assembled to oversee all grant activities.

B.4.2 Program Outcomes

Between 2007-2011, Massachusetts reached a total of 6,862 participants across CDSMP, Healthy

Eating, and A Matter of Balance. A total of 612 workshops were offered. Participants included

economically and ethnically diverse populations of older adults from around Boston. ABCD, for

example, recruited the Boston Multicultural Coalition, the Elderly Health Disparities Coalition,

the East Boston Neighborhood Health Center, and Massachusetts General Hospital.

Additionally, the Massachusetts Office of Medicaid (“MassHealth”) funded the translation of

MOB into Chinese and Russian, and Healthy Eating into Russian. These programs were piloted

in Chinese and Russian-speaking community organizations using the same funding. Hebrew

Senior Life also provided abbreviated workshops at the Harvard Multicultural Coalition Annual

Aging Well Together Conference in the following languages: English, Spanish, Portuguese,

Chinese, Vietnamese, Haitian Creole, and Cape Verdean Creole. The Tufts Health Plan

Foundation funded the translation and piloting of the program into Spanish and Vietnamese, the

Cambridge Health Alliance into Haitian Creole, and the Visiting Nurse Association into

Portuguese. Finally, ESMV forged a partnership with the Greater Lawrence Family Health

Center to train leaders in Tomando.

Of the 351 cities and towns in Massachusetts, 20% (n = 90) have implemented A Matter of

Balance, 31% (n = 117) have implementing Healthy Eating, and 46% (n = 172) have

implemented CDSMP.

B.4.3 Challenges

Over the course of this grant period, Massachusetts identified challenges in all five RE-AIM

categories.

Under Reach, low participant recruitment was an issue. To address this, community partners

began by offering information sessions to recruit participants. Hebrew Senior Life has included

nutrition counseling into their information sessions to provide direct referrals to the Healthy

Eating workshops. Additionally, they have incentivized participation by financially supporting

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the “Optional Seventh Session” of the Healthy Eating program, which includes a restaurant

outing where participants can practice newly acquired skills (e.g., portion control, following

healthy eating guidelines, advanced planning, and asking questions) when ordering their meals.

For Effectiveness, Massachusetts noted that it was challenging for partner organizations to

conduct six-month follow-up evaluations due to lack of staff time. Therefore, these

organizations used interns and volunteers to make the follow-up phone calls. Hebrew Senior

Life has also helped by streamlining the survey tool and by using foundation grants to provide

stipends to organizations that submit data.

Adoption challenges included the rapid demand for workshops. Hebrew Senior Life responded

by developing a cross-training module to train certified CDSMP leaders to also lead Healthy

Eating workshops. Staff turnover and budget cuts at the state, lead community partner, and local

partner levels were also issues. The project leadership team provided support and technical

assistance to partner organizations while they sought other sources of funding, and also held

conference calls and meetings to support new lead community partners’ staff.

Under Implementation, fidelity was identified as a challenge for all community organizations

focusing on rapid implementation of EBDP. Although fidelity observations are requirements of

all three programs, in reality they are time consuming and hard to implement when Master

Trainers have other job responsibilities and live far away from where leaders implement

workshops. A strategy devised to counter this challenge has been to pair experienced leaders

with newly trained leaders to implement workshops. The experienced leader provides feedback

immediately onsite, and in the case of a major concern a Master Trainer or state program

coordinator is sent to conduct a full fidelity check.

Under Maintenance and Sustainability, Massachusetts struggled with partner and facilitator

recruitment and retention. To meet this need, partners and facilitators have been provided 1:1

technical assistance, online tools (i.e., group websites), conferences, and webinars. Experienced

leaders have also been paired with newly trained leaders to boost trainer confidence and

availability of feedback. For leader attrition, greater emphasis has been placed on screening

potential organizations and leaders to ensure that leaders participating in training have a full

understanding of all responsibilities involved.

Also under Maintenance and Sustainability, partner organizations frequently provided in-kind

donation of leaders’ time to facilitate sessions for all programs. However, when they needed to

recruit leaders from other organizations to co-facilitate, a stipend was expected, thus posing a

financial challenge. In the first year of the grant, regional and state leadership approved stipends

of $300 to co-facilitate CDSMP and other programs.

Lastly, the program administrators for A Matter of Balance changed the data collection system

during the last year of the grant to an online reporting tool, which Master Trainers needed to use

to enter data directly. This posed a challenge due to the $200/organization use fee to access the

system and the time needed to enter all data. ABCD staff assisted by entering the majority of the

data centrally, while some data was entered regionally by Master Trainers.

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B.4.4 Sustainability

Massachusetts has been successful in obtaining foundation support for healthy aging

programming at both the public policy and the community levels. In 2009, the Tufts Health Plan

Foundation launched its Healthy Aging Initiative designed to help older adults live longer

healthier lives. Many partner organizations have received funding from Tufts to support and

evaluate their initiatives. The Foundation for Metrowest, the Clipper Foundation, and the TJX

Foundation have also funded healthy aging programming. In addition, opportunities for

marketing healthy aging programs to third party payers and Accountable Care Organizations are

currently being explored.

Currently ABCD is actively seeking funding to create Healthy Aging and Wellness Centers at its

Neighborhood Service Center sites throughout Boston.

Hebrew Senior Life (HSL) has been able to secure diverse sources of funding in order to ensure

continuation of program coordination activities for HE. Resources include support staff from

Hebrew Senior Life, financial and technical assistance from the Tufts Health Plan Foundation

(through August 2013), financial assistance from the TJX Corporation (beginning in 2012), and

on-going philanthropy support.

Medicare reimbursement for the Diabetes Self-Management Program as well as the

incorporation of CDSMP in Care Transition models in Northeastern Massachusetts offer

concrete opportunities for the sustainability of CDSMP.

Representatives from Hebrew Senior Life, Elder Services of the Merrimack Valley, and the

National Council on Aging are engaged in negotiations with a major Massachusetts Health Care

Plan to purchase both community CDSMP and online CDSMP (Better Choices, Better Health)

for plan members.

B.4.5 Lessons Learned and Recommendations for Future Efforts

Though numerous challenges were faced during this grant, Massachusetts also learned many

lessons in the areas of Reach, Effectiveness, Adoption, and Maintenance and Sustainability.

For Reach, they learned the participant recruitment is challenging, but best practices that have

been implemented include: conducting information sessions, offering programs in places where

older adults already congregate, collaborating with medical providers, insurance companies,

corporations, inter-faith organizations, and wellness centers, and developing a yearly calendar of

EBDP offerings.

Under Effectiveness, success in partnership development has been due to the model of

collaboration created to implement EBDPs. Organizations have collaborated in marketing the

programs, bringing leaders from different organizations to co-load workshops, and sharing

among them other resources like transportation, space, materials, etc. Volunteer placements for

classes frequently work best when the volunteer is paired with an experienced staff person who

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can ensure that everything is ready for the class and provide consistent support and follow up to

the volunteer leader, and volunteers work best if they only have responsibility for teaching

classes with the staff person coordinating all other details.

An Adoption lesson learned was that the combined expertise in coalition building and

infrastructure development was used to support and nurture the development of the Western MA

coalition and successfully implement programs in that area of the state.

Finally, many lessons pertaining to Maintenance and Sustainability were learned. Grants from

private foundations have enabled broader expansion of EBDPs throughout the state by offsetting

some program costs and by allowing organizations to hire staff dedicated to coordination of

implementation efforts. In order to prevent leader attrition, greater emphasis must be placed on

screening potential organizations and leaders to ensure that leaders participating in training have

full understanding of all responsibilities involved. Maintenance of an accurate leader database is

key to the ability to respond quickly to program demand. Dedicated resources are needed to

coordinate, support, recognize, and retain volunteers. Volunteer recruitment works most

smoothly with stipends. Often these are offered to cover transportation costs. If there is no

stipend provided, acknowledgement of their services and accomplishments becomes even more

important. Online websites, such as Craigslist, Idealist and Volunteer Match, as well as graduate

school volunteer and career fairs are good sources for volunteer recruitment. And, partner

organizations (as opposed to older adults) have more luck recruiting younger volunteers,

especially students in the Boston area who have school requirements for volunteering.

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Ohio’s Evidence Based Prevention Program Initiatives

Grant Award: 90AM3119/05

B.5 Introduction

The Ohio Department of Aging (ODA) was awarded grant funding in September 2006. The

overall goals of this project were to build a collaborative infrastructure aimed at improving the

health of older Ohioans and their caregivers through evidence-based health promotion/disease

prevention initiatives. Thus, CDSMP, A Matter of Balance (MOB), and Active Living Every

Day (ALED) were implemented to address chronic disease self-management, falls prevention

and physical activity.

Measurable goals set for the grant project included conducting 113 CDSMP courses to reach

1,165 older adults, conducting 56 A Matter of Balance courses to reach 420 older adults, and

conducting 15 Active Living Every Day courses to reach 225 older adults. As noted in Table B-

5, these goals were far exceeded. See below for a summary of participant demographics.

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Table B-5: Demographic Data on Participants in Ohio’s Evidence Based Prevention

Program Initiatives (N = 7,773)

Characteristics 5-Year Total % of Known Statistics

Age

Under 60 123 5%

60-64 111 5%

65-69 241 10%

70-74 326 13%

75-79 359 15%

80-84 534 22%

85-89 439 18%

90 and Over 292 12%

Unknown 5,348 69% (% of total)

Gender

Female 2,064 83%

Male 436 17%

Unknown 5,273 68% (% of total)

Living Arrangement

Living Alone 1,291 53%

Living With Someone 1,145 47%

Unknown 5,337 69% (% of total)

Race/Ethnicity

Native American 76 2%

Asian 14 0%

Black 374 12%

Pacific Islander 4 0%

Hispanic/Latino 29 1%

White 2,684 83%

Other Race 21 1%

Multi-Racial 37 1%

Unknown 4,534 58% (% of total)

B.5.1 Infrastructure Development

The AAAs were key partners in implementing the aforementioned programs. In order to do so,

site coordinators were designated in each of the six participating AAA regions. The person in

this position was responsible for overseeing all local program coordination and reporting to

ODA.

State and regional partners were important in arranging Master Trainer trainings for CDSMP,

while three other partners in the Cleveland region were responsible for coordinating MOB

Master Trainings. ALED was active prior to the beginning of this project, but grant funding

would enable its expansion to additional service areas.

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Healthy IDEAS was introduced later in the grant. A key partner, the Ohio Association of

County Behavioral Health Authorities (OACNHA), offered the program to AAAs and their

member agencies, and eventually became program champions, sponsoring regional trainings and

train-the-trainer activities.

Many other statewide partners and organizations were approached with the intention of finding

support for embedding and sustaining EBDP programs. A partial list of partners includes: State

of Ohio Retirement Systems, Ohio Departments of Health, Insurance and Mental Health, Older

Ohioans Behavioral Health Network, Older Adult Falls Prevention Coalition, Campaign for

Better Care, Ohio Coalition for Adult Protective Services, Ohio Community Service Council,

Corporation for National and Community Service/Senior Corps, Ohio Health Coverage and

Quality Council, Ohio Commission on Minority Health, Ohio Association of Health Plans,

Unified Long-term Care System Workgroup, Ohio Academy of Primary Care Physicians, Ohio

Benefits Bank, Ohio Health Policy Institute, Veterans Medical Centers, Rehabilitative Service

Commission, and National Church Residences.

B.5.2 Program Outcomes

The original combined goal for CDSMP, MOB, ALED, and Healthy IDEAS courses was 1,810

participants. By the end of the project period, Ohio reached over 9,960 participants.

As a product of participating in these evidence-based programs, 39% of participants noted that

their overall health and their ability to manage their health condition(s) had improved. Specific

areas of improvement identified were increased exercise, better coping strategies and symptom

management, better communication with their physicians, and overall fewer physician visits.

B.5.3 Challenges

Reach, Adoption, Maintenance and Sustainability, and Other challenges were identified by Ohio.

Under Reach, recruitment of participants presented a challenge. Program sites sought to remedy

this by offering a session zero to educate potential participants about what the program entailed

(content, time commitment).

Under Adoption, Ohio experienced inadequate staffing at AAAs. Most site coordinators ended

up training additional staff to assist with coordination/administration. Some sites used SCSEP

workers or interns to assist with duties.

For Maintenance and Sustainability, the state struggled with recruitment and retention of a strong

leader network due to the significant time commitment required of lay leaders to receive training,

and continuous recruitment of volunteers who can commit to the requirements. To address this

challenge, they used flexible scheduling of training (e.g., scheduling it over two weeks instead of

five straight days), developed personal interview tools and orientation webinars for potential

leaders to ensure they understood the scope of the program and the expectations, and shared

leader training opportunities between regions to accommodate the schedules of potential leaders.

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Lastly, Ohio’s need for in-home interventions led to seeking funding to pilot the evidence-based

program, Reducing Disability in Alzheimer’s Disease (RDAD). Ohio is currently partnering

with seven Alzheimer’s Association Chapters to implement the program.

B.5.4 Sustainability

The evidence-based disease and disability prevention goals were integrated into the 2008-2011

and 2012-2013 State Plans on Aging. Several AAAs have begun to fund EBDPs through their

Title III-D allocations and local senior service property tax levy funds. ODA has included EBDP

as a fundable activity with the new Enhanced Community Living Medicaid Waiver service. In

ODA’s 2012-2013 biennium budget proposal, Senior Volunteer Subsidy funds have been

targeted to Senior Corp Programs that implement and/or support EBDPs. Prevention and disease

self-management initiatives are major components of Ohio’s AoA funded Systems Integration

Initiative. Ohio is placing special emphasis on embedding programs into existing reimbursement

streams and payroll reform.

B.5.5 Lessons Learned and Recommendations for Future Efforts

The one main lesson identified fell under the Maintenance and Sustainability category. Ohio

constituents noted that it is important to ensure program sustainability and scalability through

buy-in from the aging network, primarily the 12 AAAs, and a strong array of partners that are

committed to embedding and sustaining EB programs. Partnership development was a large

component of this project.

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81

APPENDIX C: PRODUCTS/RESOURCES DEVELOPED

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82

Type of Resource/Product Access Point

PUBLICATION

Arizona: A four-page insert that includes program

descriptions, sites, and education included in the

monthly agency newsletter.

Final Report Appendix D

Colorado: Issues Briefs

www.bewellColorado.org and

www.bewellColorado.com

Connecticut: Press Release

Final Report Appendix

Connecticut: UCONN Center on Aging – Live Well

Evaluation and Descriptive Statistics

Final Report Appendix

Connecticut: Fall Prevention Summary – Barriers,

Challenges, Changes in Attitudes

Final Report Appendix

Connecticut: UCONN Center on Aging – Tai Chi

Summary Statistics

Final Report Appendix

Connecticut: UCONN Center on Aging – Live Well

Evaluation and Descriptive Statistics

Final Report Appendix

Florida: Three articles about falls prevention programs

printed in The Suncoast News

Appendix A

Florida: Five articles about falls prevention programs

published in the St. Petersburg Times

Appendix B

Florida: Article printed in the DOEA’s Elder Update

about Tai Chi

Appendix C

Florida: Article published in the Tampa Tribune

Appendix D

Florida: A Matter of Balance press release

Appendix F

Florida: Article in Miami Gardens Newsletter

Appendix J

Florida: “A Seamless Approach to Providing Health

Education and Promotion Programs to Older Adults”

Appendix O

Hawaii: Enhance Fitness with Asian Pacific Islanders (Attachment A) www.HawaiiADRC.org

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83

Illinois: Leader Newsletter Attachment A

Illinois: Decatur Herald & Review newspaper article

Attachment A

Illinois: RUMC Newsletter

Attachment B

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Type of Resource/Product Access Point

Illinois: The Courier News article about Fit and

Strong! at Heritage Woods of South Elgin

Attachment B

Maryland: Articles in local newspaper, newsletters

(County and Office on Aging)

MD Semi-Annual Report

New Jersey: Blueprint for Healthy Aging

http://www.state.nj.us/health/senior/

blueprint/

New Jersey: NJ’s activities featured in Massachusetts

Health Policy Forum’s report and form on CDSMP

Not listed

New Jersey: CDSMP model highlighted in the

National Association of Chronic Disease Directors’

publication “Meeting the Challenges of an Aging

Society – The Experience of State Health

Departments”

Not listed

New Jersey: CDSMP article published in NJ State

Nurses Association newsletter

Not listed

New Jersey: CDSMP Master Trainer Newsletter

Not listed

Ohio: Hamilton County General Health District press

releases

Final Report Appendix

Ohio: AAA Newsletters

Final Report Appendix

Ohio: NASUAD article, “Ohio’s Aging and Mental

Health Networks Partner to Strengthen Services to

Aging Ohioan,” Volume 3, Issue 6, July 2010

Final Report Appendix

Oregon: Healthy Aging: Programs That Make A

Difference (2009)

http://www.oregon.gov/DHS/spd/pr

ovtools/healthy-aging-programs.pdf

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85

Type of Resource/Product Access Point

Oregon: Healthy Aging in Oregon

Counties (2010)

http://public.health.oregon.gov/diseasesconditions

/chronicdisease/pages/healthyagininoregoncounti

es.aspx

Oregon: Living Well Impact Report

(2010)

http://public.health.oregon.gov/DiseasesConditio

ns/ChronicDisease/LivingWell/Documents/Livin

g%20Well%20Program%20Impact%20Report%2

0Final.pdf

Oregon: Living Well Data reports

http://public.health.oregon.gov/DiseasesConditio

ns/ChronicDisease/LivingWell/Pages/pubs.aspx

South Carolina: Final Eval Report

Program office

South Carolina: Dissemination of an

evidence-based program to Reduce Fear

of Falling in three geographic areas in

South Carolina

Preventing Chronic Diseases journal

Texas: Journal publications (two)

Not listed

NEW TOOLS and MATERIALS

Arkansas: Mapping tools to assist with

implementation site development

Not listed

California: Implementation Toolkit

www.aging.ca.gov/ebhp

California: Web-based Calendar for all

EB workshops (including caregiver

support programs), complete with Google

mapping functionality

www.aging.ca.gov/ebhp

California: Statewide Listserv for master

trainers and lay leaders

www.picf.org

Colorado: Evaluation Tools / Forms,

Evaluation Briefs, Report and PowerPoint

www.bewellColorado.org and

www.bewellColorado.com

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86

Type of Resource/Product Access Point

Colorado: Revised Evaluation Forms

www.bewellColorado.org and

www.bewellColorado.com

Colorado: Colorado Fidelity Manual and

Checklist

www.bewellColorado.org and

www.bewellColorado.com

Connecticut: Participant Agreement and

Intake Form

Final Report Appendix

Connecticut: Example of CDSMP Charts

(week-by-week workshop overview)

Final Report Appendix

Connecticut: Pre-Post Evaluation Intake

Forms

Final Report Appendix

Connecticut: CDSMP Participant Stipend

Agreement

Final Report Appendix

Connecticut: Letter of Agreement

between DSS and DPH

Final Report Appendix

Connecticut: CDSMP Intro Letter to

Community Service Providers

Final Report Appendix

Connecticut: Certificate of Completion

Final Report Appendix

Connecticut: IRB Permission Letter

Final Report Appendix

Connecticut: Leader Reunion Flyer

Final Report Appendix

Florida: Tai Chi Assessment Form

Appendix N

Florida: Rhomberg Balance Assessment

Results Form

Appendix P

Florida: “Bridging the Gap Between

Health & Wellness and the Aging

Resource Center” Training Webinar

Toolkit

Appendix Q

Hawaii: HHAP Hybrid Model (Attachment B) www.HawaiiADRC.org

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Type of Resource/Product Access Point

Idaho: Participant Information Pre-Survey

Appendix B

Idaho: Participant 6 Month Post-Survey

Appendix C

Idaho: Attendance Log

Appendix D

Idaho: Leader Evaluation (English)

Appendix E

Idaho: Leader Evaluation (Spanish)

Appendix F

Idaho: Site Tracking Log

Appendix G

Idaho: Participant Contact Information

Form

Appendix H

Illinois: Host Site Registration Form

Attachment A

Illinois: Patient letter for physician

referrals

Attachment A

Illinois: Participant Demographic Sheet

Attachment A

Illinois: Participant Baseline/Follow-Up

Survey

Attachment A

Illinois: Class Leader Baseline and

Follow-Up Survey

Attachment A

Illinois: Strong for Life Participant

Calendar

Attachment A

Illinois: Healthy IDEAS Forms, Flowchart

and Tracking Form

Attachment B

Illinois: Staff questionnaire

Attachment B

Illinois: Evaluation of Pilot Program

Attachment B

Maine: Enhance Wellness Progress

Measure Report Card

Attachment B

Maine: A Matter of Balance

Volunteer/Lay Leader Follow-Up Survey

Attachment C

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88

Maine: CDSMP Lay Leader Follow-Up

Survey

Attachment D

Maine: HCFME Data Collection Toolkit

Attachment E

Maryland: Prescription Pads disseminated

to doctor’s offices to help refer patients to

the Living Well (CDSMP) program

MD Semi-Annual Report

Maryland: 2009 and 2010 evaluations by

Towson University’s Center for

Productive Aging

MD Semi-Annual Report

Maryland: Maryland’s Living Well

Fidelity Evaluation

MD Semi-Annual Report

Maryland: Living Well toolkit created in

2009, updated in 2010

MD Semi-Annual Report

Massachusetts: A Matter of Balance

program translations into Chinese,

Russian, Haitian-Creole and Portuguese

MaineHealth (available for purchase)

Massachusetts: CD for A Matter of

Balance coaches and master trainers,

including all necessary documents to

conduct a participant class as well as

additional helpful resources. The CDs

include recruitment materials, participant

surveys, and handbooks for participant,

guest healthcare therapist, data collection

flow chart, and several useful flyers and

brochures.

Action for Boston Community Development

(ABCD)

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89

Type of Resource/Product Access Point

Massachusetts: Healthy Eating program

translations into Spanish, Russian and

Vietnamese

MassHealth

Massachusetts: Healthy Eating Exercise

DVD

Hebrew Senior Life

Massachusetts: “Formulating Strategic

Business Plans for Healthy Aging

Programs” – a toolkit that provides

specific guidance for developing a

program business plan including the

identification and assessment of key

stakeholders and partners in the

community

Final Report Index

Michigan: Fidelity Evaluation Report

Program office (website inactive)

Minnesota: Online forms for evaluation /

data

www.mnhealthyaging.org and

Appendix D

Minnesota: State classes calendar

www.mnhealthyaging.org and

Appendix C

Minnesota: A Matter of Balance low-

vision program materials and curriculum

www.mnhealthyaging.org

New Jersey: Operation Manuals for Lay

Leaders and Master Trainers

Not listed

New Jersey: CDSMP page on Department

of Health and Senior Services website

http://nj.gov/health/senior/cdsmp/index.shtml

New York: Dissemination / Fidelity

Manual

http://nycdsmp.groupsite.com

New York: Online Learning Community

Resources

http://nycdsmp.groupsite.com

New York: Participant Satisfaction Survey

http://nycdsmp.groupsite.com

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Type of Resource/Product Access Point

New York: Leader Feedback Form

http://nycdsmp.groupsite.com

North Carolina: A Matter of Balance

Coach Retreat Agenda

Final Report Appendix, pp. 182-183

North Carolina: Sample EBHP Schedules

Final Report Appendix, pp. 2-20

North Carolina: Workshop Sponsor

Thank You Cards

Final Report Appendix, pp. 56-59

North Carolina: Leader Memorandum of

Agreement

Final Report Appendix, pg. 21

North Carolina: Physician Referral Pad –

Sample #1

Final Report Appendix, pg. 22

North Carolina: Workshop Roster and

Emergency Contact Sheet

Final Report Appendix, pg. 23

North Carolina: Physician Referral Pad –

Sample #2

Final Report Appendix, pg. 55

North Carolina: Sign Up Sheet for Health

Fairs

Final Report Appendix, pg. 62

North Carolina: Leader Bingo (developed

for Leader Retreat)

Final Report Appendix, pg. 122

North Carolina: Agency/Partner

Memorandum of Agreement

Final Report Appendix, pp. 123-124

North Carolina: Workshop Site

Confirmation

Final Report Appendix, pp. 125-126

North Carolina:: CDSMP/DSMP Leader

Training Registration Form and Screening

Final Report Appendix, pp. 127-128

North Carolina: A Matter of Balance

Leader Training Registration Form and

Screening

Final Report Appendix, pp. 152-153

North Carolina: A Matter of Balance

Jeopardy (developed for Coach Retreat)

Final Report Appendix, pp. 154-181

North Carolina: Tips to Recruit Final Report Appendix, pg. 184

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91

Workshop Participants

North Carolina: CDSMP Workshop

Evaluation Form

Final Report Appendix, pp. 185-186

North Carolina: Leader Tips (developed

for presentation for master trainers and

NC Regional Coordinators)

Final Report Appendix, pp. 187-188

North Carolina: Sample Save the Date

Card for Leader Training

Final Report Appendix, pg. 47

Ohio: Active Living Every Day Training

Agenda and Evaluation

Final Report Appendix

Ohio: Healthy IDEAS Informational

Letter

Final Report Appendix

Ohio: EB Program Referral Card

Final Report Appendix

Oklahoma: Geographic coverage maps

http://www.ok.gov/health/Community_Health/Co

mmunity_Development_Service/Health_Equity_

&_Resource_Opportunities/Community_Evidenc

e-Based_Programs/index.html or

www.livinglongerlivingstronger.org

Oregon: Living Well Fidelity Tools

http://public.health.oregon.gov/DiseasesConditio

ns/ChronicDisease/LivingWell/Pages/fidelity.asp

x

Oregon: Marketing & Financial

Sustainability Toolkit

http://publichealth.oregon.gov/DiseasesCondition

s/ChronicDisease/LivingWell/Pages/LivingWell

MarketingToolkit.aspx

Oregon: Tai Chi: Moving for Better

Balance DVD (2008)

Not listed

South Carolina: Final Eval Report

Program office

South Carolina: Ambassador Project

materials

NCOA website

South Carolina: Fidelity Tool Kit

(checklist and monitoring tool)

Program office

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92

South Carolina: Program Fidelity manual Program office

Texas: Texas Fidelity Plan Worksheet

www.txbcbh.ino

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93

Type of Resource/Product Access Point

Texas: Patient Education Materials,

including a Patient Diabetes Passport,

Physician RX Pad for referrals and a

Physician and Clinic Checklist

Not listed

Wisconsin: Stepping On Leader Manuals

and Kits

www.healthyaging.org

Wisconsin: Stepping On Implementation

Guide

http://wihealthyaging.org/cdc-approved-site-

implementation-guide-for-stepping-on.org

NEW PROTOCOLS / GUIDELINES

Colorado: Statewide Structure System

www.bewellColorado.org and

www.bewellColorado.com

Connecticut: Leader Job Description

Final Report Appendix

Connecticut: Title III-D Program

Instruction

Final Report Appendix

Hawaii: HHAP Hybrid Model

(Attachment B) www.HawaiiADRC.org

Idaho: Evaluation Protocol Manual

Appendix A

Illinois: Memorandum of Understanding

Attachment A

Illinois: Leader Roles

Attachment A

Illinois: Healthy IDEAS Policies and

Protocols

Attachment B

Minnesota: CMCOA business plan

www.mnhealthyaging.org and

Appendix E

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Type of Resource/Product Access Point

North Carolina: Draft of Policies and

Procedures

Final Report Appendix, pp. 108-120

Wisconsin: “Selling” Living Well

Presentation Guide

www.wihealthyaging.org

BRANDING MATERIALS

Arizona: AAA-specific websites,

newsletters, activity calendars and fliers at

health and senior centers, public libraries,

senior living complexes and grocery

stores.

AAAs http://azlwi.org/

Arizona: Flyers for each Enhance Fitness

site were produced and distributed and

health promotion presentations are

scheduled and presented regularly

throughout the community.

Not listed

Arizona: Radio spots to promote Enhance

Fitness, A Matter of Balance and CDSMP

Not listed

Arkansas: Public Service Announcements

(PSAs) and Flyers

Not listed

Colorado: Public Health Meets Public

Health Insurance (PowerPoint)

www.bewellColorado.org and

www.bewellColorado.com

Colorado: Tomando / Tomando Diabetes

brochures and flyers

www.bewellColorado.org and

www.bewellColorado.com

Colorado: Video Testimonials (6) and

television interviews (one in Spanish)

www.bewellColorado.org and

www.bewellColorado.com and

www.bewellColorado.org/Spanish.html

Colorado: Press Kit

www.bewellColorado.org and

www.bewellColorado.com

Connecticut: Live Well CDSMP Program Final Report Appendix

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95

Logo

Connecticut: CDSMP Fact Sheet

Final Report Appendix

Connecticut: Program Flyer

Final Report Appendix

Florida: A Matter of Balance Flyer

Appendix E

Florida: Tai Chi flyer example

Appendix G

Florida: A Matter of Balance Flyer

Appendix H

Florida: Fit and Strong! Flyer

Appendix I

Florida: CDSMP Flyers

Appendix L

Florida: Living Healthy Brochures

Appendices R & S

Florida: Enhance Fitness Brochure

Appendix T

Florida: Evidence-Based Program Fact

Sheet

Appendix V

Hawaii: Enhance Fitness Kauai brochure

(Attachment C) www.HawaiiADRC.org

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96

Type of Resource/Product Access Point

Illinois: CDSMP Fact Sheets

Attachment A

Illinois: CDSMP and Next Steps

Flyers/Handouts

Attachment A

Illinois: Fact Sheets on Depression

Attachment B

Illinois: A Matter of Balance Flyers in

English and Chinese

Attachment B

Maine: Marketing Materials (promotional

flyers, brochures, post cards and web-

based messaging)

Not listed

Maryland: Fliers

MD Semi-Annual Report

Maryland: T-shirts, giveaways and

recognition awards

MD Semi-Annual Report

Maryland: Statewide tri-fold brochure

MD Semi-Annual Report

Michigan: Public Health Video

Testimonials

Program office (website inactive)

Michigan: Brochures (customizable)

Program office (website inactive)

Minnesota: A Matter of Balance low-

vision program materials

www.mnhealthyaging.org

New Jersey: Extensive portfolio of sample

promotional materials including posters,

fliers, and newsletter inserts; 30-minute

introductory presentation, etc.

Not listed

New York: Adaptable marketing brochure

and poster

http://nycdsmp.groupsite.com

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97

Type of Resource/Product Access Point

North Carolina: DSMP Workshop Posters

Final Report Appendix, pp. 48-49

North Carolina: Door Hangers

Final Report Appendix, pg. 50

North Carolina: Living Healthy (DSMP)

with Diabetes brochures

Final Report Appendix, pp. 51-52

North Carolina: Workshop Posters

Final Report Appendix, pp. 53-54

North Carolina: Sample Advertisements

Final Report Appendix, pp. 60-61

Ohio: Healthy U program flyers

Final Report Appendix

Ohio: Active for Life flyers

Final Report Appendix

Ohio: A Matter of Balance coach flyer

Final Report Appendix

Oklahoma: Flyers / promotional materials http://www.ok.gov/health/Community_Health/Co

mmunity_Development_Service/Health_Equity_

&_Resource_Opportunities/Community_Evidenc

e-Based_Programs/index.html or

www.livinglongerlivingstronger.org

South Carolina: Promotional materials

Program office

Texas: Outreach program materials

Not listed

Texas: Program website class schedules

www.MyLifeMyHealth.info

Wisconsin: Program brochures and fact

sheets

www.wihealthyaging.org

Wisconsin: “Selling” Living Well

Presentation Guide

www.wihealthyaging.org

OTHER

Arkansas: Arkansas Healthy Aging

Community website

Not listed

California: CDA’s Evidence Based web

www.aging.ca.gov/ebhp

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98

page

Colorado: Be Well Colorado and Be Well

Colorado with Diabetes websites

www.bewellColorado.org

and www.bewellColorado.com

Connecticut: CDSMP PowerPoint

presentations

Sample title page included in Final Report

Appendix

Florida: Fit and Strong! Presentation

Appendix K

Florida: Evidence-Based Program

Presentation

Appendix U

Florida: Health and Wellness Website

Appendix M

Hawaii: HHAP Partnership Training flyer

(PowerPoint)

(Attachment D) www.Hawaii.ADRC.org

Illinois: Workshop Date Sheet

Attachment A

Illinois: ECIAA website

Attachment A

Illinois: General Depression (PowerPoint)

Attachment B

Illinois: Identifying Individuals at Risk for

Suicide (PowerPoint)

Attachment B

Illinois: Depression 101 (PowerPoint)

Attachment B

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99

Type of Resource/Product Access Point

Massachusetts: A Matter of Balance

website

www.massmob.org

Massachusetts: Healthy Eating Group

website containing a complete library of

resources

https://healthyeating.groupsite.com/login (login

information: [email protected];

HealthyEating)

Minnesota: Website

www.mnhealthyaging.org

New York: Project website

http://nycdsmp.groupsite.com

North Carolina: Sample PowerPoint

presentation to Healthcare Providers

Final Report Appendix, pp. 22-46

North Carolina: Sample PowerPoint

presentation for ADRC

Final Report Appendix, pp. 63-84

North Carolina: PowerPoint Presentation

for CDMSP 2010 Leader Retreat

Final Report Appendix, pp. 85-107

North Carolina: PowerPoint Presentation

for A Matter of Balance 2010 Coach

Retreat

Final Report Appendix, pp. 129-151

Ohio: Healthy IDEAS Presentation

Agenda

Final Report Index

Oklahoma: Evaluation data / slide

presentation

http://www.ok.gov/health/Community_Health/Co

mmunity_Development_Service/Health_Equity_

&_Resource_Opportunities/Community_Evidenc

e-Based_Programs/index.html or

www.livinglongerlivingstronger.org

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100

Type of Resource/Product Access Point

Texas: Aging Texas Well Clearinghouse

for Evidence-Based Research

http://www.dads.state.tx.us/services/agingtexasw

ell/initiatives/ebased/index.cfm

Texas: Bibliography

www.txbcbh.info

Texas: Promotional video for exercise

programs

http://www.dads.state.tx.us/services/agingtexasw

ell

Texas: NCI web page on EBHP http://neighborhood-centers.org/en-

us/content/ACES.aspx

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101

APPENDIX D: LESSONS LEARNED BY RE-AIM CATEGORY

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102

Reach

Pick partners already serving your target audience(s) to reach ethnic and underserved

populations

Use GIS mapping tools to identify program locations; trainer availability and this shows

uncovered areas for development and expansion

Create/designate “champions” (ambassadors) from the most enthusiastic program

completers and train them as leaders and/or to assist with recruitment

Training Tomando leaders creates networks that can help recruit Hispanic participants

To address rural transportation problems, try ride sharing programs, scheduling classes

after other activities at times when people would already be at the site, and in some cases,

consider whether program leaders can pick up participants on their way to the site.

Effectiveness

Get input and buy in for the scope and requirements of any planned evaluation with the

agencies you expect to participate in advance

To assure the highest quality of leaders, set up a screening and/or interview protocol for

potential leaders before enrolling them in a leader training program

Use of buddy systems creates a connection to encourage continued participation

Adoption

Its best, when possible, to have a dedicated employee who specifically is in charge of

heath promotion programs within the AAAs

Use an organizational readiness tool and spend time meeting with potential agencies

before partnering to do programs to make sure staff at all levels in organization

understand the commitment they are making in offering the programs.

State centralized leadership and support is critical and should be emulated at the regional

levels

Clearly define responsibilities and outline commitments for partnering agencies at each

juncture of the program roll out (from planning to maintenance)

Engage large, well-established networks with health promotion missions to adopt and

deploy the programs within their systems. This is more efficient and easier to sustain

over time. This also helps in leveraging funding, since many of these larger host

organizations can apply for funding and/or reimbursement for workshop participation

Implementation

A key role at the state level continues to be the development and oversight of protocols to

foster fidelity monitoring and quality at all levels of program implementation.

Provide in- person fidelity monitoring training for all new leaders and develop regularly

scheduled refresher sessions to ensure reinforcement of critical implementation elements.

The Cost Calculator not only identifies program costs but can also be used to identify

cost variations across programs and delivery sites/regions

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Consider a combined leadership model: The state level can provide centralized resources

(training, TA, website, data management and analysis), while the local agencies can build

community delivery systems and own coordination for area programs

Use available toolkits to monitor fidelity and do fidelity assurance training

Maintenance and Sustainability

Use business planning principles to approach sustainability and to diversify funding

sources in sustainability planning

Planning to pay for an agency or regionally based program coordinator to manage

program logistics is the best investment that can be made

Involve the state Medicaid office leadership as part of project planning and the advisory

committee from the start

Standardize partner contracts that are based on the number of completers by grantee. In

that way, there is a measurable outcome while incentivizing providers to engage

participants and yield a high number of completers per workshop. This worked better

(for Florida) than initiating contracts based on reimbursement for lay leader trainings,

participants and workshops, incentives, or license fees.

Make sure that EBP is in the state plan for both aging and public health

Having good outcome data on participant health improvement and costs provides the

basis for state budget support and makes the business case for proposals for additional

funding


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