1
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-
23
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
24
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
25
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
26
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
27
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
28
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
29
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.
30
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
34
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
35
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
36
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
37
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
39
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.
40
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.
41
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
42
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.
43
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
44
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
45
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.
46
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.
47
48
APPENDIX A: DATA EXTRACTION TOOLS AND SCORING RUBRICS
49
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
50
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
51
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,
52
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]
53
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
54
Table 5: NCOA/AOA State Reports Analyses Rubric – Number of Older Adults Reported by Individual Programs
Program Stated Goal # Served Completed
# and %
55
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]
56
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
57
APPENDIX B: CASE STUDIES OF FIVE GRANTS
58
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).
59
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.
60
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
61
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.
62
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.
63
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
64
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
65
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.
66
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.
67
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.
68
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.
69
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.
70
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.
71
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.
72
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
73
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
74
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.
75
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
76
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.
77
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.
78
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.
79
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.
80
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.
81
APPENDIX C: PRODUCTS/RESOURCES DEVELOPED
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
83
Illinois: Leader Newsletter Attachment A
Illinois: Decatur Herald & Review newspaper article
Attachment A
Illinois: RUMC Newsletter
Attachment B
84
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
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
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
87
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
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)
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
90
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
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
92
South Carolina: Program Fidelity manual Program office
Texas: Texas Fidelity Plan Worksheet
www.txbcbh.ino
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
94
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
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
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
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
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
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
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
101
APPENDIX D: LESSONS LEARNED BY RE-AIM CATEGORY
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
103
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