Administration on Aging

Chronic Disease Self-Management Program (CDSMP) 

Process Evaluation

HHSP233201100492G

Final Report

April 30, 2013 

Authors: 

Cynthia Woodcock, IMPAQ International

Holly Korda, Altarum Institute

Erkan Erdem, IMPAQ International

Sarah Pedersen, IMPAQ International

Michelle Kloc, Altarum Institute

Erik Tollefson, Altarum Institute

Submitted to:

Project Officer: Susan Jenkins

Office of Performance and Evaluation

Administration for Community Living

 Department of Health and Human Services 

330 Independence Ave SW # 4760

Washington, DC 20201

Submitted by:

Project Director: Tina Barretto

IMPAQ International, LLC

10420 Little Patuxent Parkway 

Suite 300

Columbia, MD 21044

Telephone: (443) 367-0088
TABLE OF CONTENTS

Page

EXECUTIVE SUMMARY.............................................................................................................. III

CHAPTER 1. INTRODUCTION.......................................................................................................1

1.1 Purpose of the Process Evaluation....................................................................................1

1.2 AoA’s Role in Funding CDSMP...........................................................................................1

1.3 Stanford CDSMP...............................................................................................................2

CHAPTER 2. PROCESS EVALUATION DESIGN...............................................................................4

2.1 Process Evaluation Research Questions............................................................................4

2.2 Data Sources ....................................................................................................................4

2.3 Evaluation Approach ........................................................................................................5

CHAPTER 3: CHARACTERISTICS OF ARRA-FUNDED STATE GRANTEES .........................................8

3.1 Introduction .....................................................................................................................8

3.2 Grantee Characteristics ....................................................................................................8

CHAPTER 4: POPULATIONS SERVED BY CDSMP........................................................................13

4.1 Introduction ...................................................................................................................13

4.2 Characteristics of CDSMP Participants............................................................................14

4.3 Looking Ahead to the Future ..........................................................................................22

4.4 Reach of CDSMP.............................................................................................................24

CHAPTER 5: IMPLEMENTATION OF CDSMP ..............................................................................26

5.1 Introduction ...................................................................................................................27

5.2 Program Oversight and Administration...........................................................................28

5.3 Program Delivery Infrastructure .....................................................................................33

5.4 Program Fidelity .............................................................................................................41

5.5 Partners..........................................................................................................................46

5.6 Expanding CDSMP to New Populations...........................................................................50

5.7 Post-ARRA Changes........................................................................................................52

CHAPTER 6: PROGRAM COMPLETION RATES ...........................................................................54

6.1 Introduction ...................................................................................................................55

6.2 Completion Rates for ARRA Grantees.............................................................................55

6.3 Regression Analysis of Completion Rates........................................................................70

6.4 Summary and Discussion ................................................................................................77

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CHAPTER 7: DATA COLLECTION AND EVALUATION ..................................................................78

7.1 Introduction ...................................................................................................................78

7.2 Findings..........................................................................................................................79

7.3 Data Collection under ARRA Funding ..............................................................................80

7.4 Data Use and Reporting..................................................................................................82

7.5 Evaluation Efforts...........................................................................................................85

7.6 Post-ARRA Changes........................................................................................................90

7.7 Future Plans ...................................................................................................................93

CHAPTER 8: SUSTAINABILITY OF CDSMP ..................................................................................95

8.1 Introduction ...................................................................................................................96

8.2 Deliver CDSMP through Existing Networks .....................................................................98

8.3 Organizational Strategies................................................................................................99

8.4 Partner with Strong Organizations................................................................................104

8.5 Build Provider Referral Systems....................................................................................105

8.6 Educate Students in the Health Professions..................................................................106

8.7 Leverage Grant Funding................................................................................................106

8.8 Build Third-Party Billing Capability................................................................................107

8.9 Integrate Evidence-Based Programs into Health Reform Initiatives ..............................111

CHAPTER 9: BEST PRACTICES AND RECOMMENDATIONS.......................................................113

9.1 Best Practices...............................................................................................................113

9.2 Recommendations........................................................................................................119

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EXECUTIVE SUMMARY

The U.S. Administration for Community Living (ACL) supports states in their efforts to develop 

and implement delivery systems for Chronic Disease Self-Management Education programs. 

This includes the Chronic Disease Self-Management Program (CDSMP) developed by Stanford 

University. CDSMP, one of the most recognized evidence-based health promotion programs,

provides participants with the education and tools they need to help them manage chronic 

conditions such as diabetes, heart disease, or arthritis. The highly developed protocol for 

delivering Stanford CDSMP makes it possible to disseminate, evaluate, and bring the program 

to scale. 

This process evaluation examines state CDSMP programs funded through Communities Putting 

Prevention to Work: Chronic Disease Self-Management Program, an initiative of the 

Administration on Aging (AoA)—now a part of ACL1

—in collaboration with the Centers for 

Disease Control and Prevention (CDC) and the Centers for Medicare & Medicaid Services (CMS).

Under this initiative, AoA awarded two-year grants totaling $27 million to 45 states, the District 

of Columbia, and Puerto Rico in 2010. Grant funds were authorized by the American Recovery 

and Reinvestment Act (ARRA) of 2009.

In their ARRA grant applications, each state was to provide “a vision for long-term sustainability 

of CDSMP as part of its overall approach to helping older adults remain independent and living 

in their own home and communities.”2 AoA endeavored to support states in developing strong, 

sustainable delivery systems for CDSMP that would continue to thrive after federal funding 

came to an end. AoA promotes these key elements for an integrated, sustainable service 

delivery system:

1. State-level aging and public health leadership. Regardless of which agency is the lead 

for CDSMP implementation, AoA encourages states to develop effective collaborations 

between the state unit on aging and the public health agency.

2. Effective partnerships to embed CDSMP into statewide health and long-term services 

and supports systems. AoA encourages states to strategically recruit and partner with 

organizations that can embed CDSMP into their ongoing operations, with priority to 

delivery system partners with multiple delivery sites, the capacity to reach large 

populations, and a commitment to offering workshops on an ongoing basis beyond the 

grant period.

3. Delivery infrastructure/capacity to provide programs throughout the state. AoA 

encourages states to develop adequate capacity to deliver CDSMP workshops 

throughout the state.

 

1 In April 2012, AoA, the Office on Disability, and the Administration on Developmental Disabilities were combined 

into ACL, a single agency with the U.S. Department of Health and Human Services. AoA is now a part of ACL.

Throughout this report, we refer to AoA as the sponsor and administrator of the agency’s CDSMP initiative. 2 ARRA grant RFP, page 16.

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4. Centralized or coordinated processes for recruitment, intake, referral, and 

registration/enrollment. AoA encourages states to develop centralized or coordinated 

outreach and marketing efforts and to coordinate with ADRCs in the state. 

5. Quality assurance program and ongoing data systems and procedures. States are 

strongly encouraged to have a strong quality assurance program to ensure fidelity and 

facilitate continuous quality improvement, as well as data collection systems to support 

these functions.

6. Business planning and financial sustainability. States are expected to develop and 

execute business or sustainability plans to help ensure financial sustainability beyond 

the grant period, working with government agencies, foundations and corporations, 

health care providers, employer groups, and public and private insurers.

In September 2011, AoA awarded Contract No. HHSP233201100492G entitled CDSMP Process 

Evaluation and Detailed Outcome Evaluation Design to IMPAQ International and Altarum 

Institute. AoA was particularly interested in learning about states’ experiences in delivering 

CDSMP to adults aged 60 and older, the agency’s target population. This report details findings 

from the process evaluation of CDSMP.

Research Questions

The process evaluation addresses five research questions:

1. Who do ACL CDSMP grantees serve? How do the individuals served through the ACL CDSMP 

grants compare with populations studied through other CDSMP evaluations?

2. How are local sites implementing the CDSMP? For example, how do their organizational 

structure, financial resources and allocation and their fidelity compare to the Stanford 

CDSMP model? Are there common adaptations being made at ACL supported sites? Are 

there adaptations which specifically improve the applicability of the CDSMP to seniors (age 

60+) with chronic diseases?

3. What are program completion rates, in general and by important sub-groups? What barriers 

and supports affect the existing completion rates?

4. What data are ACL CDSMP grantees collecting and what is the state of their records 

systems? What is the evaluation capacity of state-level grantees and/or local sites including 

whether they have conducted or participated in program evaluations?

5. Have these grantees built sustainable statewide distribution and delivery systems which

increase the availability of evidence-based self-management programs and provide an 

ongoing distribution channel for other evidence-based programs that may be delivered by 

community based organizations?

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Process Evaluation Approach and Data Sources

The research team employed a multi-method approach using multiple qualitative and 

quantitative data sources (Exhibit ES1). We consulted with AoA program and regional staff and 

formed a Technical Advisory Group (see Appendix A) to inform the process evaluation design. 

The team conducted site visits to six states in January-February 2012 to observe program 

implementation on the ground and further inform development of the process evaluation. For 

the site visit interviews, we mapped the five research questions to research domains and then 

developed interview questions for each domain. Next, during April-June 2012 we conducted 

one-hour telephone discussions with key informants representing each of the 47 state grantees 

as part of AoA’s ARRA grant close-out activities. We used an abbreviated list of questions that 

focused on the current landscape for CDSMP and the anticipated changes in the post-ARRA 

funding environment in order to assess the current status of each program and prospects for 

sustainability. We also analyzed program data submitted to the National Council on Aging 

(NCOA) by the state grantees to present a descriptive analysis of participants, workshops, and 

leaders. The program data were also used to conduct regression analyses to examine the 

influence of various factors on participant completion rates, such as participant demographics 

and chronic conditions, size and location of the workshops, seasonal factors, and characteristics 

of the state’s CDSMP delivery system. 

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Exhibit ES1. Process Evaluation Approach and Data Sources

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Summary of Findings

Characteristics of State Grantees

1. The lead agency in the majority of states is the state unit on aging. In two-thirds of the 

ARRA-funded states, the lead agency is the state unit on aging. The department of 

health is the state lead for one-third of the states. 

2. Grant awards varied by state. Grant awards totaled $27 million; awards to states 

ranged from $50,000 to $1.19 million. 

3. Most state grantees had received prior funding to implement CDSMP. Only ten 

grantees had never before received significant Federal funding to develop a CDSMP 

program; the other states had received prior funding from AoA, the Centers for Disease 

Control and Prevention (CDC), and/or CDC’s National Association of Chronic Disease 

Directors (NACDD) so already had experience implementing the program. 

4. All but one state met their goals for the number of participants and completers. ARRA 

grantees agreed to goals at the outset of their awards that were based on the number 

of Medicare beneficiaries in each state. Only one grantee did not achieve their goals 

during the two-year grant period or during a no-cost extension. Nine grantees exceeded 

their goals by more than 200 percent.

CDSMP Participants

1. ARRA grantees provided CDSMP to nearly 90,000 participants. During the two-year 

ARRA grant period, 22,043 individuals under age 60, 57,870 individuals aged 60 and 

older, and 9,945 individuals of unknown age participated in CDSMP workshops in 

grantee states, for a total of 89,861 participants. 

2. Disproportionately more CDSMP participants were served by state units on aging. 

Eighty percent of participants were enrolled in CDSMP operated by state units on aging; 

20 percent participated in programs operated by public health departments even 

though two-thirds of grantees were state units on aging.

3. The majority of participants attended workshops in metropolitan areas. Seventy-nine 

percent of participants attended workshops in metro areas; 21 percent participated in 

workshops in non-metro areas.

4. Participants were largely white and female, although grantees were targeting more 

diverse populations. Among those aged 60 and older, 72 percent of participants were 

female, just over half were white, and 15 percent were African American. Many state 

grantees reported targeting special populations, particularly Latinos, Asians, and Native 

Americans. 

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5. On average, participants reported 2.44 chronic conditions. However, women reported 

more chronic conditions than men (an average of 2.51 for women; 2.17 for men). 

Hypertension/high blood pressure and arthritis/rheumatic disease were the most 

commonly reported chronic conditions for participants aged 60 and older. Rates of 

cancer, heart disease, stroke, and osteoporosis tended to increase with increased age. 

Depression or anxiety disorders and diabetes tended to be more prevalent among those 

younger than age 60 and those aged 60 to 64, with rates decreasing with age thereafter.

6. Longer funding histories were not associated with serving more diverse populations. 

Although the research team hypothesized that grantees with longer and more diverse 

funding histories for CDSMP implementation would be serving more diverse 

populations, this was not the case. Participant demographics were generally consistent 

across the three types of funding histories examined.

Implementation of CDSMP

1. CDSMP was implemented successfully in a diverse set of organizational arrangements.

Aging services networks served as grantees in most states, using aging services 

providers such as AAAs, state and local public health departments, and private health 

systems as key partners for CDSMP program oversight and delivery. Grantees used 

centralized, decentralized and shared infrastructures.

 Oversight: Grantees used centralized program administration and oversight in 14 

states, decentralized models in 23 states, and shared systems of oversight in 10 

states. 

 Delivery: Most grantees (37) used decentralized delivery systems to deliver CDSMP 

through public and private organizations including AAAs, 9 used centralized 

infrastructures such as private or public health systems, and one grantee used a 

mixed approach. Grantees that used centralized systems to deliver CDSMP typically 

centralized communications, licensing, and referral as well.

2. No single approach works best in all contexts. However, centralized approaches offer 

advantages such as standardization of training and delivery, leverage for data 

collection, and certain economies of scale—while decentralized approaches can be 

more responsive to local conditions and resource availability. CDSMP oversight and 

delivery arrangements typically reflected historical funding and partnerships, 

geographical relationships, or political structures already established within the state. 

3. Marketing and recruitment continue to be challenges for many grantees, especially 

those with limited staff and financial resources for outreach. Grantees that leveraged 

established partnerships and networks (e.g., AAAs, Area Health Education Centers, etc.) 

to market and recruit participants were more likely to be successful reaching older 

adults and filling workshops.

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4. Retaining participants throughout the 6 workshop sessions can be difficult—but 

grantees have identified successful strategies to support retention. Transportation and 

weather problems, illness, and participant motivation or interest can all interfere with 

attendance. Grantees and workshop leaders reported using small incentives such as gift 

cards, key chains, and other giveaways; scheduling workshops at convenient times and 

places; and assisting participants with transportation to and from workshops as key 

strategies for improving retention.

5. Reaching cultural and ethnic minorities can be difficult, especially if funding for 

outreach is limited. However, many sites have been able to reach and serve these 

populations successfully. Once enrolled, these populations are likely to stay with the 

program and show high rates of completion. Several grantees have expanded reach and 

reported success serving special populations including prisoners and disease-specific 

populations. More information is needed about grantees’ experiences with these 

groups.

6. Program success depends highly on the commitment of key leaders and champions. 

Program champions are key to the success and sustainability of CDSMP programs, 

especially at start up. Grantees of programs lacking champions or continuity of 

leadership encountered more problems with ongoing program operations and had more 

difficulty making the case to sustain the program at the end of ARRA funding. Grantees 

should be sure to start establishing policy and infrastructure immediately so the 

program does not fail if the champion is gone.

7. Fidelity is multi-faceted, with multiple components identified as important to program 

success in the Stanford protocols. Grantees reported fidelity as a priority and 

approached it in various ways. The relative importance of specific items to program 

success is unclear. Grantees and workshop leaders questioned some items, including 

class size and presentation format. Questions were also raised regarding the relative 

importance of specific workshop sessions. Some grantees suggested a study of the 

relative importance of CDSMP fidelity requirements would be helpful to shed light on 

these and other issues.

8. Grantees called out a need for state-specific information about the effectiveness, cost 

effectiveness, and return on investment of CDSMP. This information is often requested 

by legislators and is needed to support third-party payment and funding to continue 

program availability.

Completion Rates

Grantees were expected to track the number of participants and “completers” (i.e. the number 

of individuals who completed at least four out of six workshop sessions).

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1. The average completion rate for CDSMP participants was 75 percent. However, 

average completion rates varied from 63 percent in Oregon to 86 percent in Oklahoma. 

Completion rates for individuals aged 60 and older were slightly higher than for those 

under age 60 (77.2 percent compared to 74.5 percent). At 77 percent, female 

participants had higher completion rates than males. Workshops that were held by 

faith-based organizations had the highest completion rates of any type of 

implementation site. 

2. Completion rates varied by type of program oversight. States that instituted a 

centralized model to oversee CDSMP had the highest completion rates for participants 

under age 60 (75.4 percent) and over age 60 (79.3 percent). Average completion rates 

were slightly higher for programs led by state units on aging than for programs led by 

public health agencies.

3. Individuals with certain chronic conditions were more likely to complete CDSMP. 

Individuals reporting hypertension and osteoporosis had greater odds for completion. 

Not unexpectedly, individuals reporting depression were less likely to complete CDSMP, 

suggesting the need for more supports for this population.

4. Smaller workshops tend to have higher completion rates. Participants in smaller 

workshops (i.e., with no more than 5-6 participants) had significantly higher completion 

rates even though workshops of this size are not recommended in Stanford’s program 

fidelity guidelines. Greater camaraderie and peer pressure combined with possibly more 

individualized attention from leaders may explain the higher completion rates. 

5. Leader experience matters. Participants who attended workshops with leaders who 

taught a workshop in the previous quarter or with leaders who had taught together 

previously had higher odds of completion. 

6. Completion rates were higher for Spanish language CDSMP (Tomando Control de su 

Salud). Cultural elements included in the Spanish language CDSMP curriculum may have 

a positive effect on completion rates and should be examined more carefully for 

applicability to English language CDSMP.

7. Completion rates in non-metro areas were higher than in metro areas. This was 

despite barriers common in rural areas such as a lack of public transportation, long 

travel distances to classes, and a greater impact of inclement weather reported by 

grantees. 

8. The relationship between Class Zero and completion rates is unclear. Regression 

analysis did not find strong evidence that participation in Class Zero improved the 

overall odds of completing CDSMP. Participants in workshops that offered an 

introductory Class Zero had slightly higher completion rates than other participants 

(75.8 percent compared to 74.7 percent) and the difference is statistically significant. 

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Taken together this suggests that additional research on which populations and in which 

situations Class Zero might prove beneficial is needed. 

Data Collection

1. More than half (31 of 47) of grantees reported using CDSMP data required under the 

ARRA grant, often supplemented with other primary and secondary data on programs, 

for program management or process evaluation, and 17 grantees reported conducting 

special studies of health outcomes, cost or utilization. Grantees often evaluate 

participant (and sometimes workshop leader) satisfaction, with 3-, 6- and 12-month 

follow up after completion of the workshops. Even states collecting only the data 

requested under the grant were able to use the information for program planning (e.g., 

to target need for leader training and to target populations and locations for 

workshops). 

2. Grantees used a wide array of approaches to collect data on CDSMP participants 

required under their ARRA grants. All grantees were able to collect and submit program 

data. Some used basic commercially available software such as Excel or Access to track 

or collect additional data, while others developed or expanded data collection programs 

used by state agencies, contracted organizations or host sites. Data collection activities 

were typically conducted by program staff funded by the CDSMP grant or integrated as 

part of other grantee infrastructure for CDSMP or other programs.

3. Several grantees reported partnering with universities to conduct rigorous research 

studies. Grantees’ studies use many different types of measures, and are starting to 

build a research base for CDSMP as implemented at the state and local levels. 

Measures track changes in functional status, health care utilization, cost and clinical 

indicators. 

4. Grantees reported various benefits of data collection and reporting, including program 

planning and oversight, program improvement, and reporting to stakeholders. Some 

grantees and host sites have incorporated evaluation into their aging and public health 

programs. Data collection and monitoring require funding to support. Not all states are 

able to continue these activities post ARRA funding. 

Program Sustainability

1. Strong leadership and vision at the state level will be a key factor in program 

sustainability. Whether a state opts for centralized or decentralized oversight or a 

centralized or decentralized delivery system, state-level commitment to CDSMP will be 

critical. Leaders at the state level who ensure that CDSMP is integrated into statewide 

strategic planning, actively support implementation at the local level through technical 

assistance and other supports, and advocate for statewide standards for fidelity 

monitoring are likely to be rewarded with stronger, more sustainable programs. 

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2. A symbiotic partnership between the state unit on aging and the public health 

department benefits CDSMP implementation and sustainability. Aging brings access to 

a state’s aging network, which is important for reaching older adults and, increasingly, 

persons with disabilities (through ADRCs). Public health brings a commitment to 

evidence-based health promotion and prevention programs and partnerships with 

established delivery systems. States in which aging and public health collaborate 

effectively tended to have stronger CDSMP delivery networks, even though the agingpublic health partnerships vary significantly in structure and function across the states. 

3. Agency leaders at the state level will not be successful in advocating for and sustaining 

CDSMP unless they are able to effectively communicate the program’s benefits to the 

governor’s office, legislators, and other stakeholders. Many grantees reported that 

state officials and legislators want evidence of program benefits and cost-effectiveness 

before considering broader support for CDSMP. 

4. While strong leadership is needed at the state level, regional and local leadership is 

also important to sustainability. Regional or local leaders committed to CDSMP, as well 

as “embedded” agency staff who are trained as CDSMP leaders, can bring stability and 

continuity at the local level. Embedded leaders can also reduce dependence on 

volunteers. Many sites reported that recruiting, training, and sustaining an all-volunteer 

corps of workshop leaders can be challenging and costly. 

5. With their boundless energy and tenacity, state and local champions often play a 

pivotal role in launching successful programs; however, sufficient attention must be 

given to building a strong delivery system and broad support for the program.

Otherwise, a program may not be able to weather the loss of a champion or a change in 

leadership. 

6. Strong infrastructure is key to sustainability, whether at the state level (centralized 

models) or the regional level (decentralized models). Some grantees advocated for 

centralized infrastructure to support multi-site, multi-program licenses and data 

collection and support for community-based organizations. Others advocated for 

decentralized approaches, making efforts to have community-based organizations take 

on program responsibilities to ensure sustainability of CDSMP in the event of state 

budget cuts or reorganizations might impact capacity to support ongoing program 

activities. There is not strong evidence for one approach over the other as a 

sustainability strategy.

7. Simultaneous pursuit of multiple strategies to promote sustainability can be beneficial 

in a program’s start-up phase, but a focus on the most effective strategies is ultimately 

the best approach. “Let a thousand flowers bloom” was the mantra of a number of 

ARRA grantees in their quest for sustainability; however, those who systematically 

evaluate the various strategies and ultimately focus only on those likely to result in the 

greatest benefit will be most successful over the long term.

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8. Outsourcing program oversight and technical assistance can be an effective strategy as 

long as there is funding to do so. Grantees such as California and New York have been 

able to build strong programs by outsourcing program implementation responsibility to 

other organizations. However, this is a sustainable model only if there is a dedicated 

source of funding for these organizations (e.g., grant funding or a state budget line) or 

program revenue streams that can support them (e.g., technical assistance fees).

9. Perhaps most challenging for grantees was developing effective referral networks and 

few “best practices” emerged. While all but one grantee met their goals for workshop 

participants, virtually all reported difficulty recruiting participants. Developing more 

effective recruiting strategies will be an important factor for ensuring long-term 

sustainability of CDSMP. 

10. “Smart” investment of program development funds can help to build sustainability. 

Many grantees avoided using ARRA funds to support state and/or local staff salaries, 

understanding that it would be difficult to find replacement funds when the ARRA grant 

came to an end. Instead, investing in infrastructure building was more likely to position 

a program for sustainability over the long term (e.g., developing marketing materials 

and Web sites, training program coordinators and leaders, establishing processes for 

fidelity monitoring).

11. Long-term sustainability is likely to depend on integration of CDSMP into new delivery 

system and financing models. States cannot rely on public or private grant funding to 

sustain CDSMP, which can ebb and flow as budgets and priorities change. Incorporating 

CDSMP into medical home models, large medical practices like Kaiser Permanente, and 

public and private managed care programs is likely to be a more sustainable strategy.

Best Practices and Recommendations

Our analysis of data collected during site visits and telephone discussions with grantees 

suggests a number of “best practices” for developing and sustaining CDSMP programs for older 

adults. Federal and state policies can advance adoption of evidence-based programs, such as 

the new federal requirement that Title IIID funding may only be used for evidence-based 

programs and Arkansas’ requirement that AAAs include at least one evidence-based program in 

their four-year State Plans on Aging. State health reform initiatives that incorporate CDSMP can 

have a significant impact on incentivizing program development and sustainability (e.g., 

Vermont’s Blueprint for Health). States that have developed effective referral networks (e.g., 

with physician practices, health plans, FQHCs, ADRCs) are more likely to have strong programs, 

as are states that have established strong and creative partnerships to expand the reach of 

CDSMP. Grantees also benefit from partnerships with universities (specifically, special centers, 

programs, or research groups) and other external organizations whose missions align with 

CDSMP. Organizations such as these can provide technical assistance, data collection, and 

evaluation expertise.

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Ensuring long-term sustainability will require multiple strategies, but the evaluation team 

believes that positioning states to diversify their funding streams and receive third party 

payment should be a goal shared by all states and stakeholders. This will require documenting 

the effectiveness and efficiency of CDSMP delivery, conducting cost finding and establishing 

payment rates and approaches for delivering the program, and working with private health 

plans, Medicare Advantage plans, and Medicaid managed care organizations to incorporate 

CDSMP as a billable service for members. The time is right, with public and private health plans 

actively embracing health promotion, care coordination, and medical home models and states 

adopting more expansive managed care for public beneficiaries.

To continue to build and expand CDSMP, the evaluation team offers the following 

recommendations to ACL.

Recommendation 1: Support Grantees in Communicating the Benefits of CDSMP to State 

Policy Makers

State grantees often remarked that in order to convince state legislators and agency leaders of 

the importance of building and sustaining a strong CDSMP program, they must be able to 

demonstrate the benefits of CDSMP for residents of their state. Grantees stressed the 

importance of having data on both improved health outcomes and demonstrated cost savings. 

The peer-reviewed literature includes a number of evaluation studies in which improvements in 

health behaviors, health status, and health service utilization have been documented through 

self reports by CDSMP participants as well as more rigorous studies of impact and outcome 

including the original clinical trials that establish the evidence base for CDSMP by Stanford 

University. Grantees could benefit from guidance on which research studies could best support 

their advocacy efforts at the state level, as well as how to “message” research findings to 

convince policy makers that similar outcomes could be expected in their state. 

ACL and CMS should continue to pursue studies of cost effectiveness using Medicare and 

Medicaid fee-for-service administrative data. In addition, cost-effectiveness studies in managed 

care settings could help persuade health plans to either provide CDSMP directly or offer 

members access to state programs. Several grantees reported interest from Medicare 

Advantage plans, Medicaid managed care plans, and private insurance plans. Health plans 

active in multiple states may be interested in multi-state demonstrations and evaluations. Once 

cost-effectiveness studies are completed, grantees will need assistance with messaging findings 

so that their applicability can be understood by state policy makers. 

Grantees should also be encouraged in their efforts to continue collecting and monitoring 

program performance data (e.g., through technical assistance). It will be important for grantees 

to monitor participation and completion rates, participant satisfaction, leader performance, 

and fidelity in order to help convince state policy makers that program dollars are well spent 

and to continue funding the program. To support data collection efforts, ACL should continue to 

allow grantees to enter data into and receive reports from the NCOA database even if they are 

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no longer receiving AoA funding. Technical assistance could also be provided to states 

interested in collecting additional data. Encouraging grantees to partner with local universitybased research centers to collect, analyze, and report performance data could be beneficial as 

well. 

Recommendation 2: Assist States with Determining the Cost of CDSMP and Preparing for 

Third-Party Payment

States are eager to seek payment for provision of CDSMP from diverse funding sources but do 

not have an established methodology for determining the true cost of the program. While 

NCOA provides a cost calculator developed by the Lewin Group that states can use to estimate 

the costs of program delivery, more sophisticated state and region-specific information is 

needed to determine the actual per capita cost of providing a CDSMP session to ensure that the 

service is priced correctly and the program does not operate at a loss. As in any business model, 

the cost calculation should include product development, marketing, service provision, quality

assurance, and indirect costs. States would benefit from a more complex model developed by a 

reputable accounting firm, as well as technical assistance in applying the model. Having 

defensible estimates for per capita cost will be important in negotiating payment with 

providers, third-party payers, and employers. Payment options range from fee-for-service 

payment per workshop or workshop session, to per capita completion payments, bundled 

rates, or global payments from health plans, patient-centered medical homes, accountable care 

organizations, and other purchasers. 

The transformation from grant-funded programs to a third-party payment business model will 

require the capability to bill for services. A technical assistance program that aids states in 

developing billing system requirements, issuing procurements to prospective vendors, 

implementing new billing systems and linking them to other systems (e.g., Medicaid MMIS, 

electronic registration systems), and training staff to manage billing functions would be 

welcomed by states. Grants to states for purchase and implementation of systems would also 

be beneficial.

Accreditation processes and programs for Medicare reimbursement for community-based 

delivery of the Diabetes Self-Management Program (DSMP) are now available and several 

respondents in the evaluation interviews suggested that DSMP could well provide a model for 

CDSMP. ACL should continue to provide grants and technical assistance to states seeking to 

become accredited to receive Medicare reimbursement for DSMP. In addition to expanding 

access to DSMP, this will help states to build the capacity to bill for self-management programs, 

which will in turn support state efforts to bill health plans and Medicaid. Additionally, ACL and 

CMS should evaluate the DSMP experience and consider the prospects for statutory change 

that would permit Medicare reimbursement for CDSMP. 

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Recommendation 3: Promote Peer Learning Among Grantees

State grantees are eager to learn from the experiences of other grantees. Creative peer learning 

opportunities in which grantees are “matched” with other grantees to provide peer technical 

assistance could spur more rapid program expansion through the use of proven 

implementation strategies. This could be coupled with a Web site that organizes resources 

supplied by grantees (i.e., manuals, organizational charts, marketing plans and materials, 

legislative reports, sample contracts, requests for proposals, Medicaid rules, survey 

instruments, evaluation reports) around implementation topics (e.g., delivery system oversight 

and organization, outreach and marketing, recruitment and retention of leaders, building 

referral networks, fidelity monitoring, program evaluation). Mini-case studies on best practices 

and peer technical assistance that had a significant impact on program implementation could 

also be shared. Activities such as these are currently provided by NCOA. ACL should continue to 

support current and expanded options for peer knowledge transfer.

Recommendation 4: Develop an Electronic Registry for Leaders

Few states have electronic systems for registering leaders, scheduling leaders for workshops, 

and monitoring leader certification. An electronic registry could facilitate efficient training and 

leveraging of leaders within and across states and regions, including providing interstate access 

to leaders. ACL could sponsor the development of a web-based electronic registry that could be 

used by all states. The registry could be designed for states to use individually (i.e., each state 

would only have access to their own data, but all states could use the system) or by groups of 

states (e.g., smaller states in the northeast that may want to share leaders across state lines). 

Alternatively, ACL could sponsor the development of registry software that could be 

downloaded and customized for use by individual states (i.e., a freeware or shareware 

program). 

Recommendation 5: Educate Health Professionals about Self Management

Universities in New Jersey, Ohio, and Illinois have incorporated education about selfmanagement and evidence-based health promotion programs into their nurse training 

programs. In some states, health professions students are being trained as CDSMP leaders and 

are referred to organizations that are seeking volunteer leaders. While this strategy is not likely 

to significantly increase the leader workforce in the immediate future, educating health 

professionals about the importance of self management could, over time, have an impact in 

practice settings and in terms of referrals to self management programs. ACL could work with 

professional societies such as the American Association of Colleges of Nursing to develop 

curricula on self-management education that could be adopted by other nurse training 

programs. Curricula could also be developed for practicing professionals that could be offered 

online or at professional meetings, with continuing education unit (CEU) credits awarded to 

professionals completing the programs. 

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Recommendation 6: Assist Grantees in Developing More Effective Strategies for Building 

Referral Networks for Recruiting Participants 

Grantees reported that building an effective referral network for recruiting participants was 

perhaps the most daunting challenge they faced. Given the pressures on today’s medical 

practices, getting physicians to directly refer patients was rarely a successful strategy. However, 

some grantees reported success with special mailings generated by physicians’ offices (signed 

by the physician) to patients whose medical records indicated they might benefit from CDSMP. 

Other grantees reported efforts to incorporate a “button” in the electronic medical record that 

could trigger a patient referral. Additionally, some health plans were identifying members who 

might benefit from a self-management program through medical record reviews—and in some 

cases, providing cash rewards for participation. Strategies such as these warrant further 

exploration. In addition, more research is needed to identify the personal, social-behavioral, 

and clinical characteristics of individuals most likely to participate, complete, and benefit from 

the program and how to effectively target these individuals using electronic medical records. 

With the growth of ADRCs, ACL has a unique opportunity to encourage referrals within the 

aging and disability services networks. ADRCs in many states are referring consumers to 

CDSMP. ACL’s technical assistance contractor for the ADRC program could develop a training 

module for ADRC staff on incorporating self-management program referrals into the ADRC 

screening and options counseling processes. This could include developing several questions 

related to chronic disease management for integration into the initial screening questions 

ADRCs use when a consumer contacts them for the first time, as well as developing guidelines 

for building self-management program counseling and referrals into options counseling. 

Nevada’s vision for integrating CDSMP into their ADRC Web site—using the portal for consumer 

information, workshop schedules and registration, communications with and reporting by 

leaders, and on-line leader training—could be promoted to other states through webinars and 

presentations at ADRC grantee meetings, as well as through technical assistance on 

implementing these functions.

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CHAPTER 1. INTRODUCTION

1.1 Purpose of the Process Evaluation

To provide older adults with the education and tools they need to manage chronic diseases 

such as hypertension, diabetes, arthritis, and heart disease, the U.S. Administration for 

Community Living (ACL) supports states in their efforts to develop and implement delivery 

systems for the Chronic Disease Self-Management Program (CDSMP) developed by Stanford 

University. This process evaluation examines state programs funded through Communities 

Putting Prevention to Work: Chronic Disease Self-Management Program, an initiative of the 

Administration on Aging (AoA)—now part of ACL3

—in collaboration with the Centers for 

Disease Control and Prevention (CDC) and the Centers for Medicare & Medicaid Services (CMS).

Under this initiative, AoA awarded two-year grants totaling $27 million to 45 states, the District 

of Columbia, and Puerto Rico in 2010. Grant funds were authorized by the American Recovery 

and Reinvestment Act (ARRA) of 2009. Many of the states used grant funds to support CDSMP 

as well as other evidence-based, disease-specific self-management programs such as the 

Arthritis Self-Management Program (ASMP) and the Diabetes Self-Management Program 

(DSMP). However, the focus of the process evaluation is on the development and dissemination 

of CDSMP.

In September 2011, AoA awarded Contract No. HHSP233201100492G entitled CDSMP Process 

Evaluation and Detailed Outcome Evaluation Design to IMPAQ International and Altarum 

Institute. The process evaluation conducted under this contract was intended to examine the 

populations served by state grantees, how grantees implement their CDSMP programs, and 

how programs differ in terms of completion rates, distribution channels, delivery systems, and 

the capacity of grantees to disseminate and sustain their programs. AoA was particularly 

interested in learning about states’ experiences in delivering CDSMP to adults aged 60 and 

older, the agency’s target population. Prior studies of CDSMP did not focus specifically on the 

older adult population.

1.2 AoA’s Role in Funding CDSMP

The ARRA grants were awarded to state grantees for the two-year period March 31, 2010, to 

March 30, 2012. In each state, funding was awarded to either the state unit on aging or the 

state department of health as the lead agency. Development and delivery of CDSMP is carried 

out by the lead agency together with host and implementation sites. A host site is an

organization that oversees program operations (e.g., an Area Agency on Aging (AAA)) and may 

also manage recruitment and enrollment of participants. An implementation site (also known 

as a program delivery site) is where the workshop is conducted (e.g., a senior center, YMCA, or 

 

3 In April 2012, AoA, the Office on Disability, and the Administration on Developmental Disabilities were combined 

into ACL, a single agency with the U.S. Department of Health and Human Services. AoA is now considered a 

program of ACL. Throughout this report, we refer to AoA as the sponsor and administrator of the agency’s CDSMP 

initiative.

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faith-based organization). In some locations the host and implementation sites are the same

organizations; in other locations they are different.

AoA has a cooperative agreement with the National Council on Aging (NCOA) to provide 

technical assistance to CDSMP grantees and other AoA grantees implementing evidence-based 

prevention programs. Technical assistance may include web-based training, on-site visits, 

targeted teleconferences, peer-to-peer mentoring, strategies and models for developing 

statewide CDSMP distribution systems, and strategies to sustain programs beyond the grant 

cycle (http://www.healthyagingprograms.org). NCOA maintains a database on programs, 

including location, number, and characteristics of participants served, and workshops offered.

Grantees submit program data to NCOA for inclusion in this database.

1.3 Stanford CDSMP

CDSMP was developed in 1992 by the Stanford Patient Education Research Center working with 

the Divisions of Family and Community Medicine and the Division of Rheumatology and 

Immunology. CDSMP consists of 2.5-hour workshops offered once a week for 6 weeks. CDSMP 

is generally administered in community settings such as churches, libraries, YW/MCAs, senior 

centers, public housing projects, community health centers, and cooperative extension 

programs. The program is also available online, named Better Choices, Better Health.

4 Because

the program is not disease-specific, people with different chronic health problems attend 

together. Several key characteristics of the Stanford CDSMP intervention make it unique when 

compared to other such evidence-based disease and disability prevention initiatives. The highly 

developed protocol for delivering Stanford CDSMP makes it possible to disseminate, evaluate, 

and bring the program to scale. CDSMP uses master and lead (lay) trainers and in-person 

workshops. Workshop leaders are trained to strictly adhere to specific program requirements 

and processes in order to attain and maintain fidelity to the program as originally designed. For 

example, they are asked to conform to guidelines regarding numbers of workshop participants, 

workshop content, duration, and more. 

Master trainers. Master trainers provide some oversight of CDSMP workshops, train workshop 

leaders, work in pairs, and serve as workshop leaders themselves. In addition, master trainers:

 Attend 4.5-day master training.

 Facilitate one 4-day leader training within a year of completing master training.

 Lead a full 4-day leader training at least once a year to remain certified.

Lay Leaders. These are individuals who facilitate the CDSMP workshops. They work in pairs and 

commit to the following requirements:

 Attend four 6-hour days of training over 2 weeks and complete two practice teachings 

during training.

 

4 NCOA has licensed the CDSMP online program.

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 Commit to facilitating at least one 6-week workshop in the year in which they were 

trained.

 Must come from the same communities which the CDSMP intends to serve.

In-person workshops: 

 Are offered to group sizes of 10–16 participants.

 Are offered 2.5 hours a week over 6 weeks.

 Are conducted by two lay leaders who received training from a master trainer.

Workshop topics include: 1) techniques to deal with problems such as frustration, fatigue, pain, 

and isolation; 2) appropriate exercise for maintaining and improving strength, flexibility, and 

endurance; 3) appropriate use of medications; 4) communicating effectively with family, 

friends, and health professionals; 5) nutrition; and 6) how to evaluate new treatments. 

Findings from Stanford’s evaluation of CDSMP are available on the Stanford web site. They 

found that CDSMP participants—when compared to those who did not participate in CDSMP—

had significant improvements in exercise, cognitive symptom management, communication 

with physicians, self-reported general health, health distress, fatigue, disability, and social/role 

activities limitations. Participants in a randomized trial also had fewer hospitalizations and 

spent fewer days in the hospital.5

 

5 See: 

(1) Lorig KR, Sobel DS, Stewart AL, Brown Jr BW, Bandura A, Ritter P, González VM, Laurent DD, Holman HR. 

Evidence suggesting that a chronic disease self-management program can improve health status while 

reducing hospitalization: A randomized trial. Medical Care, 37(1):5-14, 1999

(2) Lorig KR, Ritter P, Stewart AL, Sobel DS, Brown BW, Bandura A, González VM, Laurent DD, Holman HR. 

Chronic Disease Self-Management Program: 2-Year Health Status and Health Care Utilization Outcomes. 

Medical Care, 39(11), 1217-1223, 2001. 

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CHAPTER 2. PROCESS EVALUATION DESIGN

2.1 Process Evaluation Research Questions

The process evaluation addresses five research questions:

1. Who do AoA CDSMP grantees serve? How do the individuals served through the AoA 

CDSMP grants compare with populations studied through other CDSMP evaluations?

2. How are local sites implementing the CDSMP? For example, how do their organizational 

structure, financial resources and allocation and their fidelity compare to the Stanford 

CDSMP model? Are there common adaptations being made at AoA supported sites? Are 

there adaptations which specifically improve the applicability of the CDSMP to seniors 

(age 60+) with chronic diseases?

3. What are program completion rates, in general and by important sub-groups? What 

barriers and supports affect the existing completion rates?

4. What data are AoA CDSMP grantees collecting and what is the state of their records 

systems? What is the evaluation capacity of state-level grantees and/or local sites 

including whether they have conducted or participated in program evaluations?

5. Have these grantees built sustainable statewide distribution and delivery systems which 

increase the availability of evidence-based self-management programs and provide an 

ongoing distribution channel for other evidence-based programs that may be delivered 

by community based organizations?

Evaluation findings will assist AoA in its continuing efforts to work with grantees to refine, bring 

to scale, and sustain CDSMP and other evidence-based prevention programs. Specifically, 

findings will guide improvements to partnership building, marketing and outreach, 

development of referral systems, ensuring program fidelity and quality, program evaluation, 

and financial viability. 

2.2 Data Sources 

The evaluation team used a mix of qualitative and quantitative data sources in conducting the 

process evaluation. A description of data sources follows. 

Technical Advisory Committee (TAG) input. During telephone meetings convened on March 2, 

2012, and July 20, 2012, the TAG provided valuable insights that informed development of the 

process evaluation design (see Appendix A for TAG members). 

State survey on program sustainability. AoA provided the evaluation team with data from a state 

survey conducted in 2011 that examines six elements identified by AoA as central to a sustainable 

infrastructure and delivery system. The survey instrument, entitled Sustainable Infrastructure and 

Delivery System Self-Assessment, is available at 

http://www.ncoa.org/chamodules/documents/AOASustainabilityAssessmentTool.pdf. 

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Conference calls with AoA regional and program staff. AoA has central office staff and regional staff 

all of whom are involved in monitoring AoA’s CDSMP grantees. The project team held two calls with 

AoA regional staff to gain a better sense of the on-the-ground experience with CDSMP in order to 

inform a) site selection criteria, site selection, and the interview guide for the site visits, and b) 

discussion topics, participant selection, and the discussion guide for the telephone discussions 

conducted with key informants as part of the grant close-out process. The IMPAQ team held calls 

with the AoA Regional offices on November 9, 2011, and December 1, 2011.

Site visits. The evaluation team site visited CDSMP programs in six states in January-February 2012

to observe program implementation on the ground and inform development of the process 

evaluation. During the two-day visits to Arkansas, California, Kansas, New York, Tennessee, and 

Vermont, the evaluation team met with state lead agency staff, host sites, implementation sites, 

leaders, program participants, and other stakeholders. To select the six states for site visits, the team 

used data from AoA’s Sustainable Infrastructure and Delivery System Self Assessment to develop a 

system for ranking state performance and then selected a mix of states.6 The site visit guide, 

organized around six research domains that address the process evaluation research questions, is 

provided in Appendix B. A summary of site visit findings can be found in Appendix C. 

Telephone discussions with key informants. The evaluation team conducted telephone discussions 

with state grantees, partners, and host sites over the three-month period April-June 2012 as part of 

AoA’s ARRA grant close-out activities. The discussions focused on program status, challenges and 

opportunities, and plans forsustaining the program when ARRA funding comes to an end. Telephone 

discussion topics can be found in Appendix D. 

CDSMP program data. NCOA, the technical assistance contractor, manages a web-based data 

collection system that states use to upload data on CDSMP participants, workshops, and leaders 

each quarter. NCOA provided the evaluation team with a dataset consisting of program data about 

CDSMP sessions conducted by the 47 grantees during the ARRA grant period (April 2010 to March 

2012). 

Grantee reports. Grantees are required to submit quarterly progress reports and final reports 

to AoA. The reports follow a format outlined in AoA program guidance and document program 

goals, history, progress in reaching milestones, and other accomplishments. The evaluation 

team consulted the reports in preparing for site visits and prior to conducting grant closeout 

interviews with key informants. 

2.3 Evaluation Approach

To address the five research questions for the process evaluation, we employed a multi-method 

approach using the multiple data sources described above. Our approach is depicted in Exhibit 

2.1 and a description follows.

 

6 For more information on how the six sites were selected, see the Site Visit Summary in Appendix C.

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Exhibit 2.1. Process Evaluation Approach and Data Sources

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1. Consultations with stakeholders: As discussed in Section 2.2, we consulted with AoA 

program and regional staff and the TAG to inform the process evaluation design, 

planning for the site visits, and planning for the key informant telephone discussions.

2. Site visits to six states: We mapped the five research questions to the research 

domains listed below. Then, within each domain, we developed a series of questions 

and probes for site visit interviews with state grantee agency staff, representatives from 

host and implementation sites, CDSMP participants, and other stakeholders. See the 

interview guide in Appendix B. The site visit report can be found in Appendix C. Site visit 

findings were used to guide planning for the key informant telephone interviews.

S.No. Research Domains

1 CDSMP Populations, Marketing/Recruitment

2 Site Implementation

3 CDSMP Eligibility, Enrollment, and Completion

4 Data Collection

5 Statewide Distribution and Delivery System

6 Consumer and System-Level Environment

3. Telephone interviews with key informants: For the one-hour telephone discussions 

with groups of key informants representing each of the 47 state grantees that were 

conducted as part of the grant closeout process, we developed an abbreviated list of 

questions that mapped to the five research questions. The questions focused on the 

current landscape for CDSMP versus anticipated changes in the post-ARRA funding 

environment in order to assess the current status of each program and prospects for 

sustainability. The interview guide can be found in Appendix D. The evaluation team 

consolidated and analyzed interview notes by research domain.

4. Analysis of NCOA program data: The dataset provided by NCOA included information, 

by state grantee, on program participants, workshops, and leaders. We designed a data 

analysis plan that enabled us to use these quantitative data to complement the 

qualitative data and address, to the extent possible, the research questions for the 

process evaluation. Specifically, we examined CDSMP participant characteristics, 

program completion rates, workshop size and location, and leader experience. In 

addition to a descriptive analysis, we designed a series of regression analyses to 

examine the influence of multiple factors on workshop completion, such as participant 

characteristics, workshop size and location, and differences in funding history among 

state grantees. 

In the following chapters, we describe the CDSMP programs in grantee states and discuss 

findings of our quantitative and qualitative data analyses related to populations served, 

program implementation, completion rates, evaluation capacity, and prospects for 

sustainability. We conclude with a summary of best practices and recommendations.

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CHAPTER 3: CHARACTERISTICS OF ARRA-FUNDED STATE GRANTEES 

Key Findings

1. The lead agency in the majority of states is the state unit on aging. In two-thirds of the ARRA-funded 

states, the lead agency is the state unit on aging. The department of health is the state lead for onethird of the states. 

2. Grant awards varied by state. Grant awards totaled $27 million; awards to states ranged from 

$50,000 to $1.19 million. 

3. All but one state met their goals for the number of participants and completers. ARRA grantees 

agreed to goals at the outset of their awards that were based on the number of Medicare 

beneficiaries in each state. Only one grantee did not achieve their goals during the two-year grant 

period or during a no-cost extension. Nine grantees exceeded their goals by more than 200 percent.

 3.1 Introduction

Forty-seven grantees7—45 states, the District of Columbia, and Puerto Rico—received ARRA 

funding under the Communities Putting Prevention to Work: Chronic Disease Self-Management 

Program. This chapter presents information on funding levels, funding history, and the number 

of CDSMP participants and completers in each grantee state. While our analysis does not 

extend to a regional analysis, the exhibits below do designate the 10 AoA regions in the event 

AoA is interested in comparing regions.

For the analyses below and in the chapters that follow, the NCOA database was our primary 

source for quantitative data. Because our process evaluation is limited to CDSMP, we 

eliminated two grantees from the sample for our quantitative analysis in Chapters 4 and 6—

Delaware and the District of Columbia. These grantees chose not to implement CDSMP with 

their ARRA funding but instead developed Diabetes Self-Management Programs (DSMP). 

3.2 Grantee Characteristics

As shown in Exhibit 3.1, the lead agency for 30 state grantees is the state unit on aging. The 

department of public health is the lead agency for 15 grantees, including a small cluster of 

western mountain states—Idaho, Utah, Colorado, New Mexico, and Arizona—with large rural 

populations. 

 

7 Referred to as “state grantees,” “states,” or “grantees” in this report.

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Exhibit 3.1. States Receiving ARRA Grants for CDSMP in 2010

Exhibit 3.2 shows the amount of the funding awarded to each grantee. Awards ranged from 

$50,000 for Alaska and the District of Columbia to $1,190,610 for the State of New York. Eleven 

grantees received awards of $1 million or more: California, Florida, Illinois, Massachusetts, 

Michigan, New York, North Carolina, Ohio, Pennsylvania, Texas, and Virginia. 

Exhibit 3.2. Funding Awarded to ARRA Grantees in 2010

Grantee Amount Grantee Amount Grantee Amount

Alabama $600,000 Kentucky $600,000 Ohio $1,000,000

Alaska $50,000 Louisiana $400,000 Oklahoma $400,000

Arizona $600,000 Maine $200,000 Oregon $478,873

Arkansas $400,000 Maryland $600,000 Pennsylvania $1,000,000

California $1,000,000 Massachusetts $1,141,783 Puerto Rico $400,000

Colorado $452,582 Michigan $1,106,479 Rhode Island $200,000

Connecticut $400,000 Minnesota $600,000 South Carolina $750,000

Delaware $100,000 Mississippi $400,000 Tennessee $800,000

DC $50,000 Missouri $632,864 Texas $1,000,000

Florida $1,000,000 Nebraska $200,000 Utah $298,660

Georgia $905,164 Nevada $200,000 Vermont $100,000

Hawaii $200,000 New Hampshire $200,000 Virginia $1,046,084

Idaho $200,000 New Jersey $974,835 Washington $652,582

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Grantee Amount Grantee Amount Grantee Amount

Illinois $1,000,000 New Mexico $252,583 West Virginia $400,000

Indiana $600,000 New York $1,190,610 Wisconsin $810,328

Kansas $400,000 North Carolina $1,006,573 Total: $27,000,000

Source: Administration on Aging

Over the two-year period April 2010 to March 2012, 89,861 individuals participated in CDSMP 

workshops in grantee states. This includes 57,870 adults aged 60 and older, 22,043 individuals 

under age 60, and 9,948 of unknown age. 

Exhibit 3.3 shows the total number of CDSMP participants of all ages in each state during the 

two-year grant period. More heavily populated states—such as California, Oregon, Florida, 

Michigan, Illinois, Ohio, Pennsylvania, New York, and New Jersey—each served more than 3,000 

participants. Less populated states with large rural populations like Arkansas, Colorado, Maine, 

Nebraska, Nevada, and West Virginia typically served fewer than 1,000 participants. Exhibit 3.4 

shows a similar pattern for the number of individuals completing CDSMP in each state. 

Exhibit 3.3. ARRA Grantees: Number of CDSMP Participants, April 2010 to March 2012

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Exhibit 3.4. ARRA Grantees: Number of CDSMP Completers, April 2010 to March 2012

Exhibit 3.5 shows the state grantees that met the goals they agreed to at the outset of their 

awards for the number of CDSMP participants and completers of all ages (e.g., individuals both 

older and younger than age 60). These goals were set based on the total number of Medicare 

beneficiaries in each state.8 State grantees achieving their goals during a no-cost extension to 

their ARRA grants (i.e., after March 2012) are indicated separately. It is worth noting that nine 

states exceeded their goals by more than 200 percent.

 

8 For Medicare data used to set state goals, see U.S. Administration on Aging. American Recovery and 

Reinvestment Act, Communities Putting Prevention to Work, Chronic Disease Self-Management Program: Program 

Announcement for Cooperative Agreements. 2009, December 16. 

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Exhibit 3.5. ARRA Grantees Meeting Goals for Number of Participants and Completers, 

April 2010 to March 2012

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CHAPTER 4: POPULATIONS SERVED BY CDSMP

Research Question 1: Who do AoA CDSMP grantees serve? How to individuals served through 

AoA’s CDSMP grants compare with populations studied through other CDSMP evaluations?

Key Findings

1. ARRA grantees provided CDSMP to nearly 90,000 participants. During the two-year ARRA grant 

period, 22,043 individuals under age 60, 57,870 individuals aged 60 and older, and 9,945 individuals of 

unknown age participated in CDSMP workshops in grantee states, for a total of 89,861 participants. 

2. Disproportionately more CDSMP participants were served by state units on aging. Eighty percent of 

participants were enrolled in CDSMP operated by state units on aging; 20 percent participated in 

programs operated by public health departments, while only two-thirds of grantees were state units 

on aging. 

3. The majority of participants attended workshops in metropolitan areas. Seventy-nine percent of 

participants attended workshops in metro areas; 21 percent participated in workshops in non-metro 

areas.

4. Participants were largely white and female, although grantees were targeting more diverse 

populations. Among those aged 60 and older, 72 percent of participants were female, just over half 

were white, and 15 percent were African American. Many state grantees reported targeting special 

populations, particularly Latinos, Asians, and Native Americans. 

5. On average, participants reported 2.44 chronic conditions. However, women reported more chronic 

conditions than men (an average of 2.51 for women; 2.17 for men). Hypertension/high blood pressure 

and arthritis/rheumatic disease were the most commonly reported chronic conditions for participants 

aged 60 and older. Rates of cancer, heart disease, stroke, and osteoporosis tended to increase with 

increased age. Depression or anxiety disorders and diabetes tended to be more prevalent among 

those younger than age 60 and those aged 60 to 64, with rates decreasing with age thereafter.

4.1 Introduction

AoA’s primary target population is individuals aged 60 and older. In addition to this primary 

target population, AoA encouraged CDSMP grantees to reach older adults within diverse 

populations. As described in the Request for Proposals (RFP) to potential grantees, AoA 

required grantees “to reach a broad population and demonstrate their capacity and ability to 

achieve health equity among disparately effected populations.”9 Grantees were also “expected 

to coordinate with tribal entities in their jurisdiction... and give special attention to serving lowincome, minority, and limited English-speaking seniors.” 

 

9 U.S. Administration on Aging. American Recovery and Reinvestment Act, Communities Putting Prevention to 

Work, Chronic Disease Self-Management Program: Program Announcement for Cooperative Agreements. 2009, 

December 16.

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This chapter describes who AoA grantees served during the ARRA grant period, with a particular 

focus on age, ethnic/racial groups, metro versus non-metro populations, and reported chronic 

conditions. Because AoA-funded CDSMP is intended to target individuals aged 60 and older, 

AoA was interested in learning the extent to which grantees actually served older adults. AoA

was also interested in comparing the populations served by grantees to populations studied in 

prior evaluations to better understand the extent to which the findings from other evaluations 

can be generalized to populations served by AoA grantees.10 

Data sources used to identify and describe populations served by ARRA grantees include AoA 

and NCOA data and reports, site visits, key informant interviews, and grantee reports. Our

analysis of NCOA data examines only CDSMP (not the Diabetes Self-Management Program, or 

Arthritis Self-Management Program). Two grantees receiving ARRA funding but only 

implementing DSMP are therefore not included in the data analysis: Delaware and the District 

of Columbia.

4.2 Characteristics of CDSMP Participants 

The tables below present characteristics of CDSMP participants based on NCOA data. These 

data illustrate who AoA CDSMP grantees served while receiving ARRA funding. Appendix E

provides data on CDSMP participants by AoA region. 

ARRA grantees operated CDSMP either under their state’s aging or public health agency. As 

shown in Exhibit 4.1, 80 percent of CDSMP participants (63,741) were enrolled in programs 

offered by aging agencies and 20 percent (16,172) participated in programs operated by public 

health agencies. Though public health agencies served one-fifth of CDSMP participants, onethird of grantees operated CDSMP through their public health agency. This difference may be 

because public health agencies tended to be the lead in states with lower populations and a 

higher proportion of rural residents. Within each age group (under age 60 and aged 60 and 

older), the percentages were similar for those enrolled in aging- versus public health-led 

programs. 

Specifically, 72 percent of CDSMP participants were aged 60 and older (57,870 of 79,913 

participants). Of the total number served by states with aging leads, 73 percent were 60 years 

of age and older; among those served by public health leads, 71 percent were aged 60 or older.

 

10 Findings from an evaluation design report conducted by IMPAQ under a prior contract reviews CDSMP 

populations studied in other evaluations.10 The mean age of participants in a majority of the studies was 60 years 

and older. However, many of the programs that were studied included adults under the age of 60. For example, 

Goeppinger et al. (2007) included adults 18 years of age and over in a comparative study of a small arthritis 

education program and traditional CDSMP and Gordon’s review of the CDSMP literature (Gordon, 2008) shows 

that many U.S. CDSMP programs include middle-aged adults (i.e., 40 years old and older). The participant samples 

described in the studies were predominately white and female, with a majority of study groups consisting of 60 

percent or more females and 80 percent or more whites. In addition, a majority of the studies required 

participants to have one or more chronic conditions in order to be included.

IMPAQ International, LLC Page 14 CDSMP Process Evaluation Final Report
Exhibit 4.1. CDSMP Participants by Age and Type of Lead Agency Operating Program

Lead Agency

Participants

Under Age 

60

Percent of 

Participants

Under Age 

60

Participants

Age 60+

Percent of 

Participants

Age 60+

Participants

Total

Percent of 

Participants

Total

Aging 17,408 79% 46,333 80% 63,741 80%

Public Health 4,635 21% 11,537 20% 16,172 20%

Total 22,043 100% 57,870 100% 79,913 100%

Note: Excludes participants with missing date of birth.

Source: NCOA data

Exhibit 4.2 shows CDSMP participants by age group and sex. Across all age categories, CDSMP 

participants were more likely to be female. The percentage of female participants tends to 

increase slightly with age. Interestingly, males constituted a larger portion of participants in the 

younger than 60 age group than in other age categories. 

Exhibit 4.2. CDSMP Participants by Sex

Note: Excludes participants with missing date of birth.

Source: NCOA data

Total number of CDSMP participants by age group is as follows:

Age <60 60-64 65-74 75-84 85+ Total

Total participants 22,043 9,717 23,044 18,165 6,944 79,913

IMPAQ International, LLC Page 15 CDSMP Process Evaluation Final Report
Exhibit 4.3 shows CDSMP participants by ethnicity. The proportion of those who identify as 

Hispanic or Latino tends to decrease as age increases. Twenty-four percent of participants 

younger than 60 identified as Hispanic or Latino, while only five percent of participants older 

than 85 identified as Hispanic or Latino. 

Exhibit 4.4 shows CDSMP participants by race. White or Caucasian participants are the most 

numerous across all age groups, followed by African Americans. Exhibit 4.4 illustrates how the 

proportion of minority participants steadily declines as age increases. In the aged 85 and older 

group, almost three-quarters of participants are white. This could reflect the longer life 

expectancies of whites, as well as health and income disparities that tend to disadvantage 

people of color and could make participation more problematic. 

Table 4.3. CDSMP Participants by Ethnicity

Note: Excludes participants with missing date of birth.

Source: NCOA data

Total number of CDSMP participants by age group is as follows:

Age <60 60-64 65-74 75-84 85+ Total

Total participants 22,043 9,717 23,044 18,165 6,944 79,913

IMPAQ International, LLC Page 16 CDSMP Process Evaluation Final Report
Exhibit 4.4. Percentage of CDSMP Participants by Race 

<60 60-64 65-74 75-84 85+ Total

Hawaiian Native or Pacific Islander 1% 2% 1% 0% 0% 1%

American Indian / Alaskan Native 3% 1% 1% 1% 1% 2%

Asian or Asian American 3% 3% 4% 4% 3% 4%

Other/Multiracial 8% 6% 5% 4% 3% 5%

Unknown 14% 8% 7% 5% 5% 8%

Black or African American 19% 21% 20% 17% 14% 19%

White or Caucasian 52% 59% 62% 69% 74% 61%

Note: Excludes participants with missing date of birth.

Source: NCOA data

Total number of CDSMP participants by age group is as follows: 

Age <60 60-64 65-74 75-84 85+ Total

Total participants 22,043 9,717 23,044 18,165 6,944 79,913

IMPAQ International, LLC Page 17 CDSMP Process Evaluation Final Report
As shown in Exhibit 4.5, in each age group more participants attend workshops in metro 

locations than non-metro locations.11 

Exhibit 4.5. Percentage of CDSMP Participants Attending Workshops in 

Metro versus Non-Metro Areas by Age

Location of 

Workshop

Age <60 Age 60-64 Age 65-74 Age 75-84 Age 85+ Total

Metro 77% 80% 80% 81% 80% 79% 

Non-Metro 23% 20% 20% 19% 20% 21% 

Total 100% 100% 100% 100% 100% 100%

Note: Excludes participants with missing date of birth.

Source: NCOA data; metro and non-metro designations from NCHS and USDA ERS

Exhibit 4.6 shows the average number of chronic conditions reported by CDSMP participants by 

age and sex. Females across all age categories tend to report more chronic conditions, on 

average, than males. The differences (between male and female) are statistically significant in 

each age group. Also, the average number of chronic conditions among participants increases in 

each age group as participants age up until the age 75-84 age group, when the average number 

of chronic conditions begins to decline. As the number of chronic conditions tends to increase 

with age in the general Medicare population12, more research is needed to determine why 

older individuals with more chronic conditions are not participating in CDSMP and what sites 

may be able to do to make participation easier for that subpopulation.

Exhibit 4.6. Average Number of Chronic Conditions Reported by 

CDSMP Participants by Age and Sex

Sex Age <60 Age 60-64 Age 65-74 Age 75-84 Age 85+ Total

Male 1.75 2.41 2.41 2.37 2.20 2.17

Female 2.04 2.68 2.73 2.67 2.50 2.51

Total 1.96 2.62 2.67 2.66 2.45 2.44

Note: Excludes participants with missing date of birth and sex.

Source: NCOA data

Exhibit 4.7 shows the percentage of CDSMP participants by age and type of chronic condition. 

Hypertension/high blood pressure and arthritis/rheumatic disease are the most commonly 

reported chronic conditions among participants aged 60 and older. More than half of 

 

11 Metro and non-metro classification is based on county of the implementation site. NCHS was the primary 

source; USDA-ERS was the secondary source. For implementation sites for which counties could not be found, 

county of the participant was used. For Puerto Rico, USDA-ERS Rural-Urban continuum codes were used, as Puerto 

Rico is not available in the other two sources.

12 Centers for Medicare & Medicaid Services: Center for Strategic Planning. (2011) Chronic Conditions Among 

Medicare Beneficiaries: 2011 Chartbook. http://www.cms.gov/Research-Statistics-Data-and-Systems/StatisticsTrends-and-Reports/Chronic-Conditions/Downloads/2011Chartbook.pdf

IMPAQ International, LLC Page 18 CDSMP Process Evaluation Final Report
participants reported having hypertension/high blood pressure; a similar number reported 

having arthritis/rheumatic disease. Though percentages generally vary across age groups and 

condition types, some trends are apparent. For instance, the rates of cancer, heart disease, 

stroke, and osteoporosis tend to increase as age increases. Depression or anxiety disorders, 

diabetes, and other chronic conditions tend to be more prevalent for those younger than 60 

and from 60 to 64 years of age, with rates decreasing with age. 

Exhibit 4.7. Percentage of CDSMP Participants Reporting Chronic Conditions by 

Age and Type of Chronic Condition

Note: Excludes participants with missing date of birth. 

Source: NCOA data

During the key informant interviews, ARRA grantees were asked to share which special 

populations they targeted while receiving ARRA grant funding, why they chose to target these 

populations, and their strategies for reaching them. Grantees reported similar reasons for 

choosing to target a particular group: to reach underserved populations, many of whom face 

continued barriers to self-managing chronic conditions, including lack of knowledge and 

resources. Exhibit 4.8 shows special populations targeted by state grantees during the funding 

period as reported by grantees during the key informant interviews, supplemented by 

information available from the state survey on program sustainability conducted by ACL in 

2012.13

 

 

13 The data in Exhibit 4.8 may be incomplete because of significant limitations in the data sources: 1) the key 

informant interviews were telephone discussions and not a systematic, quantitative data collection effort; and 2) 

“target populations” were inferred from data collected on “partnerships” in the state survey on program 

IMPAQ International, LLC Page 19 CDSMP Process Evaluation Final Report
Exhibit 4.8. Special Populations Targeted by States While Receiving ARRA Grant Funding 

(April 2010-March 2012)

State Veterans Incarcerated 

Adults

Native 

Americans

African 

Americans

Latin

os

Other Ethnic 

Groups

Rural 

Residents

LowIncome Disabilities Dual 

Eligibles < 60

Alabama √ √ - √ √ √ √ √ √ - -

Alaska √ - √ - √ - - √ - - -

Arizona √ - √ - √ - √ √ √ √ -

Arkansas - - - - √ - √ - - - - 

California - - - - √ √ - √ - √ -

Colorado - - - √ - - √ √ - √ -

Connecticut √ - - √ √ - √ √ - √ -

Florida √ - - √ √ - √ √ - - -

Georgia √ - - - - √ √ √ √ - -

Hawaii √ - √ - - √ - √ √ - -

Idaho √ - - - √ - √ √ √ - -

Illinois √ - - √ √ √ √ √ √ - -

Indiana √ - √ - √ - - √ √ - √

Kansas √ - √ - √ - √ - - - -

Kentucky - √ - - - - - √ - - -

Louisiana - - - - √ √ √ √ √ - -

Maine √ √ √ - - √ √ √ √ - -

Maryland - - - - √ √ √ √ √ √ √

Massachusetts - - √ - √ √ √ √ √ √ -

Michigan √ - √ - - - - √ √ √ -

Minnesota √ - √ - - √ √ √ √ √ -

Mississippi - - √ - - - √ √ - - -

Missouri √ - - √ √ - √ √ √ √ -

Nebraska √ √ √ - √ - - √ - - - 

Nevada - - - - √ - - - - - -

New 

Hampshire

√ √ - - √ - √ √ - - -

New Jersey - √ - - √ √ √ √ √ - -

New Mexico √ - √ - √ - √ - - - -

New York √ - √ √ √ √ √ √ √ - -

North Carolina - √ - - - - √ - √ - -

Ohio √ √ - - √ - √ √ √ - -

Oklahoma - √ √ - √ √ √ √ √ - -

Oregon √ √ - - √ - √ √ √ √ -

Pennsylvania - - √ √ √ √ - √ √ √ -

Puerto Rico* - - - - - - - - - - -

Rhode Island √ √ √ - √ √ - √ √ - -

South Carolina √ √ - √ - - √ √ √ - -

Tennessee - - - √ - √ √ √ - - -

Texas √ √ √ - √ √ - √ - - -

Utah √ √ √ - - √ √ √ √ - √

 

sustainability (e.g., states reporting partnerships with Federally Qualified Health Centers were considered to be 

targeting “low-income populations” in Exhibit 4.8; states partnering with “groups working with people with 

disabilities” were considered to be targeting the “disabilities” group in Exhibit 4.8).

IMPAQ International, LLC Page 20 CDSMP Process Evaluation Final Report
State Veterans Incarcerated 

Adults

Native 

Americans

African 

Americans

Latin

os

Other Ethnic 

Groups

Rural 

Residents

LowIncome Disabilities Dual 

Eligibles < 60

Vermont √ - - - - - √ √ √ - -

Virginia √ √ - - √ √ √ √ √ - -

Washington - - √ - - √ √ √ √ - -

West Virginia √ - - - √ - √ √ √ - -

Wisconsin √ - √ - - - √ √ √ - -

Total Number 

of States 29 15 20 10 29 20 33 39 29 11 3 

*Did not report targeting special populations; residents of Puerto Rico, however, are almost exclusively Latino, so “Latinos” is not an 

applicable category.

Source: State Survey on Program Sustainability and IMPAQ/Altarum Interview Data

As shown in Exhibit 4.8, the most common special population targeted by ARRA grantees was 

the low-income population. Many grantees worked with Federally Qualified Health Centers 

(FQHCs) and non-profit organizations that support the low-income population to increase 

awareness of CDSMP and recruit participants. Another common special population targeted by 

ARRA grantees was the Latino community; 29 grantees indicated that they actively sought to 

reach this population. Many grantees partnered with community- and faith-based organizations 

to reach Latinos, particularly to increase awareness of CDSMP and recruit participants. 

Grantees focused intently on training bilingual lay leaders and master trainers to help expand 

their reach into the Latino community, as grantees believed this led to better success in 

recruiting participants and sustaining high completion rates

Reaching Latinos: New Mexico’s Southern Area Health Education Center (SAHEC), near the 

Texas border, uses promotoras, community health workers who advise residents about 

health and health resources in the community, to deliver CDSMP to Hispanic/Latino 

residents. The promotoras are respected as lay health leaders on diverse topics, and CDSMP 

has been a natural fit with their outreach activities. The SAHEC director reports that fidelity 

is very high, as the promotoras are proud of and take their role in delivery of CDSMP very 

seriously. 

Other ethnic groups, such as Asians and African immigrants and Native Americans, were also 

common populations actively targeted for CDSMP participation by ARRA grantees. Similar to 

strategies developed to reach the Latino community, grantees sought to target these 

populations by partnering with community- and faith-based organizations and residential 

facilities to increase awareness of CDSMP and recruit participants. Illinois, for instance, targeted 

immigrants and limited English speakers, particularly those 60 years of age and older, through a 

community wellness center. Implementation sites worked with the center to recruit 

participants through their established outreach program and network. 

Grantees targeted a range of other special populations, including but not limited to inmates in 

prison settings, persons with mental illness, veterans, and individuals with disabilities including 

hearing disorders and developmental disabilities, and Medicare-Medicaid enrollees (“dual 

eligibles”). Grantees offered the same program to these unique communities as was offered to 

IMPAQ International, LLC Page 21 CDSMP Process Evaluation Final Report
other populations; however, grantees made special considerations for these groups on a caseby-case basis. For instance, lay leaders would read materials to participants who were blind or 

visually impaired to keep them engaged in the class. Grantees noted that their objective was to 

find ways to deliver CDSMP to all participants in the same setting in order to preserve the social 

aspects of the workshops and maintain fidelity. Partnerships with community organizations and 

other groups were often used to reach these populations. A description of partnerships is 

included in Chapter 5.

4.3 Looking Ahead to the Future 

During the key informant interviews, grantees were asked if they plan to target special 

populations in the future, in addition to those already targeted through ARRA funding. Twenty 

grantees indicated that they do not plan to make major changes to their targeting strategies in 

the future; these states are indicated in gray in Exhibit 4.9. All grantees noted that their 

targeting strategies will be fully dependent on receiving additional funding (from AoA and 

elsewhere). Grantees expressed concern that funding challenges will significantly affect their 

ability to continue outreach to current and new populations. 

Regardless of the target population, grantees described similar strategies to expand their reach 

after ARRA funding ends. In addition to seeking ongoing program support, the most common 

strategy included developing and expanding partnerships with key stakeholders in target 

communities, such as community- and faith-based organizations, health clinics, and hospitals. 

However, many noted that they would not be able to pursue new partnerships without 

additional funding. In addition, existing partners were not instrumental in recruiting new 

partners. Grantees often developed partnerships through internal connections and networks. 

By collaborating with these entities, grantees hoped to increase and expand awareness of 

CDSMP, thereby increasing referrals and participation and completion rates. Below are a few 

examples of how grantees plan to target more diverse populations in the future. 

 Latinos: The most frequently mentioned population that grantees hope to target after 

ARRA funding ends is the Latino population. Grantees hope to increase their efforts to 

produce local training and workshop materials in Spanish and begin or increase trainings 

for Spanish-speaking lay leaders. Grantees also plan to expand their outreach efforts to 

community- and faith-based organizations in new regions throughout their states to 

reach the Latino populations in localities that have not been targeted. 

 Native Americans: Some grantees expressed a desire to reach out more actively to the 

Native American population. Colorado, for example, initiated a partnership with this 

population toward the end of the ARRA funding period. The state is developing a plan to 

build on this relationship in the future, particularly by assisting one tribal council to 

obtain a license for CDSMP. Additionally, Massachusetts hopes to build capacity, 

specifically through lay leader trainings and network building with local health systems 

to implement CDSMP in tribal communities. 

IMPAQ International, LLC Page 22 CDSMP Process Evaluation Final Report
 Low-Income Populations: Some grantees hope to expand the reach of CDSMP to 

specifically target low-income populations. Connecticut, for example, is working to 

expand availability of CDSMP in inner city areas, particularly regions with high rates of 

poverty. Similarly, Louisiana would like to expand program reach to low-income senior 

housing, and Nebraska hopes to expand their partnerships with FQHCs to strengthen 

referral systems and increase the number of participants who are low-income. In 

addition to these strategies, some grantees plan to expand or begin partnerships with 

their states’ Medicaid agencies to develop a comprehensive referral system for CDSMP 

and provide reimbursements for Medicare-Medicaid enrollees who participate in 

CDSMP. For most grantees, these strategies and partnerships are in their infancy and 

have not advanced beyond the initial stages. 

It is important to note that the information presented in Exhibit 4.9 is not intended to provide a 

comprehensive account of grantees’ intentions to target special populations in the future, but 

rather to provide examples of future target populations. The information was collected during 

key informant interviews, which were not a systematic, quantitative data collection effort, so 

the information presented below is not inclusive of all the special populations states anticipate 

targeting in the post-ARRA funding environment. Additionally, this is a rapidly changing area 

based on funding and other opportunities so information provided in the exhibit may not 

reflect states’ current focus. 

Exhibit 4.9. Special Populations States Anticipate Targeting in the 

Post-ARRA Funding Environment (after April 2012)

State Veterans Incarcerated 

Adults

Native 

Americans

African 

Americans Latinos Other Ethnic Groups

Rural 

Residents

LowIncome Disabilities Dual 

Eligibles < 60

Alabama - - - - - - - - - - - 

Alaska √ - - - - - - - - - - 

Arizona - - - - - - - - - - - 

Arkansas - - - - - - - - - - - 

California - - - - - - - - - - - 

Colorado - - √ - - - - - - - - 

Connecticut - - - - - - - √ - - - 

Florida - - - - - - √ - - - - 

Georgia - √ - - √ - - - √ - - 

Hawaii - - - - - - - - - - - 

Idaho - - √ - - - - - - - - 

Illinois - - - - √ √ - - - - - 

Indiana - - - - √ √ - - √ - - 

Kansas - - - - √ - √ - - √ - 

Kentucky - - - - - - - - - - -

Louisiana - - - - - - - √ - - -

Maine - - √ - - √ - - - - - 

Maryland - - - - - - - - - - √

Massachusetts - - √ - √ √ - - - - √

Michigan - - - - - - - - - - - 

Minnesota - - - - - - - - - - - 

Mississippi - - - - - - - - - - -

Missouri - - - √ √ - - - - √ - 

Nebraska - √ - - - - - √ - - - 

IMPAQ International, LLC Page 23 CDSMP Process Evaluation Final Report
State Veterans Incarcerated 

Adults

Native 

Americans

African 

Americans Latinos Other Ethnic Groups

Rural 

Residents

LowIncome Disabilities Dual 

Eligibles < 60

Nevada √ - - - - √ √ - √ - -

New 

Hampshire

- √ - - √ - - - - √ - 

New Jersey - - - - - - - - - - - 

New Mexico - - - - - - - - - - - 

New York - - - - - - - - - √ -

North Carolina - - - - - - - - - - - 

Ohio √ √ - - - - - - √ - - 

Oklahoma - - - - - - - √ - √ √

Oregon - - - - - - - - - - -

Pennsylvania - - - - - - - - - - -

Puerto Rico √ √ - - - - - - √ - - 

Rhode Island - - - - - - - - - - - 

South Carolina - - - - - - - - - - - 

Tennessee - - - - - - √ √ - - - 

Texas - - - - - - - - - - -

Utah - - - - - - - - - - - 

Vermont - - - - - - - - - - - 

Virginia - - - - √ √ - - √ √ - 

Washington - - - - - - - - - - - 

Wisconsin - - - - - - - - - √ - 

West Virginia - - - - - - - - - - - 

Total Number 

of States 4 5 4 1 8 6 4 5 6 7 3 

Note: States shaded in gray do not plan major changes to their targeting strategies in the immediate future.

Source: IMPAQ/Altarum Interview Data

4.4 Reach of CDSMP

AoA expressed interest in the “reach” of CDSMP—that is, what proportion of the residents in a 

state participated in CDSMP during the ARRA grant period, and how participation varied across 

different population groups and across different states. Exhibit 4.10 shows variations in reach 

by age, gender, and race/ethnicity. For example, on average 151 individuals aged 65 and older 

participated in CDSMP out of every 100,000 residents aged 65 and older. Across the 45 

grantees, minimum reach to individuals aged 65 and older was 43 participants per 100,000 

residents aged 65 and older; maximum reach was 470 participants per 100,000. The density of 

some special populations varies widely across states and may, in part, be responsible for the

variation shown in Exhibit 4.10. This may be particularly true for the categories of Latino, 

American Indian, and Hawaiian Native/Pacific Islander. The table in Appendix F, which presents 

the underlying data for Exhibit 4.10, shows variations in CDSMP reach by sex, age, and 

race/ethnicity for each of the 45 state grantees. 

IMPAQ International, LLC Page 24 CDSMP Process Evaluation Final Report
IMPAQ!International,!LLC Page!25 CDSMP!Process!Evaluation!Final!Report

Exhibit'4.10.'State'Variations'in'CDSMP'Reach'to'Specific'Populations

Under'

65

65'and'

over

Male Female

Hispanic'

or'Latino'

origin

Not'

Hispanic'

or'Latino'

origin

Asian'or'

Asian'

American

Black'or'

African'

American

American'

Indian'/'

Alaskan'

Native

Hawaiian'

Native'or'

Pacific'

Islander

White'or'

Caucasian

Other'

race

Min 3 43 3 12 4 3 0 6 3 0 7 2

Mean 17 151 17 55 29 31 18 46 107 131 31 28

Max 90 470 70 231 101 144 67 234 1,948 1,861 138 124

Source:!NCOA!and!U.S.!Census!data.

0

50

100

150

200

250

Number+of+Individuals+Served+per+100,000+Residents

470 1,948 1,861
CHAPTER 5: IMPLEMENTATION OF CDSMP

Research Question 2: How are local sites implementing the CDSMP? For example, how do their 

organizational structure, financial resources and allocation and their fidelity compare to the 

Stanford CDSMP model? Are there common adaptations being made at AoA/ACL supported 

sites? Are there adaptations which specifically improve the applicability of the CDSMP to seniors 

(age 60+) with chronic diseases?

Key Findings

1. CDSMP was implemented successfully in a diverse set of organizational arrangements. Aging services 

networks served as grantees in most states, using providers such as AAAs, state and local public health 

departments, and private health systems as key partners for CDSMP program oversight and delivery. 

Grantees used centralized, decentralized and shared infrastructures.

 Oversight: Grantees used centralized program administration and oversight in 14 states, 

decentralized models in 23 states, and shared systems of oversight in 10 states. 

 Delivery: Most grantees (37) used decentralized delivery systems to deliver CDSMP through public 

and private organizations including AAAs, 9 used centralized infrastructures such as private or public 

health systems, and one grantee used a mixed approach. Grantees that used centralized systems to 

deliver CDSMP typically centralized communications, licensing, and referral as well.

No single approach works best in all contexts. However, centralized approaches offer advantages such 

as standardization of training and delivery, leverage for data collection, and certain economies of 

scale—while decentralized approaches can be more responsive to local conditions and resource 

availability. CDSMP oversight and delivery arrangements typically reflected historical funding and 

partnerships, geographical relationships, or political structures already established within the state into 

which the administration of CDMSP programs was fit. 

2. Marketing and recruitment continue to be challenges for many grantees, especially those with limited 

staff and financial resources for outreach. Grantees that leveraged established partnerships and 

networks (e.g., AAAs, Area Health Education Centers, etc.) to market and recruit participants were more 

likely to be successful reaching older adults and filling workshops.

3. Retaining participants throughout the 6 workshop sessions can be difficult—but grantees have 

identified successful strategies to support retention. Transportation and weather problems, illness, and 

participant motivation or interest can all interfere with attendance. Grantees and workshop leaders 

reported using small incentives such as gift cards, key chains, and other giveaways; scheduling 

workshops at convenient times and places; and assisting participants with transportation to and from 

workshops as key strategies for improving retention.

4. Reaching cultural and ethnic minorities can be difficult, especially if funding for outreach is limited. 

However, many sites have been able to reach and serve these populations successfully. Once enrolled, 

these populations are likely to stay with the program and show high rates of completion. Several 

grantees have expanded reach and reported success serving special populations including prisoners and 

disease-specific populations. More information is needed about grantees’ experiences with these 

groups.

IMPAQ International, LLC Page 26 CDSMP Process Evaluation Final Report
5. Program success depends highly on the commitment of key leaders and champions. Program 

champions are key to the success and sustainability of CDSMP programs, especially at start up. Grantees 

of programs lacking champions or continuity of leadership encountered more problems with ongoing 

program operations and had more difficulty making the case to sustain the program at the end of ARRA 

funding. Grantees should be sure to start establishing policy and infrastructure immediately so the 

program does not fail if the champion is gone.

6. Fidelity is multi-faceted, with multiple components identified as important to program success in the 

Stanford protocols. Grantees reported fidelity as a priority and approached it in various ways. The 

relative importance of specific items to program success is unclear. Grantees and workshop leaders 

questioned some items, including class size and presentation format. Questions were also raised 

regarding the relative importance of specific workshop sessions. Some grantees suggested a study of the 

relative importance of CDSMP fidelity requirements would be helpful to shed light on these and other 

issues.

7. Grantees called out need for state-specific information about the effectiveness, cost effectiveness, and 

return on investment of CDSMP. This information is often requested by legislators and is needed to 

support third-party payment and funding to continue program availability.

5.1 Introduction

The initial studies of CDSMP conducted by Stanford University established the evidence base 

for the program by demonstrating the effectiveness of CDSMP in improving the ability of 

participants to self manage their health and health care. The importance of fidelity in 

implementing and delivering the program as designed was emphasized and is widely recognized 

to be essential to replicating program success. However, studies have not examined the 

organization, financing, and infrastructure of CDSMP programs as they are implemented more 

broadly in community settings, and whether or to what extent such differences may affect 

CDSMP implementation, delivery, or sustainability. These questions are important to ACL given 

its interest in supporting widespread dissemination of the program in diverse contexts, and its 

requirement that grantees develop viable models for CDSMP delivery that could be sustained at 

the completion of ARRA funding. 

To address these questions, the evaluation team developed, for each grantee, a descriptive 

profile examining organizational structure and the program delivery system. The descriptive 

profiles were then used to analyze differences across state grantees in these areas: program 

oversight and administration, delivery system structure, responsibility for resource allocation, 

marketing and recruitment strategies, leader training and oversight, and CDSMP licensure (see 

Exhibit 5.1 for a description of the variables in the state profiles). Findings from this analysis are 

presented below. In this chapter we also discuss other factors associated with implementing 

strong programs—specifically, strategies employed by state grantees to maintain fidelity to the 

Stanford model and any common adaptations, the ways in which state grantees have sought to 

build productive partnerships that complement and enhance organizational and delivery 

models, and strategies for expanding the reach of CDSMP to new populations. 

IMPAQ International, LLC Page 27 CDSMP Process Evaluation Final Report
Principal data sources for the analyses in this chapter include the site visits and telephone 

discussions with key informants conducted by the research team, grantee progress and final 

reports, program data from NCOA, and the descriptive profiles on organizational structure and 

the program delivery system developed by the evaluation team.14 

Exhibit 5.1. Variables in the State Descriptive Profiles

Variable Definition

Program Oversight and 

Administration

State programs were classified into one of three models:

 Centralized: program responsibility resides largely at 

the state level

 Decentralized: program responsibility resides mostly at 

the regional or local level

 Shared: program responsibility is shared at the state 

and regional/local levels

Program Delivery Infrastructure Refers to infrastructure and dissemination channels used for 

general communications, program coordination, conducting 

marketing and recruitment, and data collection and reporting. 

State programs were classified into one of three models:

 Centralized: delivery infrastructure coordinated at the 

state level

 Decentralized: delivery infrastructure coordinated at 

the regional and/or local levels

 Mixed: responsibility for coordination of delivery 

infrastructure is shared at the state and regional/local 

levels 

Resource Allocation Refers to whether allocation of grant funding and other 

program resources (e.g., funds for supplies ) is managed: 

 At the state level

 By local/host sites

 By both the state and the local/host sites

Leader Training and Oversight Refers to whether leader training was coordinated:

 At the state level

 By local/host sites

CDSMP Licensure Refers to whether the CDSMP license is held by:

 A state agency

 Regional or local organizations 

 

5.2 Program Oversight and Administration 

State grantees oversee CDSMP implementation and administration using a variety of 

organizational strategies and structures to ensure efficient and effective program delivery and 

 

14 The analyses of organizational structure and program management and administration presented in this chapter 

represent the best judgment of the evaluation team. Because of data limitations and the subjective nature of 

classifying state programs, category assignments could not always be made with full confidence.

IMPAQ International, LLC Page 28 CDSMP Process Evaluation Final Report
fidelity to the Stanford model. These activities can be wide-ranging and may include marketing 

and recruitment, training and supervising workshop leaders, monitoring fidelity, and collecting 

and analyzing program data. Departments of aging and departments of public health were 

eligible to serve as lead agencies; 31 grantees selected departments of aging as the lead and 16 

chose departments of public health. Infrastructure for program oversight and administration 

are often influenced by historical patterns of funding and service delivery. Many ARRA grantees 

had already been delivering CDSMP for a number of years (see Exhibit 5.2) and were able to use 

ARRA funds to build upon and expand legacy systems for program delivery. In other cases, 

grantees were using 2010 ARRA funding to build CDSMP delivery systems for the very first time, 

which was the case for 9 states. 

Exhibit 5.2. Number of States and Year of First Federal Funding to Deliver CDSMP, 2001-2010

Source: IMPAQ International and Altarum Institute

Of the 47 grantees, 14 used centralized models for program oversight and administration, 23 

used decentralized models, and 10 had delivery systems in which responsibility was shared at 

the state and regional/local level (Exhibit 5.3). Grantees’ approaches to program oversight and 

administration reflected a variety of factors, including the organization and historical roles of 

state health and human services departments, the prominence of the state unit on aging (e.g., 

whether it is a separate agency with a cabinet-level secretary or an agency within the 

department of health and human services), the role and strength of regional/local agencies in 

the state (e.g., AAAs, ADRCs, private organizations, collaboratives), and existing infrastructure 

for the delivery of evidence-based health promotion programs. 

IMPAQ International, LLC Page 29 CDSMP Process Evaluation Final Report
Exhibit 5.3. Program Oversight and Administration

Source: IMPAQ International and Altarum Institute

The evaluation team examined the various oversight models, comparing and contrasting their 

performance. No clear patterns were identified. Variations were considerable and reflected the 

unique socio-political, geographic, and historical context of each state. However, specific 

benefits appear to be associated with each approach. Centralized approaches offer advantages 

such as standardization of training and delivery, leverage for data collection, and certain 

economies of scale. Decentralized approaches can be more responsive to local conditions and 

resource availability. Shared approaches are able to offer some benefits of both centralized and 

decentralized models. 

5.2.1 Centralized CDSMP Oversight and Administration

Among the 14 states with centralized CDSMP oversight, 5 reported program oversight and 

administration provided by state departments of aging, 4 used departments of public health, 

and 5 used shared models. Some examples of centralized models are:

 New Jersey: CDSMP is overseen by the New Jersey Department of Aging, which 

actively oversees and manages the program across the state. Prospective partners 

compete in a competitive application process with selected partners receiving one of 

multiple categories of grants. The Department of Aging has established quality 

assurance protocols for fidelity monitoring and developed their own 

instruments/checklists based on national documents tailored to New Jersey’s 

program. For example, the peer leader instrument lists the major skill areas and 

operational guidelines (e.g., use of posters, room set up) and has a check list for 

each class that includes the elements the leader is to address in that session. The 

Department of Aging also actively trains and monitors trainers and leaders.

IMPAQ International, LLC Page 30 CDSMP Process Evaluation Final Report
 Nebraska: Nebraska’s Department of Health and Human Services oversees policy, 

fidelity monitoring, master trainer and lay leader training, and partnership 

development. The department has implemented memoranda of understanding 

(MOUs) with six of the eight AAAs in the state (two dropped out due to reported 

over-burden and difficulties developing partnerships). They are now seeking to 

embed the program within the public health network and Federally Qualified Health 

Centers (FQHCs).

 New York: The State University of New York (SUNY) at Albany has state-wide 

oversight and responsibility for the CDSMP program. The New York grantee 

distributes funds to SUNY Albany, which allocates those resources amongst the host 

sites. SUNY Albany develops MOUs with leaders/trainers, oversees and coordinates 

training, develops program policies, and monitors quality assurance for the state.

Of the 14 states using centralized oversight, seven contracted with private or nongovernmental entities provided program oversight. West Virginia and New York (see above) 

delegated responsibility and direct oversight of CDSMP to universities (Marshall University and 

SUNY, Albany, respectively) and California15 designated Partners in Care as their state-wide 

technical assistance provider. Statewide Area Health Education Centers (AHECs) provide CDSMP 

oversight in New Hampshire and Colorado. The Arizona Living Well Institute, a public-private 

partnership established to advance evidence-based programs throughout the state, and 

Wisconsin’s Institute for Healthy Aging, formed to advance the spread of evidence-based 

programs that encourage and support healthy living among older adults, oversee CDSMP in 

their respective states. All funds and direct project oversight were passed from the state 

grantees to these non-governmental entities to oversee funding distribution, training, data 

collection and entry, and fidelity policy and monitoring.

5.2.2 Decentralized CDSMP Oversight and Administration

Twenty-three states adopted a decentralized model for oversight in which host or delivery sites 

were delegated the majority of responsibility regarding funding, training, fidelity monitoring, 

and data collection. In these states, program oversight and administration was either regional 

or local (generally county or metropolitan-area), contributing to considerable within-state 

variation in program delivery and oversight in some cases. Additionally, decentralized delivery 

systems largely utilized the AAAs as regional CDSMP oversight entities; sixteen of the 23 states 

with decentralized models of program oversight used AAAs in a regional oversight capacity. No 

grantees solely used local health departments in this role, although five states used a mix of 

AAAs and local health departments. 

Examples of decentralized models are:

 Minnesota: All six AAAs within the state offer CDSMP. The AAAs are responsible for 

all elements of program operations, including training, materials purchase, quality 

assurance, and licensing. 

 

15 Information provided by the National Council on Aging (NCOA).

IMPAQ International, LLC Page 31 CDSMP Process Evaluation Final Report
 Kentucky: CDSMP oversight occurs within each partner site, largely AAAs. There is

little coordination between the AAAs on program operations or delivery. Fidelity

monitoring is conducted by the AAAs and varies by region.  

 Vermont: CDSMP is offered through AAAs, which are anchored in Health Service

Areas (HSAs) within the state as part of Vermont's comprehensive Blueprint for

Health. HSAs receive community health funding from the state legislature that local

stakeholder coalitions direct to develop and integrate comprehensive population

health plans within each HSA. The AAAs, as part of this plan, develop a local work

plan describing the strategy for resource use which is reviewed and approved by the

HSA community coalition. CDSMP funding is passed from the state grantee to each

HSA for distribution. Regional coordinators manage the program within each HSA.

Two states—Vermont and Nevada—used non‐governmental private organizations, specifically

health systems, to provide oversight of CDSMP at all host sites. In Vermont, CDSMP is a core

component of the state’s Blueprint for Health, a community‐based approach to health care

reform that uses a chronic care model centered around hospitals and community health

coalitions. Nevada uses local hospitals as host sites, with University of Nevada‐Reno’s Sanford

Center for Aging providing fidelity monitoring. Respondents from states using decentralized

oversight reported intra‐state variation in fidelity standards, monitoring, training, and

sustainability efforts. In these settings, partner recruitment and sustainability were generally

seen as host site responsibilities. Often, host sites had a full‐time coordinator on staff with

responsibility for CDSMP program oversight.  

5.2.3 Shared CDSMP Oversight and Administration  

In this model, oversight responsibilities are shared by the state grantee and regional host sites.

The ten grantees that used this model generally operated in a collaborative fashion to develop

and craft program policy on delivery, training, fidelity standards and monitoring, and data

collection. Additionally, these grantees used collaborative approaches to promoting

sustainability, involving multiple stakeholders at the state, regional and local, or host site levels.

Shared responsibility grantees exhibited consistency in fidelity standards, monitoring, training,

and sustainability efforts. A typical arrangement was for host sites to have a part‐time

coordinator responsible for program oversight while the state grantee maintained a full‐time

program manager. Examples of shared delivery models are:

 Hawaii: In a hybrid arrangement, Hawaii’s state grantee, the Executive Office on

Aging, and Island AAAs work collaboratively to manage the CDSMP program through

a Healthy Aging partnership. The state distributes funding to local public health

partnerships and establishes memoranda of agreement (MOAs) with leaders who

oversee and participate in quality assurance. The University of Hawaii leads

evaluation, fidelity monitoring (using Stanford’s 10‐item checklist), and partnership

efforts. Island AAAs have established steering committees in coordination with

different partners at each location to oversee and assist with CDSMP management

on each Island.  

IMPAQ International, LLC Page 32 CDSMP Process Evaluation Final Report
 Maine: To assist with CDSMP oversight, this state grantee has established a 

coordinating council consisting of representatives from partners, host/delivery sites, 

and state agencies. Established in 2004 as the Healthy Aging Advisory Committee for 

all evidence-based programs, the coordinating council now includes representatives 

of state offices on Aging and Disability and Quality Improvement, health systems, 

and AAAs, and includes three subcommittees: evaluation, marketing, and quality 

improvement/fidelity. The state grantee assists with licenses and training while the 

AAAs and other partners oversee much of day-to-day program operations. Maine is 

moving toward decentralization.

 

5.3 Program Delivery Infrastructure 

CDSMP delivery infrastructure is needed to provide the framework for program 

implementation. Delivery infrastructure includes systems for general communications, program 

coordination, allocation of resources, conducting marketing and recruitment, training and 

monitoring leaders, data collection and reporting, and the allocation of resources. To a great 

extent, grantees worked through established relationships among state agencies and regional 

organizations to build and expand CDSMP delivery infrastructure. Some grantees faced 

especially difficult contextual challenges such as rural or remote geography, populations with 

special cultural or linguistic needs, economic issues impacting resource availability and more. 

The highly unique features of each state, including program history, socio-political and cultural 

factors, program advocates, and state or local “champions,” helped to shape the delivery 

system. In some states, the delivery infrastructure aligned with the state’s model for program 

oversight; in others, the delivery infrastructure and oversight models were unrelated. A 

discussion of delivery system models is provided below. 

It is important to recognize the influential role of program advocates or champions. These 

individuals can play a pivotal role in program development, leveraging their enthusiasm, 

interpersonal skills, and in many cases sheer effort in helping to assure program success. For 

example, the director of the Alaska program--who is the sole CDSMP staff person--wears 

multiple hats to ensure delivery of the program in the nation’s geographically largest state. 

Program directors who are also champions are especially critical at program start up as 

evidenced by two grantees who struggled to recruit and retain strong directors and 

subsequently experienced difficulty meeting completer goals and sustaining their programs. 

While champions are important, they are not always available or accessible to programs. In 

addition, programs that are dependent on the energy and tenacity of a champion must be sure 

to also build a strong underlying program infrastructure that can help the program weather 

changes in leadership. 

IMPAQ International, LLC Page 33 CDSMP Process Evaluation Final Report
5.3.1 Delivery System Models

Most grantees (37 of 47, or 79 percent) adopted a decentralized model for CDSMP delivery. 

Nine grantees had a centralized delivery system and one had a mixed state/regional system 

(Exhibit 5.4). 

Exhibit 5.4. Delivery System Models

Source: IMPAQ International and Altarum Institute

Decentralized Delivery System. Grantees with decentralized systems often used a combination 

of public and private sector systems. For example, one region might rely on a public sector 

delivery system such as aging services providers, while another region might use the delivery 

system of a private or non-governmental partner. 

Of the 37 decentralized states, the majority (27) used AAA and/or ADRC delivery systems, 12 

states used non-governmental delivery systems, and 7 states used public health systems.16 The 

states using non-governmental delivery systems (e.g., health or hospital systems) often had 

long histories of productive partnerships with private community-based organizations. 

However, one grantee experienced difficulty when a private partner opted to no longer provide 

CDSMP.

 

16 Some states use multiple delivery system types, so the number of states in these examples adds up to more than 

47 (the total number of ARRA grantees).

9 

IMPAQ International, LLC Page 34 CDSMP Process Evaluation Final Report
Minnesota’s decentralized delivery system offers CDSMP workshops through host site 

agencies, with regional technical assistance provided by AAAs (e.g., multi-site licensing, 

provision of program materials). However, delivery coordination and communications is 

host-site specific and exhibits considerable variability across the state. 

Centralized Delivery System. Nine states adopted centralized delivery systems. Common 

features were statewide systems for communications, referrals, leader training, and program 

licensure. Many employed a “No Wrong Door” approach to program recruitment, typically 

using a 1-800 number and a referral system involving all public sector health agencies. 

Examples of centralized delivery systems follow.

 Alaska: Alaska’s CDSMP program is overseen by a program director from the Alaska 

Department of Public Health. The program director oversees and conducts all 

management operations for the statewide program, including marketing, training, 

partner development, and class scheduling with very limited support from 

Commission staff or other state and local agencies. 

 Virginia: The Virginia Department for the Aging and Virginia Department of Health 

are actively collaborating to deliver CDSMP through both the aging network and the 

state’s health districts. While the oversight model is decentralized, the delivery 

system is coordinated at the state level and implemented through the aging and 

public health networks, enabling consistent and coordinated communications and 

program delivery. 

 Rhode Island: Rhode Island utilizes a delivery system managed by the Department

of Health. The department, guided by a broad-based steering committee, 

establishes statewide policies, manages communications, and coordinates program 

dissemination. 

Mixed Model Delivery System. Hawaii is the only state in this category. Hawaii uses a twotiered delivery system, with communications and program delivery coordinated at the state and 

regional (island) levels. The state grantee is the Executive Office on Aging, but CDSMP is 

delivered through the aging network’s AAAs located on each island. The state distributes funds 

to local public health partnerships led by AAAs, each with its own steering committee. The 

University of Hawaii coordinates monitoring, evaluation, and partnership building across sites. 

5.3.2 Responsibility for Resource Allocation

A number of grantees reported that CDSMP—compared to other evidence-based health and 

wellness programs—requires significant resources to implement (e.g., staff time for marketing, 

scheduling workshops, registering participants, monitoring leaders, and program reporting; the 

cost of workbooks and supplies). As shown in Exhibit 5.5, grantees adopted a variety of 

approaches to managing allocation of grant funding and other program resources.

IMPAQ International, LLC Page 35 CDSMP Process Evaluation Final Report
Exhibit 5.5. Responsibility for Resource Allocation

Source: IMPAQ International and Altarum Institute

Resource Allocation by Local/Host Sites. Twenty-two grantees (47 percent) distributed funding 

to the local/host sites that then had responsibility for expending funds in accordance with local

policies and priorities. This resulted in considerable within-state, as well as across-state, 

variation in resource availability and use. Local sites frequently use funds for purchase of 

workbooks, snacks, and supplies, stipends for leaders, and a full- or part-time coordinator 

whose salary was either partially or fully covered with funding received from the state. Some 

local sites used state funding for participant incentives (e.g., coffee mugs) and snacks. 

State-Level Resource Allocation. Twelve state grantees retained primary control for purchasing 

workbooks and supplies for local sites. Georgia, for example, provides each AAA with a set of 

materials intended to last a full year. Some state grantees provided local sites with stipends for 

workshop leaders or incentives for participants to encourage workshop completion (e.g., coffee 

mugs). When the state has responsibility for resource allocation, resource availability tends to 

be more consistent across local sites. 

Mixed State/Local Government Resource Allocation. Twelve grantees retained control over 

much of the funding dedicated to resource purchasing, but local/host sites received some 

discretionary funds. For example, in some cases the state purchased workbooks and the local

sites used their discretionary funds to purchase incentives for participants. 

12 12

22

IMPAQ International, LLC Page 36 CDSMP Process Evaluation Final Report
Other Resource Allocation. New York—the only state in this category—delegates to SUNY

Albany responsibility for resource allocation as well as program oversight and administration.   

5.3.3 Marketing and Recruitment

Marketing and recruitment are key activities for viable, sustainable CDSMP programs and

occurred at two levels:  

 Marketing to potential partner organizations. Grantees sought out funding partners

as well as partners who could offer host and implementation sites and refer

prospective participants to CDSMP, such as hospitals, clinics, and senior centers.

Marketing was conducted through community presentations, one‐on‐one visits,

letters, and telephone calls, and involvement in larger coalitions of public health and

aging services groups.   

 Marketing to prospective workshop participants. As discussed above, responsibility

for marketing varied by delivery system model (i.e., centralized versus

decentralized). Marketing typically consisted of distribution of pamphlets and

brochures, outreach to local newspapers and other media, community

presentations, and announcements on state and local Web sites. Class Zero—which

is included in the Stanford curriculum and is intended to give individuals interested

in the workshops an idea of what to expect—was offered by some grantees in some

localities. While we were not able to examine the effects of Class Zero on

recruitment, we did examine its effects on workshop attendance patterns and found

some evidence for higher completion rates for those who attended Class Zero

compared to those who did not.17   

AoA’s RFA for the ARRA funded CDSMP instructed applicants to target underserved minority

populations as they implemented and expanded their programs. Established programs with a

history of broad program reach to diverse participants, like those in New Jersey and New York,

were able to deepen program penetration by building on and replicating outreach already in

place. Partnership development with organizations serving target populations was an effective

way to expand reach to minorities. In fact, New Jersey leveraged its relationship with the Office

of Minority Health to reach a range of cultural and ethnic minority participants. Grantees newer

to CDSMP were faced with the challenge of establishing new relationships with special

population constituents. Several respondents commented about the difficulties this presented

given the modest resources available. Program outreach and recruitment practices are

discussed in Sections 5.5 and 5.6 below on partnerships and expanding CDSMP to new

populations.  

Both established grantees and grantees newer to CDSMP delivery acknowledged the

importance of funding for marketing and recruitment activities, especially in reaching minority

and non‐traditional populations. Several grantees expressed interest in sharing information

                                                       

17 See regression analyses in Chapter 6 for the effect of Class Zero on completion rates.

IMPAQ International, LLC Page 37 CDSMP Process Evaluation Final Report
about “what works,” and called for more information about cost effective approaches that 

could be implemented in their communities. While grantees expressed their ongoing 

commitment to these populations, several expressed concern about how marketing and 

recruitment could continue to be supported after their ARRA grants ended.

5.3.4 Leader Training and Oversight

Leader training and the ability of the state to maintain a sufficient number of active master 

trainers and lay leaders are crucial to the successful delivery of CDSMP. For 21 grantees, 

training was primarily the responsibility of the state. For the other 26 grantees, training was 

coordinated at the regional or local level, although in some states master training was 

coordinated at the state level and responsibility for supplemental training and lay leader 

training resided at the regional or local level (Exhibit 5.6). 

Exhibit 5.6. Responsibility for Leader Training and Oversight

Source: IMPAQ International and Altarum Institute

Grantees frequently reported difficulty in retaining leaders and having sufficient numbers of Ttrainers and/or master trainers to meet training needs. A number of grantees reported that 

incentives for leaders—such as modest stipends or reimbursement for transportation 

expenses—were especially important to demonstrate appreciation and encourage long-term 

participation in CDSMP. To curb leader attrition, states with centralized oversight and delivery 

systems were increasingly considering use of MOAs or MOUs with new trainers and leaders

that detail expectations such as the number of required workshops, refresher requirements if 

any, data collection responsibilities, and fidelity monitoring requirements. Some grantees have 

IMPAQ International, LLC Page 38 CDSMP Process Evaluation Final Report
engaged in multi-state partnerships to reduce the travel costs associated with training and 

enable states to share master trainers and other key program delivery personnel. 

While many grantees reported a shortage of leaders in rural areas, an analysis of leaders 

conducting workshops in metro versus non-metro locations during the ARRA grant period 

indicated, on average, a greater number of unique (or unduplicated) leaders per 100 

participants in non-metro locations (Exhibit 5.7). However, because of the dispersed 

populations and long travel distances involved in delivering CDSMP in rural areas, it is likely that 

states require even larger numbers of trained leaders to adequately staff rural workshops.

Exhibit 5.7. Number of Leaders per 100 CDSMP Participants and Workshop

Source: IMPAQ International and Altarum Institute

Note: Calculations based on number of unique leaders by host organizations. Leaders might lead multiple 

workshops over time for the same host organization. 

5.3.5 CDSMP Licensure

Stanford requires any organization offering CDSMP to purchase a license.18 Two types of 

licenses are available for Stanford’s self-management programs: a single-program license or a 

multiple-program license. Multiple program licenses are also available to organizations that 

wish to offer more than one program. The fee is based on how many total workshops an 

organization offers annually, regardless of which ones. 

 

18 Stanford’s licensing policies and fees are described on their web site at: 

http://patienteducation.stanford.edu/licensing/. 

IMPAQ International, LLC Page 39 CDSMP Process Evaluation Final Report
Thirty-eight state grantees hold a state-level license for CDSMP (Exhibit 5.8). The types of statelevel agencies holding licenses are shown in Exhibit 5.9. In the 9 remaining states AAAs or other 

regional-wide host sites were typically the license holders. 

Exhibit 5.8. Ownership of CDSMP Licenses

Source: IMPAQ International and Altarum Institute

Exhibit 5.9. State-Level Ownership of CDSMP Licenses, by Agency

Source: IMPAQ International and Altarum Institute

IMPAQ International, LLC Page 40 CDSMP Process Evaluation Final Report
There appears to be a trend towards increased use of multi-site licenses at either the state or 

regional levels, although some grantees disagree with this approach. Many grantees said that 

CDSMP licensing costs can be a barrier for community organizations with limited budgets, 

especially when other evidence-based programs are available free of charge (e.g., programs

offered by the Arthritis Foundation).19 In contrast, Ohio encourages sites to purchase their own 

licenses and sees this as a strategy to enhance CDSMP availability and sustainability in the event 

state funding becomes unavailable. Ohio sites that have obtained their own licenses include the 

Veterans Administration Medical Center and Jewish Family Services, both of which are well 

funded. Some grantees reported difficulty in obtaining a CDSMP license and said this 

contributed to difficulties in meeting goals for workshops and participant completion rates.

5.4 Program Fidelity 

An important aspect of the process evaluation was to assess the extent to which ARRA-funded 

grantees have been able to maintain program fidelity, or adherence to the intent and design of 

CDSMP, to achieve the benefits to participants obtained in the original clinical studies 

conducted by Stanford University. Fidelity as described by Stanford involves numerous features: 

selecting and training program personnel, workshop trainers, and leaders, delivery of CDSMP 

workshops, and oversight and retraining of leaders over time. Initial studies conducted by 

Stanford included participants of varying ages. AoA has a particular interest in understanding 

the extent to which grantees have been able to maintain fidelity for delivery of CDSMP for 

adults aged 60 and older in community settings. All state grantees were required to maintain 

and monitor fidelity as part of the ARRA-funded awards.

Stanford University has developed a list of 144 “must do” and 49 “nice to do” fidelity standards

for delivery of CDSMP, published in the Program Fidelity Manual20 issued in May 2010 (Exhibit 

5.10). The Stanford Self-Management Fidelity Tool Kit, including a Fidelity Checklist, was issued 

concurrently. “Must do” standards range from instructions for minimum and maximum class 

size, to buddy matching approaches for group problem solving, emphasis on strict adherence to 

the curriculum, and more. Leaders are encouraged to follow Stanford’s CDSMP delivery 

standards and to seek review of any adaptations from the program’s designer, Dr. Kate Lorig.

 

19Stanford offers single licenses for a single program in one language for $500 (up to 30 workshops and 6 leader 

trainings) or $1,000 (up to 90 workshops and 12 leader trainings). Multiple-program licenses that allow an 

organization to offer more than one Stanford self-management program (e.g., CDSMP and Tomando Control de su 

Salud) are available for $1,000 (up to 75 workshops (all programs) and 6 leader trainings) or $1,500 (up to 120 

workshops (all programs) and 12 leader trainings). Multi-site licenses are available for $8,000 that allow states to 

offer up to 200 courses a year for three years; mix and match multiple programs; and include as many 

organizations as desired. Organizations that cannot afford the fees are encouraged to contact Stanford for a fee 

reduction.

20 Program Fidelity Manual, Stanford Self Management Programs, May 2010. Available at 

http://patienteducation.stanford.edu/ 

IMPAQ International, LLC Page 41 CDSMP Process Evaluation Final Report
Exhibit 5.10. Fidelity Standards

Fidelity Standards Must Do Nice to Do

Fidelity in Choosing Personnel

Personnel Overview

 

4 items 2 items

Program Coordinator 6 items 1 item

Leader 15 items 7 items

Master Trainer

 

11 items 10 items

T-Trainer 9 items 2 items

Fidelity Before Leader or Master Training

Before Leader Training 27 items 2 items

Before Master Training 24 items See: Selecting Leaders, Master 

Trainers, T-Trainers

Fidelity During Training

Leader Training 17 items 2 items

Counseling Leader Out of Program 12 items -

Master Training 4 items 4 items

Fidelity After Training

Leaders 3 items 3 items

Master Trainers 2 items 8 items

Fidelity During Workshops

During Workshop 3 items 5 items 

Fidelity for Leader & Master Trainer

Retention

Retention 5 items 3 items

After Workshop 2 items -

Stanford’s fidelity standards are numerous and the relative importance of various items, alone 

or in combination, has not been studied. Some grantees—as well as some host and 

implementation sites—reported that the large number of standards was cumbersome and 

presented challenges in their efforts to monitor and maintain fidelity. Some states called for 

simplification or consolidation of standards to facilitate offering CDSMP workshops. Rural areas, 

in particular, found standards for class size, leader trainings, updates, and workshop delivery to 

be difficult in sparsely populated areas where demand for CDSMP was limited. 

IMPAQ International, LLC Page 42 CDSMP Process Evaluation Final Report
5.4.1 Challenges to Fidelity

While grantees reported understanding the importance of maintaining fidelity of their CDSMP 

programs, most recounted problems and challenges at the state, regional, and local levels 

relating to serving the older adult populations. Attendance among individuals with chronic 

conditions could be interrupted by health and health care needs. Transportation often posed 

problems for older adult participants, especially those in rural areas or during poor weather 

conditions (heat in the summer in southern states, and snow and ice in northern regions). 

Host and implementation sites typically addressed workshop participation by individuals with

special needs on a case-by-case basis. Workshop leaders at several sites noted their preference 

to “mainstream” individuals with visual or hearing impairments, dementia/cognitive 

impairments, behavioral health conditions, or limited literacy, and include these individuals in 

workshops, where other participants often stepped in to assist them. One respondent noted, 

however, that individuals with behavioral issues could be disruptive, depending on their 

condition. At one site an individual with traumatic brain injury likely to benefit from the 

workshop was asked to leave as his behaviors were disruptive to the class.

Meeting Stanford’s class size requirements for a minimum of 10 and a maximum of 16 

participants per workshop was a common fidelity challenge across all grantees. The evaluation 

team used data reported to NCOA by sites to assess class size and found significant fidelity 

issues in this area (see analysis presented in Appendix G).

5.4.2 Fidelity Monitoring

All grantees were required to address fidelity as described by Stanford program developers. The 

methods and approaches they used varied widely and represented differing degrees of 

complexity and resource intensity. Despite these variations, there is a lack of information about 

the relationship of fidelity monitoring approaches to actual fidelity and CDSMP program 

outcomes, even by Stanford developers. Examples of fidelity monitoring used by state grantees 

and their sites are provided below.

New Jersey and Massachusetts, states with established programs, developed customized 

fidelity monitoring tools and approaches.

 New Jersey established its own protocol for fidelity monitoring and developed 

instruments/checklists from national materials customized for its state. The state 

observes peer leaders training and completes and maintains a checklist. Master 

trainers are required to observe the first workshop of their trainees, and maintain 

records of this effort. A refresher course including observation and feedback for 

peer leaders was developed in 2012. The state also convenes annual in-service days 

and webinars for master trainers and is available for ongoing technical assistance 

and support.

 In Massachusetts, the Department of Public Health contracted with the University of 

Massachusetts Donahue Institute to develop a Fidelity Monitoring and Continuous 

IMPAQ International, LLC Page 43 CDSMP Process Evaluation Final Report
Quality Improvement Plan. The plan includes three sections. Section I is comprised 

of commonly asked questions about program fidelity, definitions, and references.

Using the National Institute for Health’s Behavior Change Consortium framework, 

Section II charts the plan’s fidelity tools, level of responsibility, and fidelity 

processes. Section III includes fidelity forms and checklists to facilitate fidelity 

adherence and standardize data collection.

Most grantees use more basic fidelity monitoring approaches that require fewer staff and

resources. Many reported that master trainers or others observe at least one workshop by new 

trainers to monitor fidelity. Sometimes observations were combined with use of checklists, for 

example, the Stanford Fidelity Checklist or a state adaptation of the checklist. Other examples 

are provided below.

 Wisconsin uses 12 fidelity coaches to oversee fidelity across the state for CDSMP 

and other evidence-based programs. These coaches observe classes and assess them 

using a fidelity tool similar to that developed by Stanford program developers. 

Program staff report that their programs, initiated in 2004, had fidelity concerns in 

the early years, and they contacted Dr. Kate Lorig about them. Many of the areas of 

focus in Stanford’s current fidelity tool are reportedly based on issues Wisconsin 

staff brought to her attention. 

IMPAQ International, LLC Page 44 CDSMP Process Evaluation Final Report

 Washington posts fidelity materials on the CDSMP website co-developed and 

provided by Oregon, Idaho, and Alaska (see http://livingwell.doh.wa.gov/). One AAA 

in the state reportedly uses a “mystery shopper” who attends workshop sessions 

and reports observations back to the program.

 New Hampshire uses a self-assessment survey developed by the state’s AHECs to 

monitor fidelity as the state does not have funds and master trainers do not have 

time to conduct onsite monitoring of leaders.

 Colorado started to use master trainers to conduct fidelity checks, but found this 

was not feasible in rural areas. Shifting its approach, the state had leaders videotape 

workshops for master trainers to review. This grantee also developed a Coloradospecific fidelity manual. 

State grantees with centralized CDSMP delivery structures were more likely to include some 

level of central fidelity monitoring, providing more standard oversight than in states with 

decentralized delivery structures. Centralized program oversight was often based in the state’s 

department of public health or aging. Decentralized oversight was likely to be delegated at the 

AAA region. Decentralized monitoring allows more local control, but can result in greater 

variation across regions than centralized state approaches.

Maintaining a cadre of trained and certified leaders was identified as a challenge by some 

grantees, particularly those serving participants in rural areas. Due to low population density in 

rural areas it is can be difficult for workshop leaders, especially volunteer leaders, to facilitate a 

sufficient number of workshops to maintain certification over time. Additionally, trained 
volunteers who do not have regular opportunities to facilitate workshops often lose interest 

and drop out of the trainer pool.

5.4.3 Adaptations

State grantees and sites are expected to follow Stanford’s standards for CDSMP. Grantees and 

sites understand the importance of this directive; however, grantees reported making 

adaptations and accommodations such as those listed in Exhibit 5.11. Stanford does request 

that adaptations be submitted for comment and Stanford will comment on those that it does 

not deem permissible. The most common adaptation reported was allowing smaller class sizes 

in rural areas due to problems enrolling a sufficient number of participants in sparsely 

populated areas. The majority of state grantees acknowledged that class size requirements 

were difficult to meet due to transportation and recruitment.

Exhibit 5.11. CDSMP Adaptations/Accommodations Reported by State Grantees and Sites

Common Adaptations/Accommodations to CDSMP 

Smaller class sizes in rural settings. In rural settings class sizes ranged from 1 to 20, with the 

average class size of 12.

 Temporary class size exception for workshop of 6 homeless individuals and a class of 8 

incarcerated individuals.

 Some changes to the first class to address problems with participant retention. For 

example, one site postponed the first class until at least 10 participants could attend.

 Program name changes to increase interest. For example, one grantee changed the 

program’s name to “Take Charge of Your Health: Live Well, Be Well.” Another grantee 

changed the name to “Are You Sick and Tired of Being Sick and Tired?”

 Some faith-based groups use opening and/or closing prayer.

 Voluntary 6-month participant reunion meetings provided opportunities for participants to 

reconnect, socialize, and compare progress since workshop completion.

 Tracking stick to designate speakers/discussants used for Navajo populations.

 Starting classes late if transportation issues arise.

 Shorter class times are sometimes requested, and some classes may skip breaks in order to 

reduce the overall class time needed.

 Postponing class when there is a death in a tribe (cultural sensitivity).

 Allowing some participants to maintain the same partner instead of changing partners at 

each workshop session.

 Leaders supplement CDSMP script with their own experiences to “personalize” the sessions.

Source: IMPAQ International and Altarum Institute

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5.5 Partners

State grantees have established relationships with diverse partner organizations in their efforts 

to market and deliver CDSMP. Partnerships with AAAs were common and provided essential 

networks for CDSMP marketing, enrollment, delivery, data collection, and management. In 

many states AAAs also served as ADRCs, facilitating direct referral to CDSMP through their 

service provision partners. Other common partner organizations included other state programs, 

particularly state and local departments of public health, Area Health Education Centers and 

their networks; provider organizations including community hospitals, Veterans Affairs Medical 

Centers, health plans, community health centers, physician groups; universities and community 

colleges; and community-based organizations such as YMCAs, churches, and other faith-based 

organizations. 

Grantees also reported some unusual partners, including departments of corrections and parks 

and recreation, public libraries (in rural areas), fire stations, and mental health clinics. Most of 

the more unusual partners were selected as a means of reaching specific target populations--

for example, inmates at local prisons, older adults at risk for or who had used emergency 

medical services through fire stations, individuals with serious mental illness, and others. New 

Jersey, with funding from the Office of Minority and Cultural Health, reported partnering with 

the New Jersey Sickle Cell Association. While this partnership serves individuals below age 60, it 

provides ready access to individuals with this chronic condition likely to benefit from CDSMP. 

Successful behavior change outcomes were reported in these settings, anecdotally in most 

cases, leading to ongoing partnerships with these unconventional organizations. 

Medicaid programs and local philanthropic foundations were also named as partners. 

Foundations such as Tufts Health Plan Foundation and Health Foundation of South Florida have 

provided significant funding for program development and implementation. 

Examples of partner organizations are shown in Exhibit 5.12. 

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Exhibit 5.12 CDSMP Partner Organizations

Partner Organizations

 Departments of Public Health

 Networks (AAAs, AHECs)

 Hospitals

 Veterans Administration Medical Centers

 Health Plans

 Community Health Centers

 Physician Groups

 Senior Housing

 Universities and Community Colleges

 YMCAs

 Faith-based organizations

 Other state agencies (Medicaid, Corrections, Parks and Recreation)

 Other community organizations (libraries, fire stations, mental health 

providers)

 Local philanthropic foundations

Source: IMPAQ International and Altarum Institute

Grantees’ selection of partners reflected historical relationships, capacity, and willingness to 

participate and coordinate efforts among state and local agencies and networks. Typically, 

grantees sought out and engaged groups with capacity and experience in reaching and serving 

older adults, for example AAAs and senior centers. However, grantees seeking to serve 

populations such as cultural/ethnic minorities or older adults in rural areas developed 

partnerships with organizations already serving these groups. Oklahoma partnered with 

libraries in rural communities, several states reported partnering with churches to reach older 

African Americans, and states such as New Hampshire and New Mexico leveraged relationships 

developed by the AHEC programs serving rural and underserved individuals. As one respondent 

advised on partner selection, 

“Go where the enthusiasm is. The answer is in the community...”

 --Statement by host site staff during evaluation team interview

5.5.1 Departments of Public Health

Sixteen grantee awards were made to state public health departments and many had prior 

experience in offering CDSMP, the Diabetes Self-Management Program (DSMP), and/or the 

Arthritis Self-Management Program (ASMP) with funding from the CDC (one state, Vermont, 

reported providing the Chronic Pain Self-Management Program in one community region). Even 

when departments of aging were the primary awardees of ARRA funds, state and local health 

departments were important contributors and supporters of CDSMP. The aging-public health 

partnerships were especially close when these agencies were organizationally located within 

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the same umbrella agency at the state level. Such arrangements often enabled sharing of 

resources and infrastructure for data collection, evaluation, program development, and more. 

Some examples include:

 The Arkansas CDSMP grantee is in the state’s Department of Public Health, which 

worked closely with the Department of Aging during the ARRA grant award. The 

Department of Public Health had provided CDSMP and DSMP on a limited basis for 

several years prior to the ARRA awards. Prior to the ARRA award the CDSMP director 

had been a Public Health DSMP trainer.

 Puerto Rico’s CDSMP grant was awarded to the Department of Health. ADRCs are 

part of an Advisory Committee of public, private, and community-based 

organizations used to market CDSMP, enroll participants, and deliver the program. 

5.5.2 Area Agencies on Aging

AAAs served as host sites as well as coordinated program implementation by other 

organizations, from community hospitals and clinics to senior housing, community-based 

organizations such as churches and YMCAs, and others. Where AAA networks exist, states 

typically used their resources and existing partnerships, statewide or in specific regions, to 

support the CDSMP program. Washington reported that ARRA funding allowed the state to 

expand CDSMP to four additional AAAs. The AAAs played critical roles in states with all three 

(centralized, decentralized, and mixed) program delivery models. 

All AAAs make available basic, core services for older adults (information and referral 

assistance, legal assistance, transportation, meal services (both congregate and homedelivered), and family caregiver support services) as required by the Older Americans Act. 

However, the capacity and capabilities of AAAs varied considerably. Some AAAs deliver services 

directly while others deliver those services through arrangements with local service providers. 

States like New Jersey and North Carolina were able to build on well established AAA 

organizations with robust data collection and evaluation capabilities. Other states provided 

CDSMP through a mix of well developed AAAs and smaller AAAs with more limited resources, 

particularly those located in many rural areas. Many of the AAAs provided not only CDSMP, but 

other self-management programs such as DSMP or ASMP, as well as other evidence-based 

community-based programs and, therefore, had an already established presence in the 

community. 

Grantees also offered CDSMP through community-based AAA partners and outside 

organizations, in various roles and configurations. Oftentimes AAAs also functioned as ADRCs; 

with their “no wrong door” and “single point of entry” approach to information and referrals 

for long-term services and supports, ADRCs can be excellent partners for recruiting and 

referring CDSMP participants. Examples of AAA partnerships include these:

 Ohio’s AAAs are also ADRCs, providing direct referrals for workshops. Other partners 

include the VA Medical Centers, Ohio’s Public Employees Retirement System, and 

Miami University School of Nursing, among others.

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 In Hawaii, the AAAs and the University of Hawaii work together in a partnership 

established through the Department of Health. Each AAA has a local steering 

committee to help shape program delivery, while the University leads evaluation 

and fidelity monitoring activities, including pre-post testing of social and role activity 

limitations and communications with physicians, self-rated health and time spent 

engaging in exercise, self-reported physician visits, ability to cope with symptoms, 

and self efficacy across different populations in the state. 

 The Arizona Department of Health Services, the CDSMP grantee, delegated funds to 

three organizations to provide statewide coverage. Host sites include AAAs, 

behavioral health organizations, county health departments, and local faith-based 

organizations. 

5.5.3 Providers

A variety of provider types have partnered with CDSMP grantees. These partnerships have 

typically been developed at the local level through grantee outreach to individuals or 

organizational leaders, or have evolved as a result of local, regional, or state coalitions

established to coordinate community health and aging services. Some grantees report they 

have had solid, impressive experiences with workshop leadership, continuity, and stability 

when partnered with provider organizations. Veterans Administration Medical Centers provide 

CDSMP on site or through community referral in Ohio, Arizona, and New Mexico. FQHCs in 

Vermont, physician groups in Rhode Island, and nursing students from local colleges and 

universities have provided CDSMP in Ohio and New Jersey. Vermont’s statewide health care 

reform initiative, Blueprint for Health, is anchored around the state’s hospital network and their 

local community health coalitions. Vermont developed its Blueprint from a chronic care model 

and has embedded CDSMP as part of this reform from its launch in 2003. 

Partnering with public and private health plans is a topic raised by several grantees, but to date 

few have consummated successful arrangements. Many health plans are familiar with CDSMP 

and its proven benefits to both participants and the health plan; referral to community-based 

providers is a “win-win” for all. Health plan referrals and reimbursement strategies being 

pursued by state grantees are discussed in more detail in Chapter 8. 

5.5.4 Colleges and Universities

Grantees have partnered with colleges and universities for assistance with data collection and 

evaluation, but these groups frequently support CDSMP program implementation and delivery

as well. Student nurses are being trained to deliver CDSMP in at least two states (New Jersey 

and Ohio), although it is too early to know whether nurse training is having an impact on 

professional awareness, the availability of leaders, and patient referrals. Adult education 

classes in Los Angeles, California, offer CDSMP training to students. In Kansas, interns from 

Wichita State University provide hands-on program support as well as research support, and 

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the University of Missouri Extension program is an implementation partner through its eight

regional offices in Missouri. 

5.5.5 Community-based Organizations

A wide range of community-based organizations including YMCAs, United Ways, Jewish Family 

Services, senior housing and assisted living programs, churches, and other faith-based 

organizations have partnered with grantees in a number of states. These organizations usually 

serve as implementation sites for CDSMP. Grantees reported providing the program at libraries, 

bowling alleys, fire stations, prisons, and mental health clinics, all to increase accessibility and 

with positive results. Offering CDSMP through mental health clinics is reported to lead to better 

self management of chronic mental illness by participants living in community settings. Reports 

on these populations are anecdotal and will require further study.

5.5.6 Other State and Local Agencies

State agencies including departments of corrections and departments of parks and recreation 

have partnered with grantees, as well as state offices of minority health. Early experience 

offering CDSMP to inmates is reported to have resulted in improved self-management 

behaviors. One respondent reported that CDSMP has helped inmates more effectively advocate 

for themselves as well as for family members. Several grantees reported attempts to partner 

with state Medicaid agencies, and have been successful receiving referrals or are investigating 

other arrangements to embed CDSMP in Medicaid programs and/or receive state 

reimbursement. Arrangements with Medicaid have been slow to develop but appear to hold 

potential for future program delivery and sustainability. 

5.5.7 Local Philanthropic Foundations

Local foundations offer additional CDSMP partnership options. Many local foundations share 

community health and wellness missions and in some cases have initiated evidence-based 

programming as part of their larger organizational offerings. Notable examples are the Amherst 

H. Wilder Foundation in Minnesota, which has become a partner in delivery and program 

funding, and Health Foundation of South Florida, which has invested substantial funding in 

support of CDSMP and other evidence-based community-based programs. Health Foundation 

of South Florida launched the Healthy Aging Regional Collaborative in 2008 with $7 million in 

foundation funds, providing CDSMP and other classes and programs that have been attended 

by 17,000 older adults.

5.6 Expanding CDSMP to New Populations

An explicit objective of AoA’s ARRA grants was to support grantees in their efforts to provide 

CDSMP to diverse and underserved older adult populations. Grantees addressed this 

requirement in several ways, reflecting the demographic, geographic, organizational, and 

historical arrangements in their states, and reported serving cultural/ethnic minorities, 

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individuals with low incomes, rural populations, incarcerated individuals, persons with mental 

illness, and others. 

Many grantees used ARRA funds to offer or expand availability of CDSMP to populations with 

limited access to CDSMP. States with mature delivery infrastructure in place were generally 

most successful reaching new groups, as easier to reach populations were already being served.

Newer, less developed programs often reported successful implementation in terms of 

marketing and offering workshops to build general program capacity at the community level. 

States where self-management programs or other evidence-based programs have been offered 

through previous federal, state, or other grants were able to readily incorporate CDSMP with 

their other offerings. For example, New Mexico’s partner organization, Southern AHEC (SAHEC), 

offered CDSMP and Tomando Control de su Salud near the Texas border on a limited basis from 

2003-2007 through its promotora program. While the early CDSMP programs were not 

sustainable, the early presence as part of the local promotora program facilitated re-entry of 

CDSMP with ARRA funds. The SAHEC partnership also facilitated access to participants in this 

region. 

5.6.1 Underserved Groups

Non-Hispanic White females were the overwhelming majority of participants served by all state 

grantees. However, ARRA funding was credited with expansion of CDSMP to many populations 

that have been traditionally challenging to reach for health promotion activities. ARRA funds 

helped grantees to serve Hispanic-Latino/a populations and rural residents in Oregon; Native 

American and tribal groups in Colorado, Michigan, New Mexico, Utah, Pennsylvania, Minnesota, 

Oklahoma, and Maine; African Americans in churches and senior centers in Arkansas; and 

Somali women in Minnesota and Maine. Grantees in Puerto Rico, Rhode Island, Oklahoma, 

Kentucky, Delaware, New Jersey, and Virginia reported serving individuals in correctional 

facilities. 

5.6.2 Linguistic Minorities

Pennsylvania provided two Chinese language workshops, Illinois delivered CDSMP in Hindi, and 

Hawaii reported targeting Micronesian groups. The Maryland grantee offered CDSMP to South 

Americans in Spanish as part of a Breast Cancer initiative. Georgia currently offers workshops in 

Korean and Vietnamese. For many languages, translations of CDSMP program materials are 

available through the Stanford website. Working with Dr. Kate Lorig, developer of Stanford’s 

CDSMP, a AAA in Maine translated and adapted CDSMP for use with the Somali community. 

The adaptation involved reducing class size to accommodate cultural norms allowing 

participants to fully express their needs. A Hawaii host site reports having modified the 

program for Asian and Pacific Islander communities, providing supplemental books in Hawaiian, 

Ilocano, and Chinese, and providing additional support to participants outside class time. Other 

adaptations reported in Hawaii include program name changes due to language, use of an 

opening prayer, and six-month reunions.

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The New Jersey Office of Minority and Cultural Health has funded 26 agencies to deliver 

CDSMP since 2008. As a result, CDSMP has been offered in seven languages and has been 

targeted to Latinos, African Americans, Koreans, and members of other ethnic minority 

groups.

Grantees also reported serving other, non-linguistically diverse special populations. Grantees in 

Rhode Island and Kentucky served homeless individuals. Grantees have also targeted CDSMP to 

individuals with developmental disabilities and obese individuals. Georgia has not yet but would 

like to offer the workshops to individuals with HIV, early stage dementia, mental health issues, 

and incarcerated individuals. Several state grantees that reached out to rural areas reported 

challenges marketing the program and addressing transportation issues to ensure participation 

in the workshops.

Respondents in several states recognized the additional effort required to reach these priority 

populations. While all grantees and host sites stated their commitment to continue serving 

these diverse groups, some expressed concern about their ability to continue to serve their 

needs with the expiration of ARRA funds. Maintaining workshop leaders with special cultural or 

linguistic skills was identified as a concern without leader stipends and other resources to 

support marketing and outreach in communities of interest. Many leaders with these skills are 

volunteers from the communities themselves, with low incomes, and are unable to participate

without these resources.

5.7 Post-ARRA Changes

For many grantees the end of the ARRA funded period of performance on March 31, 2012, 

raised questions about potential impacts on delivery systems and infrastructure building as well 

as the future of CDSMP programs overall. Of particular interest to AoA is understanding the 

extent to which states will continue to offer the CDSMP program, and to what extent delivery 

will be impacted by the change.

Delivery models, infrastructure, and communication and referral networks are not expected to 

change significantly with loss of ARRA funding. States that report that they expect changes as a 

result of reduced funding reported making efforts to recruit health systems and other more 

“stable” delivery partners. A few grantees reported that partners would likely drop the program 

given competing interests or priorities and/or the availability of less resource intensive wellness 

and prevention programs. Almost all grantees report anticipated decreases in number of 

workshops offered and inability to expand reach to new areas or populations. 

Among grantees with private sector delivery partners, there is increased focus on securing 

partnerships with health systems, health insurance groups, and other larger partners with their 

own funding sources. In most cases, grantees have reached out locally in the attempt to recruit 

these partners, or have contacted partners through local, regional, or state coalitions. States 

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report that a challenge to recruitment is the general lack of research on program impact 

specific to their state population, limited understanding of existing evaluation results, and 

limited availability of information about cost effectiveness and return on investment (ROI) 

associated with CDSMP needed to persuade partners of the value of CDSMP. Additionally, 

considerable focus is being placed on partners with the ability to sustain CDSMP on their own. 

However, overall communications and referral networks are expected to be stable. Grantees 

report that some AAAs and other partners will stop offering CDSMP if there is no funding. These 

partners are usually community-based organizations or public agencies that have limited 

operating budgets or anticipate funding cuts that render the organizations unable to make 

long-term commitments to support ongoing programming. 

Some grantees reported that they will purchase licenses at the state level rather than rely on 

regional- or site-level organizations to purchase licenses. Grantees also reported increasing use 

of MOAs with partners, master trainers, and leaders. Many reported they were continuing 

existing approaches for resource allocation, but would increasingly rely on lending libraries for 

program materials. Some stated they are considering charging a nominal fee for classes and 

books, decreasing or eliminating stipends for leaders, and eliminating transportation support. 

Additionally, there is expected to be a considerable shift in funded staff, with many state-level 

and regional-level coordinators either reducing time spent on CDSMP, shifting to other funding 

mechanisms, or being removed from the program completely. In many cases, grantees 

reported that any available funds will be directed towards books and supplies rather than 

toward coordinator or other staffing support. One approach considered embedding the CDSMP 

by training staff in public agencies or organizations where CDSMP can be considered part of the 

individual’s salaried (or volunteer) position.

Grantees report further training of master trainers or lay leaders will be reduced and expect 

difficulty meeting the requirements following Stanford’s recent revision of the CDSMP manual

once their current licensing agreements end. To maintain fidelity, if sites renew their licenses or 

apply for new licenses they will have to use the updated version of the CDSMP manual and 

curriculum. 

Fidelity monitoring is generally expected to decrease across the grantees, particularly for those 

with centralized systems. State level coordinators generally expect to shift the majority of 

responsibility for fidelity to the regional/host partners. Regional/host agencies are attempting 

to maintain current levels of monitoring, but expect some difficulty doing so. 

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CHAPTER 6: PROGRAM COMPLETION RATES

Research Question 3: What are program completion rates, in general and by important subgroups? What barriers and supports affect the existing completion rates?

Key Findings

1. The average completion rate for CDSMP participants was 75 percent. However, average completion

rates varied from 63 percent in Oregon to 86 percent in Oklahoma. Completion rates for individuals aged

60 and older were slightly higher than for those under age 60 (77.2 percent compared to 74.5 percent). At

77 percent, female participants had higher completion rates than males. Workshops that were held by

faith‐based organizations had the highest completion rates of any type of implementation site.  

2. Completion rates varied by type of program oversight. States that instituted a centralized model to

oversee CDSMP had the highest completion rates for participants under age 60 (75.4 percent) and over

age 60 (79.3 percent). Average completion rates were slightly higher for programs led by state units on

aging than for programs led by public health agencies.

3. Individuals with certain chronic conditions were more likely to complete CDSMP. Individuals reporting

hypertension and osteoporosis had greater odds for completion, suggesting that targeting these

populations could have a high pay‐off. Not unexpectedly, individuals reporting depression were less likely

to complete CDSMP, suggesting the need for more supports for this population.

4. Smaller workshops tend to have higher completion rates. Participants in smaller workshops (i.e., with no

more than 5‐6 participants) had significantly higher completion rates. Greater camaraderie and peer

pressure combined with possibly more individualized attention from leaders may explain the higher

completion rates.  

5. Completion rates in non‐metro areas were higher than in metro areas. This was despite rural barriers

such as public transportation, long distances to classes, and a greater impact of inclement weather

reported by grantees.   This bears further study and may be, in part, due to these sessions also having

fewer participants. (See the previous bullet.)

  

6. Leader experience matters. Participants who attended workshops with leaders who taught a workshop in

the previous quarter or with leaders who had taught together previously had higher odds of completion.  

7. Completion rates were higher for Spanish language CDSMP (Tomando Control de su Salud). Cultural

elements included in the Spanish language CDSMP curriculum may have a positive effect on completion

rates and should be examined more carefully for applicability to English language CDSMP.

8. The relationship between Class Zero and completion rates is unclear. Regression analysis did not find

strong evidence that participation in Class Zero improved the odds of completing CDSMP. Participants in

workshops that offered an introductory Class Zero had slightly higher completion rates than other

participants (75.8 percent compared to 74.7 percent) and the difference is statistically significant. Taken

together this suggests that additional research is needed about for which populations and in which

situations Class Zero might prove beneficial.

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6.1 Introduction

To monitor program participation, states tracked the cumulative number of program 

participants, the cumulative number of completers, and aggregate completion rates during the 

ARRA grant period. Completers were defined as participants who attended four or more of the 

six sessions of a CDSMP workshop. In their ARRA grant applications, grantees set goals for 

participants, completers, and completion rates and then measured progress against these 

goals. 

It is important to note that participants may benefit from CDSMP workshops even if they are 

not “completers” (i.e., participants who complete at least four of the six sessions). For example, 

some participants who attend only two or three sessions may be sufficiently encouraged and/or 

equipped to take better care of themselves and thus benefit from having participated in 

CDSMP. AoA and CMS are planning more extensive studies of CDSMP participants—including 

analysis of Medicare administrative data—that will address the extent to which “noncompleters” benefit from CDSMP. 

To address Research Question 3, the research team examined variations in completion rates

over time and by participant and program characteristics. For example, completion rates can be 

related to the stage of program implementation (developmental versus mature program), the 

quality of the state’s infrastructure and delivery system, and the characteristics of program 

participants. Understanding the factors that seem to influence completion rates can guide 

future improvements in program delivery. 

Section 6.2 presents an analysis of completion rates reported to NCOA. This section examines 

factors that influence completion rates, each looked at independently. Appendix E examines 

CDSMP completion rates by AoA region. In Section 6.3, we present findings from a series of 

regression analyses that were designed to examine the influence of multiple factors on 

workshop completion, such as participant characteristics, workshop-related information, and 

differences in program administration or funding. Section 6.4 summarizes findings from these 

two analyses. 

Data sources used to conduct the following analysis of completion rates include site visits and 

telephone key informant discussions, grantee progress and final reports, and program data 

submitted by the states to NCOA, the technical assistance contractor. Program data are for the 

period April 1, 2010, to March 30, 2012, only. Some grantees received no-cost extensions to 

their ARRA grants and therefore had additional time to achieve their participant and completer 

goals; this is not captured in our analysis.

6.2 Completion Rates for ARRA Grantees 

CDSMP completion rates varied from 63 percent in Oregon to 86 percent in Oklahoma. The 

average completion rate across the 45 grantees offering CDSMP was 75 percent (Exhibit 6.1). 

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A majority of state grantees met or exceeded their goals for number of completers during the 

ARRA grant period. Twenty-nine grantees exceeded their completer goals by 100 to 199 

percent. For example, Alabama indicated in their ARRA grantee application that they hoped to 

have 800 completers over the course of the funding period. By March 2012, Alabama had 1,453 

completers, 182 percent of their original goal. Nine state grantees exceeded their completer 

goals by 200 percent or more. Alaska, for instance, set a goal of 52 completers over the course 

of the ARRA funding period. By March 2012, 287 participants had completed CDSMP—552 

percent of the state’s original goal. Seven states did not meet their completer goals during the 

original project period: New York, North Carolina, Ohio, Pennsylvania, Tennessee, Texas, and 

West Virginia. With no-cost extensions to their grants, all states, with the exception of 

Tennessee, were able to meet their participation and completion rates/goals by the end of 

2012. 

Grantees used a variety of strategies to increase the number of completers. Many provided 

transportation for participants or offered taxi vouchers or gas reimbursement to mitigate this 

barrier. Grantees also reported holding workshops at locations where people congregate, such 

as churches and community centers. Additionally, some grantees shared that they provided 

small incentives to participants, such as certificates, coffee mugs, pens, and notepads, to 

encourage them to attend sessions. Leaders reported that small incentives such as these were 

quite effective in promoting a spirit of community and friendly competition among participants

For grantees who did not reach their completer goals, key informants indicated that common 

barriers encountered by participants were transportation, particularly in rural areas, inclement 

weather, illness, and the length of the program which, at six weeks, can interfere with other 

commitments. Efforts to recruit and provide CDSMP to new or difficult-to-engage populations, 

e.g., low literacy groups, were also reported to affect completion rates. This is not to say that 

sites should avoid expanding to new areas or populations, but rather that they should take such 

expansions into account when developing participation and completion goals. 

Exhibit 6.1. State Goals for CDSMP Participants and Completers, April 2010 to March 2012

State

Number of 

Participants 

(a)

Number of 

Completers 

(b)

Completion 

Rate (%) 

(c) = (b)/(a)

Completer 

Goal*

(d)

Percent of Goal

(e) = 100*(b)/(d)

Alabama 1,855 1,453 78% 800 182%

Alaska 434 287 66% 52 552%

Arizona 1,789 1,302 73% 800 163%

Arkansas 857 638 74% 500 128%

California 9,361 6,448 69% 2,975 217%

Colorado 922 670 73% 500 134%

Connecticut 934 711 76% 500 142%

Florida 4,913 3,932 80% 2,975 132%

Georgia 2,200 1,663 76% 1,200 139%

Hawaii 608 475 78% 300 158%

Idaho 1,297 899 69% 300 300%

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State

Number of 

Participants 

(a)

Number of 

Completers 

(b)

Completion 

Rate (%) 

(c) = (b)/(a)

Completer 

Goal*

(d)

Percent of Goal

(e) = 100*(b)/(d)

Illinois 4,226 2,964 70% 2,975 100%

Indiana 1,248 968 78% 800 121%

Kansas 1,062 861 81% 500 172%

Kentucky 1,323 990 75% 800 124%

Louisiana 648 507 78% 500 101%

Maine 673 500 74% 300 167%

Maryland 1,838 1,379 75% 800 172%

Massachusetts 2,317 1,792 77% 1,200 149%

Michigan 5,142 3,800 74% 2,975 128%

Minnesota 1,404 1,050 75% 800 131%

Mississippi 850 658 77% 500 132%

Missouri 2,315 1,640 71% 800 205%

Nebraska 481 395 82% 300 132%

Nevada 484 348 72% 300 116%

New Hampshire 532 382 72% 300 127%

New Jersey 3,942 3,010 76% 1,200 251%

New Mexico 1,065 833 78% 300 278%

New York** 3,716 2,821 76% 2,975 95%

North Carolina** 2,653 2,033 77% 2,975 68%

Ohio** 3,013 2,381 79% 2,975 80%

Oklahoma 2,324 1,997 86% 500 399%

Oregon 3,017 1,896 63% 500 379%

Pennsylvania** 3,683 2,936 80% 2,975 99%

Puerto Rico 619 521 84% 500 104%

Rhode Island 508 388 76% 300 129%

South Carolina 1,670 1,251 75% 800 156%

Tennessee 1,190 883 74% 1,200 74%

Texas** 2,105 1,495 71% 2,975 50%

Utah 2,115 1,511 71% 300 504%

Vermont 948 645 68% 139 464%

Virginia 2,325 1,794 77% 1,200 150%

Washington 2,165 1,615 75% 800 202%

West Virginia** 520 403 78% 500 81%

Wisconsin 2,570 1,859 72% 800 232%

Total 89,861 66,984 75% 48,666 138%

*Completer goals, determined by AoA and published in the CDSMP Program Announcement, were based on the 

number of Medicare beneficiaries residing in the state.

**These state grantees met their completer goals after March 2012 during no-cost extensions to their grant 

periods.

Source: NCOA data and AoA

AoA programs target individuals who are aged 60 and older; however, grantees were permitted 

to serve individuals younger than age 60 with ARRA funds. As shown in Exhibit 6.2, completion 

IMPAQ International, LLC Page 57 CDSMP Process Evaluation Final Report
rates for participants aged 60 and older were slightly higher than for the younger population 

(77.2 percent compared to 74.5 percent). The difference is statistically significant. 

Exhibit 6.2. CDSMP Workshops and Completion Rates by Participant Age

Age Group Number of Participants Number of Completers Completion Rate (%)

Under 60 22,043 16,430 74.5%

60+ 57,870 44,648 77.2%

Total† 79,913 61,078 76.4%

Note: Excludes participants with missing date of birth.

†The difference in completion rates between “under age 60” and “60 and older” age groups (2.7 percentage 

points) is statistically significant at the 0.1% significance level. 

Source: NCOA data

Exhibit 6.3 presents information on CDSMP workshops and completion rates by participant age 

and type of lead agency. Completion rates were higher for individuals participating in CDSMP 

operated by states with an aging lead agency than in programs offered by states with a public 

health lead agency. The differences were statistically significant for the aggregate and 60 and 

older age group, but not for the under 60 age group. This finding also holds after controlling for 

other factors that might affect completion rates (see Section 6.3). We are not aware of any 

confounding factors that correlate with type of lead agency in every state.

Exhibit 6.3. CDSMP Workshops and Completion Rates by Type of Lead Agency

Age 

Group

Number of

Participants

Aging

Number of

Completers

Aging

Completion

Rate (%)

Aging

Number of

Participants

Public 

Health

Number of

Completers

Public 

Health

Completion 

Rate (%)

Public 

Health

Difference: 

Completion 

Rate (%)

Under 

60 17,408 13,018 74.7% 4,635 3,412 73.6% 1.1%

60+ 46,333 35,908 77.5% 11,537 8,740 75.7% 1.8%***

Total 63,741 48,962 76.8% 16,172 12,152 75.1% 1.7%***

Note: Excludes participants with missing date of birth.

(*), (**), and (***) denote the 5%, 1%, and 0.1% level of significance, respectively, for the difference in completion 

rates between aging and public health agencies. Lower levels of significance indicate stronger test results.

Source: NCOA data

Exhibit 6.4 shows CDSMP completion rates by type of program oversight as described in 

Chapter 5. Table A in Appendix H provides results of the statistical significance tests for 

differences in Exhibit 6.4. States with shared program oversight had significantly lower 

completion rates than states with centralized and decentralized program oversight for 

participants under age 60. However, states with decentralized program oversight had 

significantly lower completion rates for the aged 60 and older group. States that instituted a 

centralized model to oversee CDSMP activities had the highest average completion rates for 

IMPAQ International, LLC Page 58 CDSMP Process Evaluation Final Report
both age groups (75.4 percent and 79.3 percent), but the difference between centralized and 

decentralized was not significant for participants under age 60. 

Exhibit 6.4. CDSMP Completion Rates by Type of Program Oversight

Organizational

Structure

Number of 

Workshops

Number of

Participants

Under Age 

60

Number of

Completers

Under Age 

60

Completion

Rate 

(%)Under 

Age 60

Number of 

Participants

Age 60+

Number of

Completers

Age 60+

Completion

Rate (%)

Age 60+

Centralized 1,768 4,405 3,321 75.4% 13,164 10,440 79.3%

Shared 1,242 3,512 2,542 72.4% 9,218 7,231 78.4%

Decentralized 4,739 14,126 10,567 74.8% 35,488 26,977 76.0%

Total 7,749 22,043 16,430 74.5% 57,870 44,648 77.2%

Note: Excludes participants with missing date of birth.

Source: NCOA data

Exhibit 6.5 shows completion rates by the type of delivery system structure. The tests of 

statistical significance for Exhibits 6.5 are provided in Appendix H, Table B. For participants 

under age 60, states with mixed delivery systems had significantly higher completion rates than 

both states with centralized and decentralized delivery systems, although it is important to 

note that the estimate for states with mixed delivery systems is based on a small number of 

states and participants as shown in Exhibit 6.5. For participants aged 60 and older, states with 

centralized delivery systems had the highest completion rates which were statistically different 

compared to states with decentralized delivery systems, but not compared to states with mixed 

delivery systems.

Exhibit 6.5. CDSMP Completion Rates by Type of Delivery System Structure 

Organizational 

Structure

Number of 

Workshops

Number of

Participants

Under Age 

60

Number of

Completers

Under Age 

60

Completion

Rate (%)

Under Age 

60

Number of 

Participants

Age 60+

Number of

Completers

Age 60+

Completion

Rate (%)

Age 60+

Centralized 1,147 2,305 1,697 73.6% 8,290 6,563 79.2%

Mixed 218 273 224 82.1% 1,511 1,165 77.1%

Decentralized 6,384 19,465 14,509 74.5% 48,069 36,920 76.8%

Total 7,749 22,043 16,430 74.5% 57,870 44,648 77.2%

Note: Excludes participants with missing date of birth.

Source: NCOA data

Exhibit 6.6 presents CDSMP completion rates by sex of participant. Except for the younger than 

60 age group, female participants had higher completion rates than male participants. The 

differences were statistically significant for all age groups except for age 60 – 64. Generally, 

completion rates decreased as the age of participants increased.

IMPAQ International, LLC Page 59 CDSMP Process Evaluation Final Report
Exhibit 6.6. CDSMP Completion Rates by Participant Age and Sex

Age 

Group

Number of

Participants

Male

Number of

Completers

Male

Completion

Rate (%)

Male

Number of

Participants

Female

Number of

Completers

Female

Completion 

Rate (%)

Female

Difference: 

Completion 

Rate (%)

<60 5,828 4,416 75.8% 15,720 11,686 74.3% 1.5%* 

60 - 64 2,078 1,584 76.2% 7,438 5,781 77.7% -1.5%

65 – 74 4,662 3,553 76.2% 17,915 14,195 79.2% -3.0%***

75 - 84 3,506 2,628 75.0% 14,268 11,116 77.9% -2.9%***

85+ 1,227 861 70.2% 5,539 4,077 73.6% -3.4%**

Total 17,301 13,042 75.4% 60,880 46,855 77.0% -1.6%***

Note: Excludes participants with missing date of birth. 

(*), (**), and (***) denote the 5%, 1%, and 0.1% level of significance, respectively, for the difference in completion 

rates between males and females. Lower levels of significance indicate stronger test results.

Source: NCOA data

Exhibit 6.7 presents data on CDSMP completion rates by participant age and race/ethnicity. 

Tables C and D in Appendix H provide results of the statistical significance tests for differences 

in Exhibit 6.7. For participants older than 60, we did not find any statistically significant 

difference between participants who had Hispanic or Latino origin and participants who did not 

have Hispanic or Latino origin for any of the age groups. However, we found a statistically 

significant difference between participants who identified as not Hispanic or Latino and those 

who identified as Hispanic or Latino for the under 60 age group. Completion rates for Hawaiian 

Natives/Pacific Islanders were higher than all other races in every age category; the differences 

were statistically significant for the 60-64 and 65-74 age groups but not for the other age 

groups.21 While most other completion rates were generally similar with insignificant 

differences, African Americans had the second highest rate at 79.4 percent. 

 

21 Hawaiians/Pacific Islanders constitute only a small portion of CDSMP participants overall (less than 1 percent). 

Sixty-three percent of Hawaiian/Pacific Islander CDSMP participants reside in Utah and the majority (99 percent) of 

these participants is served by two host sites. The completion rates for Hawaiians/Pacific Islanders at these two 

sites are 99 and 100 percent, respectively. Interestingly, only 8 percent of Hawaiian/Pacific Islander CDSMP 

participants in the NCOA data reside in the state of Hawaii.

IMPAQ International, LLC Page 60 CDSMP Process Evaluation Final Report
Exhibit 6.7. CDSMP Completion Rates by Participant Age and Race/Ethnicity 

Ethnicity/Race Age <60 Age 60-64 Age 65-74 Age 75-84 Age 85+ Total

Ethnicity: Hispanic or 

Latino origin 77.4% 77.9% 79.9% 76.1% 74.0% 77.7%

Ethnicity: Not Hispanic 

or Latino origin 74.4% 78.1% 78.7% 77.9% 73.2% 76.9% 

Ethnicity: Unknown 69.4% 70.9% 75.9% 72.7% 71.1% 72.5% 

Race: American Indian 

/ Alaskan Native 73.7% 74.1% 70.4% 72.9% 77.3% 73.1% 

Race: Asian or Asian 

American 77.5% 76.1% 77.9% 78.2% 76.6% 77.6% 

Race: Black or African 

American 76.4% 79.1% 79.3% 80.3% 77.5% 78.6% 

Race: Hawaiian Native 

or Pacific Islander 82.5% 96.7% 93.5% 84.6% 93.3% 90.5% 

Race: Other / 

Multiracial 79.4% 76.7% 79.5% 73.3% 71.9% 77.8% 

Race: White or 

Caucasian 73.9% 76.6% 78.4% 77.1% 71.9% 76.1% 

Race: Unknown Race 70.6% 73.2% 79.5% 68.8% 70.9% 71.6% 

Total 74.5% 77.1% 78.4% 77.1% 72.9% 76.4% 

Note: Excludes participants with missing date of birth. 

Source: NCOA data

Exhibit 6.8 presents CDSMP completion rates by workshop type and location. Participants in 

workshops that offered an introductory Class Zero had slightly higher completion rates than 

other participants (75.8 percent compared to 74.7 percent) and the difference is statistically 

significant. Participants in Spanish language CDSMP (Tomando Control de su Salud) had slightly 

higher completion rates than participants in English language CDSMP (76.4 percent compared 

to 74.3 percent); the difference is also statistically significant.22 Despite the transportation 

challenges that many states reported in rural areas, participants enrolled in workshops outside 

of metro areas had slightly higher completion rates than participants attending workshops in 

metro areas (75.8 percent compared to 74.4 percent); the difference is statistically significant.

 

22 It is important to note that in the NCOA data, English language CDSMP refers to all workshops conducted in any 

language other than Spanish. Therefore, workshops conducted in Farsi, for instance, are categorized into the 

general English language CDSMP.

IMPAQ International, LLC Page 61 CDSMP Process Evaluation Final Report
Exhibit 6.8. CDSMP Completion Rates by Workshop Type and Location

Workshop Type or Location Category Value / Completion Rate Difference: Completion Rate 

(%)

Class Zero Yes: 75.8%; No: 74.7% 1.1%**

Language English: 74.3%; Spanish: 76.4% -2.1%***

Location/Geography Metro: 74.4%; Non-Metro: 75.8% -1.4%***

Note: Includes all participants.

(*), (**), and (***) denote the 5%, 1%, and 0.1% level of significance, respectively, for the difference in 

completion rates between the two values of the variables. Lower levels of significance indicate stronger test 

results.

The calculations for Class Zero exclude workshops for which the information is unavailable. The calculations for 

Location/Geography exclude workshops for which the information is unavailable. Metro and non-metro 

designations are calculated using data from NCHS and USDA ERS.

Source: NCOA data

Exhibit 6.9 shows completion rates by the type of implementation site. The tests of statistical 

significance for Exhibit 6.9 are provided in Table E of Appendix H. For both age groups, the 

completion rates are the highest for faith-based organizations. The completion rates are lowest

for workshops offered at health care organizations and residential facilities. These differences 

can be partially explained by the type of participants served at these locations. For example, 

health care organizations serve the youngest participants (average age of 61.8) and residential 

facilities serve the oldest participants (average age of 73.4). As shown in Section 6.3, 

completion rates are the lowest for the very young and very old, which is consistent with the 

finding here. Additionally, health care organizations serve the largest proportion of males (33 

percent) compared to other implementation sites (24 percent on average), and as shown in 

Section 6.3, males have lower completion rates than females. Finally, there is not enough 

evidence to suggest that the differences in completion rates among different types of sites are 

due to the differences in average number of chronic conditions. 

IMPAQ International, LLC Page 62 CDSMP Process Evaluation Final Report
Exhibit 6.9. CDSMP Completion Rates by Type of Implementation Site

Type of 

Implementation 

Site

Number of 

Workshops

Number of

Participants

Under Age 

60

Number of

Completers

Under Age 

60

Completion 

Rate (%)

Under Age 

60

Number of 

Participants

Age 60+

Number of

Completers

Age 60+

Completion 

Rate (%)

Age 60+

Area Agency on 

Aging 368 1,022 782 76.5% 3,167 2,486 78.5%

Faith-based 

organization 651 2,073 1,631 78.7% 5,706 4,547 79.7%

Health care 

organization 1,799 7,010 4,860 69.3% 12,478 9,067 72.7%

Residential 

facility 1,314 7,765 1,429 71.2% 14,160 9,859 69.6%

Senior center 1,738 2,008 1,655 76.4% 18,848 14,383 76.3%

Other* 1,879 2,165 6,073 78.2% 13,459 10,212 75.9%

Total 7,749 22,043 16,430 74.5% 67,818 50,554 74.5%

*Organizations grouped under “other” category include county health departments, educational institutions, 

libraries, multi-purpose social services organizations, recreational organizations, tribal centers, workplaces, and 

other unspecified locations.

Note: Excludes participants with missing date of birth.

Source: NCOA data

Exhibit 6.10 shows CDSMP completion rates by participant age and chronic condition. When 

enrolling in CDSMP, participants are asked to indicate which chronic condition(s) they have 

from the list shown in Exhibit 6.10. Participants reporting arthritis/rheumatic disease, diabetes, 

hypertension/high blood pressure, or osteoporosis had higher average completion rates than 

participants who did not report having those conditions and the differences were statistically 

significant. The differences were not always significant when broken down by age categories, 

however. Having cancer, heart disease, breathing/lung disease, or stroke had no significant 

effect on completion rates. Participants who reported having depression or anxiety disorders 

had lower average completion rate (74.0 percent) than participants who did not have 

depression or anxiety disorders (77.2 percent) and the difference is statistically significant. 

Generally, completion rates for each chronic disease was slightly higher for participants aged 

65-74 and then declined for those in the 75-84 and 85 and older age groups.

IMPAQ International, LLC Page 63 CDSMP Process Evaluation Final Report
Exhibit 6.10. CDSMP Completion Rates by Chronic Condition

Age 

Group

Arthritis/

Rheumatic 

Disease

Arthritis/

Rheumatic 

Disease

Diff. Cancer Cancer Diff.

Depression 

or Anxiety 

Disorder

Depression 

or Anxiety 

Disorder

Diff. Diabetes Diabetes Diff. Heart 

Disease

Heart 

Disease Diff.

Age 

Group

Yes No Diff. Yes No Diff. Yes No Diff. Yes No Diff. Yes No Diff.

<60 73.1% 75.1% -2.0*** 72.7% 74.6% -1.9 71.8% 75.9% -4.1*** 74.6% 74.5% 0.1 75.3% 74.5% 0.8

60-64 77.3% 76.9% 0.4 78.8% 77.0% 1.8 75.4% 77.9% -2.5** 78.1% 76.6% 1.5 76.6% 77.2% -0.6

65-74 78.5% 78.4% 0.1 78.1% 78.5% -0.4 76.3% 79.0% -2.7*** 78.8% 78.3% 0.5 78.0% 78.6% -0.6

75-84 78.0% 75.9% 2.1*** 77.5% 77.0% 0.5 75.2% 77.4% -2.2** 78.2% 76.7% 1.5* 77.3% 77.0% 0.3

85+ 74.9% 70.6% 4.3*** 74.0% 72.8% 1.2 71.3% 73.1% -1.8 74.0% 72.7% 1.3 73.7% 72.6% 1.1

Total 76.9% 76.0% 0.9*** 76.8% 76.4% 0.4 74.0% 77.2% -3.2*** 77.3% 76.1% 1.2*** 76.7% 76.4% 0.3

Age 

Group

Hypertension/ 

High Blood 

Pressure

Hypertension/ 

High Blood 

Pressure

Diff.

Breathing/

Lung 

Disease

Breathing/ 

Lung 

Disease

Diff. Osteoporosis Osteoporosis Diff.

Other 

Chronic 

Condition

Other 

Chronic 

Condition

Diff. Stroke Stroke Diff.

Age 

Group

Yes No Diff. Yes No Diff. Yes No Diff. Yes No Diff. Yes No Diff.

<60 75.1% 74.2% 0.9 73.4% 74.8% -1.4 75.2% 74.5% 0.7 72.7% 75.6% -2.9*** 73.1% 74.6% -1.5

60-64 78.9% 75.3% 3.6*** 77.1% 77.2% -0.1 78.4% 77.0% 1.4 76.6% 77.4% -0.8 77.8% 77.1% 0.7

65-74 78.9% 78.0% 0.9 77.6% 78.7% -1.1 79.7% 78.2% 1.5 79.8% 77.9% 1.9*** 76.6% 78.6% -2.0

75-84 78.5% 75.5% 3.0*** 77.2% 77.1% 0.1 78.6% 76.8% 1.8* 78.2% 76.8% 1.4 77.7% 77.1% 0.6

85+ 74.5% 71.3% 3.2*** 74.5% 72.7% 1.8 75.1% 72.4% 2.7* 72.8% 73.0% -0.2 72.6% 73.0% -0.4

Total 77.7% 75.3% 2.4*** 76.1% 76.5% -0.4 78.1% 76.2% 1.9*** 76.2% 76.5% -0.3 76.1% 76.5% -0.4

Note: Excludes participants with missing date of birth. Many participants report more than one chronic condition; therefore completion rates are not isolated 

and may contain some overlap across chronic conditions.

Diff. = Difference in completion rate (%) 

(*), (**), and (***) denote the 5%, 1%, and 0.1% level of significance, respectively, for the difference in completion rates between those who reported having the 

specified chronic condition and those who did not report having the chronic condition. Lower levels of significance indicate stronger test results.

Source: NCOA data

IMPAQ International, LLC Page 64 CDSMP Process Evaluation Final Report
Exhibit 6.11 shows CDSMP completion rates by number of reported chronic conditions for all 

participants. Participants reporting having no chronic conditions had the lowest completion 

rate (65 percent) consistent with findings in Exhibit 6.10. The tests of statistical significance for 

Exhibit 6.11 are provided in Appendix H, Table F. The differences between not having a chronic 

condition and having at least one are statistically significant. 

Exhibit 6.11. CDSMP Completion Rates by Number of Reported Chronic Conditions

Total Number of 

Reported Chronic 

Conditions

Total Number

of Participants

Completion 

Rate

0 16,839 65.2%

1 18,145 76.2%

2 or 3 35,283 77.1%

4 or 5 15,869 76.7%

6 or more 3,725 75.0%

Note: Includes all participants.

Source: NCOA data

Stanford’s Program Fidelity Manual23 encourages an “ideal group size of 10-16 participants” 

and “at least 10 [participants] on the first day of the workshop.” Exhibit 6.12 shows completion 

rates by the number of participants enrolled in the workshop. Workshops with 5 or fewer

participants or 5-6 participants had the highest completion rates (76.0 percent and 78.0

percent respectively). The regression analyses presented in Section 6.3—which examine the 

impact of multiple factors on completion rates, such as participant characteristics, workshoprelated information, metro/nonmetro location, and differences in program administration or 

funding—support this finding. The regression models indicate that the odds of completion in 

workshops with less than 6 participants were about 46-57 percent higher than in the “ideal” 

workshops of 11-16 participants. Greater camaraderie and peer pressure combined with 

possibly more individualized attention from the leaders in a small group may explain why 

smaller groups experienced the highest completion rates. This is an area for further research.

 

23 Stanford University. Program Fidelity Manual: Stanford Self-Management Programs, 2010.

IMPAQ International, LLC Page 65 CDSMP Process Evaluation Final Report
Exhibit 6.12. CDSMP Completion Rates by Workshop Enrollment

Note: Includes all participants

Source: NCOA data

Exhibit 6.13 shows completion rates by workshop enrollment and workshop location (metro 

versus non-metro areas). Across all categories of workshop enrollment, except for workshops 

with 9-10 participants, completion rates were higher for participants attending classes in nonmetro areas. The differences between completion rates in metro and non-metro locations 

(excluding “unknown” locations) are statistically significant at the 0.1 percent significance level 

for class size of 13-14 participants. The differences for remaining class sizes are insignificant.

IMPAQ International, LLC Page 66 CDSMP Process Evaluation Final Report
Exhibit 6.13. CDSMP Completion Rates by Workshop Enrollment and Workshop Location

Note: Includes all participants. 

Source: NCOA data; Metro and non-metro designations are calculated using data from NCHS and USDA ERS

Exhibit 6.14 examines patterns of attendance and completion rates for CDSMP participants.

More than 80 percent of completers (i.e., those who attended four or more of the six workshop 

sessions) during the funding period participated in at least five of the six workshop sessions. 

Among the completers that participated in exactly four sessions, the most common pattern of 

attendance was participating in the first four sessions. About 36 percent of non-completers 

stopped attending workshops after the first session. The second and third most common 

patterns for non-completers were discontinuing after the second session (16.7 percent) and 

discontinuing after the third session (8.5 percent). This finding points to a need to better 

understand why some people do not continue attending after a single session. For example, are 

there ways to make sure that participants understand the nature of the class before enrolling, 

or are there barriers for those attending the first class that could be discussed and reduced 

(e.g., setting up car pools) for the remaining classes? 

IMPAQ International, LLC Page 67 CDSMP Process Evaluation Final Report
Exhibit 6.14. CDSMP Workshop Participation Patterns 

Patterns for Completers Patterns for 

Completers

Patterns for 

Completers Patterns for Non-Completers

Patterns for 

NonCompleters

Patterns for 

NonCompleters

Patterns Number of 

Completers

Percent of 

Total 

Completers

Patterns

Number of 

NonCompleters

Percent of 

Total NonCompleters

Participates in all 6 workshops 31,828 47.5% Participates in 1st workshop 8,121 35.5%

Misses last workshop 3,957 5.9% Participates in 1st and 2nd workshops 3,825 16.7%

Misses 4th workshop 3,893 5.8% Participates in 1st, 2nd, and 3rd workshops 1,955 8.5%

Misses 3rd workshop 3,845 5.7% Participates in 2nd workshop 1,875 8.2%

Misses 5th workshop 3,829 5.7% Participates in 1st and 3rd workshops 802 3.5%

Misses 1st workshop 3,686 5.5% Participates in 2nd and 3rd workshops 726 3.2%

Misses 2nd workshop 2,698 4.0% Participates in 1st, 2nd, and 4th workshops 706 3.1%

Misses last 2 workshops 2,655 4.0% Participates in 1st, 3rd, and 4th workshops 408 1.8%

Misses 4th and 6th workshops 1,160 1.7% Participates in 2nd, 3rd, and 4th workshops 389 1.7%

Misses 4th and 5th workshops 1,037 1.5% Participates in 3rd workshop 343 1.5%

All other patterns 968 12.3% All other patterns 3,630 16.0% 

Total 66,984 100.0% Total 22,877 100.0% 

Source: NCOA data

IMPAQ International, LLC Page 68 CDSMP Process Evaluation Final Report
As shown in Exhibit 6.15, the cost in grant dollars per CDSMP participant and per completer can 

vary from one state to the next. The average cost in grant dollars per participant for the 22 

state grantees listed in Exhibit 6.15 was $337.01 and the average cost in grant dollars per 

completer was $450.63. These are the states that completed their projects during the original 

ARRA grant period (March 31, 2010, to March 30, 2012) and did not request no-cost extensions. 

It is important to note that the estimates in Exhibit 6.15 are based on a simple calculation—i.e., 

the amount of the state’s ARRA grant award divided by the number of participants/completers. 

Consequently, the estimates do not take into account other revenue received or in-kind 

support contributed by partners and volunteers. Nor do the estimates differentiate costs for

start-up and infrastructure building from the direct and indirect costs incurred in providing 

CDSMP workshops or the costs of doing special evaluation studies or other activities to help 

sustain the programs. 

Exhibit 6.15. Costs Per Participant and Completer by State Grantee, 

April 2010 to March 2012* 

Cost Per Participant Cost Per Participant Cost Per Participant

$100 – $299 $300 - $499 $500+ 

Alaska 

California 

Florida 

Idaho

Illinois 

Maine 

Missouri

New Mexico

Utah

Vermont

Arizona

Arkansas 

Colorado

Connecticut

Georgia

Maryland 

Massachusetts

Nebraska 

New Hampshire

Nevada 

Louisiana 

West Virginia

Cost per Completer Cost per Completer Cost per Completer

$100 – $299 $300 - $499 $500+ 

Alaska 

California 

Florida 

Idaho

Utah

Vermont

Arizona

Illinois 

Maine 

Maryland 

Missouri

New Mexico

Arkansas 

Colorado

Connecticut 

Georgia

Louisiana 

Massachusetts

Nebraska 

Nevada 

New Hampshire

West Virginia

*Excludes the 23 state grantees that received no-cost extensions to their ARRA grants.

Cost per participant = number of participants (<60 and 60+) / amount of ARRA grant

Cost per completer = number of completers (<60 and 60+) / amount of ARRA grant

Source: NCOA data and AoA

IMPAQ International, LLC Page 69 CDSMP Process Evaluation Final Report
6.3 Regression Analysis of Completion Rates

Upon completion of the analysis of completion rates in the preceding section, the evaluation 

team conducted regression analyses to attempt to explain the variation in completion rates by 

observable factors, such as participant characteristics, workshop-related information, and 

differences across states (e.g., how the programs are administered). Section 6.2 discusses 

differences in completion rates by factors such as age, sex, and race/ethnicity of the 

participant, the location of the workshop (e.g., metro vs. non-metro), and participants’ chronic 

conditions. In this section, we examine multiple factors together that might influence 

completion. We conducted a logistic regression analysis using participant-level data to 

investigate the effect of a variety of explanatory (or predictor) variables.24 This analysis was 

conducted using data reported to NCOA by ARRA state grantees on CDSMP workshops 

conducted during the period April 1, 2010, through March 30, 2012, and on the participants

and leaders involved in those workshops. The list of explanatory variables includes:

 Demographic information derived from participant characteristics, such as age, sex, 

and race/ethnicity;

 Health information, such as chronic conditions reported by the participant;

 Derived variables related to the implementation site, workshop, and leaders offering 

the workshop;

 External data not directly available in the NCOA data, such as type of lead agency in 

the state, program oversight and delivery model, and location of the workshop.

For the regression analysis, we constructed two datasets. In the first dataset, we included all 

89,861 participants and 7,749 workshops in the NCOA data even when some key information 

was missing—i.e., we included all observations even when (1) participants did not provide their 

sex, age (or date of birth), race/ethnicity, or living arrangements; (2) Class Zero information for 

the workshop was missing; or (3) “metro/non-metro” assignment for the implementation site 

was unavailable. Consequently, our analyses that use the full data compare “known” attributes 

to the “unknown” ones for some of the variables. For example, the odds of completion for 

males and females are compared to participants of “unknown” sex.25 In a second restricted 

dataset with 51,893 participants and 5,302 workshops, we removed observations if any of the 

information listed above is missing or unavailable. In this dataset, the comparisons of odds of 

completion are between known attributes (e.g., males vs. females).26 

The results in Exhibit 6.16 provide odds ratios from the logistic regressions. The columns 

labeled Model 1 and 2 present findings based on the full dataset. Columns labeled Model 3 and 

 

24 For more details on logistic regression analysis, see Appendix J. 25 Note that the “unknown” attribute/value indicates a mixture of the known attributes. For example, when males 

or females are compared to the participants with “unknown” sex, each group is actually compared to a mixture of 

males and females that constitute the “unknown” category.

26 Note that the number of observations in the regressions will be different from the number of observations in the 

two datasets because of lagged variables.

IMPAQ International, LLC Page 70 CDSMP Process Evaluation Final Report
4 present findings from the restricted dataset. Models 2 and 4 incorporate variables for state 

oversight and delivery system structure.27 In Exhibit 6.16, a coefficient estimate that is greater 

(less) than 1 indicates that that variable increases (decreases) the odds of a participant 

completing the program. For example, an odds ratio of 1.25 indicates that the odds of a 

participant completing the program are 25 percent higher for a one-unit increase in the 

predictor variable. On the other hand, an odds ratio of 0.9 indicates that the odds of a 

participant completing the program are 10 percent lower for a one-unit increase in the 

predictor variable. Findings are summarized below. 

6.3.1 Demographic Characteristics

Results from the full dataset (Models 1 and 2) show that the odds of completion for male 

participants are about 9-10 percent lower than for the unknown group. However, the odds for 

female participants are not significantly different from the unknown group. Results from the 

restricted dataset (Models 3 and 4) show that the odds of completion for female participants 

are about 8 percent higher than for male participants.

 

With respect to race/ethnicity, we find in Models 1 and 2 that the odds of completion for all 

race/ethnicity groups are higher than the unknown race/ethnicity. Models 3 and 4 compare 

completion rates for non-white participants to completion rates for whites, which was 

designated as the benchmark (or comparison) race/ethnicity category for these analyses. 

Findings suggest that the odds of completion for African American participants are 

approximately 14-15 percent higher than for white participants. We also find that the odds of 

completion for Hawaiian Native/Pacific Islander participants are significantly higher (about 4.1-

4.7 times) than any other race/ethnicity in all models. We do not find significant differences 

between other races and white participants. Hispanic/Latino and Not Hispanic/Latino 

participants are more likely to complete compared to participants of unknown ethnicity 

(Models 1 and 2). However, Models 3 and 4 show no significant difference between the 

Hispanic/Latino and the Not Hispanic/Latino ethnic groups.

We also find significant differences between participants of different age groups. We find that 

the odds of completion for all age groups are significantly higher than for the participants in the 

unknown age group (Models 1 and 2). All models show that the odds of completion for the 65 - 

74 age group are the highest among all age groups, whereas the odds of completion are lowest 

for the 85+ age group. For example, Models 3 and 4—which compare completion rates for 

participants aged 60 and older to participants under age 60—indicate that the odds of 

completion for the 65-74 age group are about 18 percent higher than for the under 60 age 

group. The odds of completion for the 85+ age group are about 10 percent lower as compared 

to the under age 60 group.

 

27 Centralized oversight means that the majority of the responsibility is at the state level compared to models of 

oversight that rely relatively more on regional or local level of responsibility. Centralized delivery infrastructure

indicates that a state uses a centralized delivery system for communications or coordination as opposed to a 

decentralized infrastructure that relies more on regional, or local communications and coordination. See Chapter 5 

for more details on program oversight and delivery system infrastructure.

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Finally, our findings indicate that living arrangement does not influence the odds of completion 

in any of the models.

6.3.2 Health Status

We also consider the effect of chronic conditions reported by participants on workshop 

completion rates. Among the list of ten possible chronic conditions, we find that depression 

significantly lowers the odds of completion. The odds of completion for participants that report 

depression are approximately 17 percent lower than participants that do not report depression. 

We also find that the odds of completion increase for participants with hypertension (between 

7 and 13 percent) and osteoporosis (7 and 8 percent) in all models compared to participants 

that do not report any chronic conditions. We find that existence of other chronic conditions 

does not significantly affect the odds of completion. Even though having multiple chronic 

conditions appears to have a positive effect on completion rates in Models 1 and 2, this effect is 

no longer significant in Models 3 and 4.

6.3.3 Implementation Site, Workshop, and Leader Characteristics

We also investigated the effects of type and location of the implementation site, whether the 

workshop included a Class Zero, number of workshop participants, frequency of workshops 

offered by an implementation site, and frequency of leaders facilitating workshops on 

completion rates.28 

We find that the type of implementation site affects the odds of completion. Using residential 

facilities as the comparison group (or excluded type in the regressions), we find that the 

completion rates are the lowest in residential facilities and highest among faith-based 

organizations. 

All models consistently indicate that the odds of completion at health care organizations, senior 

centers, area agencies on aging, and faith-based organizations were about 12-14, 33-38, 34-42, 

and 57-64 percent, respectively, higher than residential facilities.29 

In Models 1 and 2, we found that the odds of completion for participants attending workshops 

at metro versus non-metro locations were approximately 20-22 and 35-38 percent, 

respectively, higher compared to workshops in unknown locations. When we compared 

workshops offered in metro areas versus non-metro areas in Models 3 and 4, the odds of 

completion are about 9 percent lower in metro areas. 

 

28 Each workshop is given by two leaders. 29 Remaining types of organizations that were grouped together under an “other” category were county health 

departments, educational institutions, libraries, multi-purpose social services organizations, recreational 

organizations, tribal centers, workplaces, and other unspecified locations.

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In Models 1 and 2, we find that the odds of completion in workshops that did not offer Class 

Zero are about 9 percent lower than in workshops for which the availability of Class Zero was 

unknown.30 The removal of these unknowns in Models 3 and 4 results in a slightly positive 

effect for workshops that offer Class Zero. However, it is statistically significant only in Model 3, 

implying an increase of approximately 7 percent in the odds of completion compared to 

workshops that did not offer Class Zero. Recall that the review of participation patterns (i.e., 

Exhibit 6.14 disaggregated by whether or not Class Zero was offered) did not provide evidence 

for differences between workshops that offer Class Zero and those that do not. Given 

contradictory results across the four models, we conclude that completion rates do not differ 

between workshops that offer Class Zero and those that do not. Our analysis of the impact of 

Class Zero on completion rates (Exhibit 6.8), which did not control for all other potential factors, 

indicated slightly higher completion rates for workshops with Class Zero. Hence, additional 

research might shed light on which populations and in which situations CDSMP participants 

benefit most from Class Zero, thus providing guidance to state grantees on when it is most 

beneficial to offer it. 

To investigate the influence of workshop size (defined as the number of participants), we 

created five size categories: (1) less than 6 participants, (2) 6 to 10 participants, (3) 11 to 16 

participants, (4) 17 to 20 participants, and (5) 21 participants or more. In Models 1 and 2, we 

analyzed the effect of workshop size using the “11 to 16 participants” category as the 

comparison group because the CDSMP fidelity manual recommends this as the “ideal” group 

size.31 We did not find any significant difference between workshops with 11-16, 17-20, and 21 

or more participants across all four models. However, the odds of completion in workshops 

with less than 6 participants were about 44 percent higher compared to workshops with 11-16 

participants. While Models 1 and 2 indicate that the odds of completion in workshops with 6–

10 participants is about 5 percent higher than in workshops with 11–16 participants, this finding 

does not hold in Models 3 and 4.

We also analyze the effect of implementation sites convening prior workshops as a proxy for 

implementation site experience, as well as the experience of the leaders. We find a positive but 

insignificant effect for implementation site experience (measured as the number of workshops 

offered at the site prior to the quarter in which the workshop the participant attended was 

held) in Models 1, 2, and 3. Similarly, Model 4 indicates that the odds of completion improve 

only slightly with implementation site experience (less than 1 percent and significant). 

Convening a workshop at the same implementation site in the previous quarter does not have a 

significant effect on the odds of completion.

Models 1 and 2 indicate that the number of workshops taught by the two leaders (i.e., 

cumulative leader experience) slightly decreases the odds of completion (about 1 percent and 

significant). However, this does not hold for Models 3 and 4. Two related factors positively 

 

30 The data on Class Zero are not available for about 24 percent (1,823 out of 7,749) of the workshops 31 Stanford Patient Education Research Center. Program Fidelity Manual: Stanford Self-Management Programs, 

2010. See page 20.

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affect the odds of completion: (1) if at least one of the leaders was active (i.e., taught a 

workshop) in the previous quarter, and (2) if the two leaders previously taught a workshop 

together. In all models, the odds of completion increased by about 5-7 percent if at least one of 

the leaders taught a workshop in the previous quarter and by about 7-8 percent if the two 

leaders previously taught a workshop together.

Finally, we find that the odds of completion are significantly higher in Spanish language CDSMP 

workshops (Tomando Control de su Salud) compared to English language workshops. Models 1 

and 2 indicate that the odds of completion are approximately 19-20 percent higher in Spanish 

workshops compared to 45-46 percent in Models 3 and 4.

6.3.4 Grantee Characteristics

When the recipient of ARRA grant funding was the public health agency, the odds of 

completion were about 17-18 percent lower in Models 1 and 2 and about 13 percent lower in 

Models 3 and 4 compared to states in which the state unit on aging was the recipient of grant 

funding. But, it is important to note that this may not be a reflection on the grantee type, rather 

it may reflect the different types of populations served by each grantee type.

The odds of completion in states with centralized oversight and/or a centralized delivery system 

increase by about 9-18 percent. 

6.3.5 Trend and Seasonal Factors

We did not find significant differences in completion rates across time (captured by a trend 

variable covering eight quarters). However, the quarter in which the workshop is offered affects 

the odds of completion. In all four models, the odds of completion in the fourth quarter 

(October-December) workshops are about 8 percent lower than the first quarter (JanuaryMarch) workshops, which we use as the comparison time frame. In the first two models, the 

odds of completion are 7 percent higher for the second quarter (April-June) workshops than for 

the first quarter (January-March) workshops. We do not find a statistically significant effect for 

the third quarter (July-September) workshops compared to the first quarter workshops.

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Exhibit 6.16. Logit Regression Results

Demographic Characteristics of 

Participants Model 1 Model 2 Model 3 Model 4

Female 0.986 0.965 1.084** 1.082**

Male 0.919* 0.901* - -

White 1.435*** 1.457*** - -

African American 1.621*** 1.643*** 1.143*** 1.148***

American Indian / Alaskan 1.181* 1.199* 0.892 0.892

Asian / Asian American 1.477*** 1.501*** 0.945 0.949 

Native Hawaiian / Pacific Islander 4.494*** 4.720*** 4.136*** 4.274***

Multi-racial / Other 1.422*** 1.425*** 1.104 1.089

Age 60 - 64 1.596*** 1.618*** 1.149*** 1.149***

Age 65 - 74 1.700*** 1.718*** 1.178*** 1.175***

Age 75 - 84 1.586*** 1.600*** 1.126*** 1.123**

Age 85+ 1.325*** 1.341*** 0.905* 0.904*

Age under 60 1.423*** 1.442*** - - 

Hispanic or Latino 1.342*** 1.338*** 0.985 0.993

Not Hispanic or Latino 1.154*** 1.139*** - -

Living alone 0.647 0.647 1.041 1.043

Living with someone 0.641 0.642 - -

Chronic Conditions Reported by 

Participants Model 1 Model 2 Model 3 Model 4

Arthritis 1.013 1.015 1.029 1.032 

Cancer 0.989 0.990 1.030 1.31

Depression 0.830*** 0.832*** 0.818*** 0.820***

Diabetes 1.022 1.023 1.008 1.009

Heart Disease 0.996 0.996 1.013 1.012

Hypertension 1.075*** 1.077*** 1.129*** 1.131***

Lung Disease 0.970 0.970 0.983 0.985 

Stroke 0.960 0.961 0.969 0.972

Other chronic disease 1.030 1.034 1.031 1.030

Osteoporosis 1.076** 1.075** 1.074* 1.076* 

Multiple chronic diseases 1.080** 1.081** 1.028 1.029 

Implementation Site, Workshop, 

and Leader Characteristics Model 1 Model 2 Model 3 Model 4

Site: Senior center 1.331*** 1.319*** 1.381*** 1.378***

Site: Health care organization 1.124*** 1.125*** 1.135*** 1.132***

Site: Faith-based organization 1.569*** 1.574*** 1.633*** 1.639***

Site: Area agency on aging 1.335*** 1.351*** 1.401*** 1.424***

Site: Other 1.420*** 1.415*** 1.441*** 1.445***

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Implementation site in metro 

area 1.201* 1.223* 0.915** 0.911***

Implementation site in nonmetro area 1.348*** 1.376*** - - 

Workshop offered Class Zero 0.956 0.938* 1.072* 1.052

Workshop did not offer Class 

Zero 0.914*** 0.914*** - - 

Less than 6 participants 1.440*** 1.440*** 1.536*** 1.537***

6 - 10 participants 1.051* 1.050* 1.014 1.012

17 - 20 participants 0.982 0.979 0.970 0.970

More than 20 participants 0.729 0.724 - -

Number of workshops convened 

by implementation site prior to 

quarter in which workshop was 

held 1.001 1.003 1.008 1.010*

Implementation site offered a 

workshop in the prior quarter 1.047 1.056 1.044 1.051

Cumulative number of workshops 

taught by both leaders in prior 

quarters 0.995* 0.995* 0.998 0.998 

At least 1 leader taught a 

workshop in the prior quarter 1.050* 1.051* 1.068* 1.069* 

Leaders previously taught at least 

one workshop together 1.067** 1.067** 1.075* 1.077*

Spanish CDSMP 1.192*** 1.199*** 1.450*** 1.457***

State Characteristics Model 1 Model 2 Model 3 Model 4

Lead agency - Public Health 0.831*** 0.824*** 0.872*** 0.876***

Both Oversight and Delivery 

Infrastructure centralized - 1.088* - 1.149**

Oversight centralized but Delivery 

Infrastructure not - 1.176*** - 1.157***

Delivery Infrastructure 

centralized but Oversight not - 1.150*** - 1.123**

Trend and Seasonal factors Model 1 Model 2 Model 3 Model 4

Trend 1.003 1.002 0.994 0.992

Workshop in Q2 (April-June) 1.065* 1.067** 1.012 1.012

Workshop in Q3 (July-September) 1.027 1.029 1.018 1.020

Workshop in Q4 (OctoberDecember) 0.919*** 0.919*** 0.916** 0.917** 

N 82,598 82,598 49,853 49,853

Reported coefficients are exponentiated coefficients (odds ratios).

Significance level: (*) p-value < 5%; (**) p-value < 1%; (***) p-value < 0.1%

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6.4 Summary and Discussion 

The analyses presented in Sections 6.2 and 6.3 confirm findings from site visits and state 

discussions in some cases, but offer unexpected findings on other fronts. As expected, females 

are more likely to complete workshops than males, pointing to the need for targeted 

interventions for males. Among the different race/ethnicity groups, African Americans were 

more likely to complete the program, as were the “young old” (i.e., individuals aged 65-74). In 

order to reach individuals most likely to benefit from CDSMP, state grantees may wish to 

specifically target these groups in their outreach efforts and choose program sites that are 

accessible to and/or frequented by these populations (e.g., faith-based organizations in the 

African American community). 

Participants in the Spanish language CDSMP had higher completion rates than participants in 

English language CDSMP. However, it is important to note that English language courses include 

all non-English speaking groups with the exception of Spanish speakers; this factor could be 

lowering completion among English language courses. Also, cultural elements in the Spanish 

language CDSMP specific to this population may be having a positive effect on completion 

rates; differences in the Spanish CDSMP curriculum should be examined.

It was no surprise that individuals with depression had lower completion rates; however, those 

reporting hypertension and osteoporosis had greater odds for completion, suggesting that 

targeting these populations could have a high pay-off. Unexpectedly, individuals in non-metro 

areas had higher completion rates even though weather and transportation can pose serious 

barriers to program participation. And the quarter in which a workshop is conducted (i.e., as a 

proxy for season of the year) can make a difference in completion rates. As one might expect, 

participants in workshops with leaders who taught a workshop in the previous quarter or with 

leaders who had taught together previously had higher odds of completion. With regard to 

Class Zero, additional research might shed light on which populations and in which situations 

CDSMP participants benefit most.

States with public health as the lead agency had somewhat lower completion rates. Perhaps 

the most unexpected finding was that participants in smaller workshops (i.e., with no more 

than 5-6 participants) had significantly higher completion rates even though workshops of this 

size are smaller than the recommended workshop size described in Stanford’s program fidelity 

guidelines.

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CHAPTER 7: DATA COLLECTION AND EVALUATION 

Research Question: What data are AoA/ACL CDSMP grantees collecting and what is the state of 

their records systems? What is the evaluation capacity of state-level grantees and/or local sites 

including whether they have conducted or participated in program evaluations?

Key Findings

1. While grantees largely used paper forms to collect data that were later entered into the NCOA data 

base to track required grant data, they used a wide array of approaches to collect additional data on 

CDSMP participants. All grantees were able to collect and submit program data. Some used basic 

commercially available software such as Excel or Access, while others developed or expanded data 

collection programs used by state agencies, contracted organizations or host sites. Data collection 

activities were conducted by program staff funded by the CDSMP grant or integrated as part of other 

grantee infrastructure for CDSMP or other programs.

2. More than half (31 of 47) of grantees reported using CDSMP data required under the ARRA grant, often 

supplemented with other primary and secondary data on programs, for program management or 

process evaluation, and 17 grantees reported conducting special studies of health outcomes, cost or 

utilization. Grantees often conduct process evaluation of participant (and sometimes workshop leader) 

satisfaction, with 3-, 6- and 12-month follow up after completion of the workshops. Even states collecting 

data for NCOA only were able to use information for program planning, e.g., to target need for leader 

training and to target populations and locations for workshops.

3. Several grantees reported partnering with universities to conduct rigorous research studies. Grantees’ 

studies use many different types of measures, and are starting to build a research base for CDSMP as 

implemented at the state and local levels. Measures address changes in functional status, health care 

utilization, cost and clinical indicators. 

4. Grantees reported various benefits of data collection and reporting, including program planning and 

oversight, program improvement, and reporting to stakeholders. Some grantees and host sites have 

incorporated evaluation into their aging and public health programs. Data collection and monitoring 

require funding to support. Not all states are able to continue these activities post ARRA funding. 

7.1 Introduction

An important focus of the process evaluation is to assess the data collection, reporting, and 

evaluation capacity of state grantees and host sites, and to understand their ability to support 

reporting requirements for CDSMP during and after the ARRA funding period. During the grant 

period, state grantees were required to report information on CDSMP participants, workshops, 

and leaders to an online data entry system developed and maintained by NCOA. However, 

grantees are no longer obligated to report data when their funding comes to an end.

The evaluation team’s interest in data collection and evaluation was initially directed to 

assessing the capacity of state grantees to participate in an outcome evaluation. However, in 

early 2012 AoA decided not to move forward with a prospective outcome evaluation based on 

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the recommendations of the Technical Advisory Group. Nonetheless, AoA and the evaluation 

team determined that it was important to assess the capacity of grantees and host sites to 

collect and use data for program planning, monitoring, and quality assurance. The evaluation 

team, therefore, examined whether and to what extent grantees and host sites used data for 

these purposes and their plans for continuing to collect program data after the ARRA grant 

came to an end. In addition, the evaluation team investigated the extent to which grantees 

were conducting evaluations of their programs or other special studies. 

Until now, information about the capacity of CDSMP grantees and their partners to collect and 

use program data has been limited, as is information on the research conducted by grantees, 

e.g., research questions addressed, measures used in the field, study findings, and data use for 

program implementation and management. Sharing information about these topics can inform 

grantees’ efforts by grantees to develop and bring to scale their CDSMP programs. 

Principal data sources were state profiles on data collection capacity developed from the site 

visits and telephone discussions with representatives from each of the 47 ARRA grantees, 

grantee progress and final reports, and listings of grantee evaluation activities compiled by AoA 

and NCOA. A detailed table of grantees’ data collection and evaluation efforts is included in 

Appendix K. 

7.2 Findings

At a minimum, ARRA grantees were required to collect the following information: 

 The number of participants in CDSMP

 The age, sex, and self-identified race, ethnicity, and chronic conditions of each 

participant

 The number of workshop sessions actually attended by each participant (out of a 

total of six sessions) 

 Feedback from participants on their experience and self-reported outcomes32 

Grantees were also required to carry out program monitoring and evaluation activities in a way 

that will allow for continuous quality improvement at both the state and community level. This 

included ensuring fidelity to the Stanford model standards and tracking the measurable 

indicators described above. 

The evaluation team examined grantees’ data collection capacity, data reporting and use, 

evaluation efforts and their post-ARRA plans regarding continuation of data collection and 

 

32 American Recovery and Reinvestment Act Communities Putting Prevention to Work Chronic Disease SelfManagement Program, Program Announcement for Cooperative Agreements, Application Instructions and Forms. 

U.S. Administration on Aging, December 16, 2009. 

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reporting, including plans for submission of program data to NCOA’s database. Findings are 

presented below, with a focus on grantees activities at the time of ARRA funding, changes 

anticipated at completion of ARRA funding, and future plans.

7.3 Data Collection under ARRA Funding

All grantees were required to collect and submit core information on their program participants 

and performance for submission to NCOA’s database. All 47 grantees were able to comply with 

this requirement, but used a wide range of approaches to collect additional data from host sites 

and partners in their distribution networks (see Appendix K). Some grantees used centralized 

data collection where host sites and/or implementation sites submitted paper forms or Excel 

spreadsheets to a program coordinator at the state level who entered the data into the NCOA 

database. Other grantees used a decentralized approach where specified individuals at the 

regional and/or local level were responsible for entering data into the NCOA database, with the 

state providing oversight for quality assurance.

7.3.1 Data Collection Strategies: State Grantees

State grantees used a range of staffing and technical arrangements to support data collection 

activities, reflecting CDSMP program size, complexity, and the availability of state resources and 

infrastructure. For example:

 In Alaska, the program director—the state’s only designated CDSMP staff—collects 

and maintains, in an Access database, NCOA-required data and additional items 

used for evaluation, e.g., pre-post participant feedback, number of participant sick 

days/well days, trainer identification numbers, trainer certification/recertification 

dates. Information is also collected on clinical measures for diabetics (BMI, LDL, 

blood pressure, A1C at 3-, 6-, and 12-month follow-ups). 

 Oklahoma relies on the state’s in-house evaluation team to collect and maintain 

CDSMP data, and to conduct small participant surveys that address how participants 

find out about workshops, whether participants feel they are better able to deal 

with their conditions after taking the workshops, and how participants feel they 

have benefited with regard to enhanced capabilities. 

 Colorado requires sites providing ARRA-funded CDSMP to submit information 

through a data portal established by a non-profit partner, Consortium for Older 

Adult Wellness. This is in addition to submission of data for the NCOA database.

Most state grantees use CDSMP or other state staff to conduct and oversee data collection. 

However, two grantees—California and New York—contract with outside organizations for data 

collection and technical assistance. California contracts with Partners in Care Foundation (PICF), 

the state’s technical assistance provider for evidence-based programs, which monitors data 

from sites for fidelity. In New York, sites send their workshop data for review and data 

entry/management to the Quality and Technical Assistance Center (QTAC) at SUNY Albany, 

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which serves as the technical assistance arm of the state’s CDSMP program. The QTAC has 

developed a master database to enable collection and linkage of data across participants for 

research purposes. They are exploring options for a new online data entry system to improve 

ease of data collection and reporting.

Fourteen of the 47 state grantees collect only required the data elements. However, many 

states collect additional information for planning and research purposes, and may require more 

than one database. Two examples are Missouri and New Jersey:

 Missouri established a database for five evidence-based programs, including 

CDSMP, in 2008. Because the data used for each purpose were different and 

intended for different purposes, the state carried out dual data entry for CDSMP 

under the ARRA grant, entering data once for state purposes and again into the 

NCOA database. 

 New Jersey has a centralized database and used ARRA funds to develop a 

supplemental database to maintain information on where workshops are offered, 

and about peer leaders and master trainers. The state reports that it receives 

requests for data from partners and the Commissioner of Health and Human 

Services. A staff person, who devotes 80 percent of her time to collecting and 

reviewing data, supports these activities. New Jersey’s Office of Minority and 

Cultural Health maintains another database with demographics on participants with 

limited English proficiency.

7.3.2 Data Collection Strategies: Host and Implementation Sites

Host and implementation sites are on the front line for data collection on their workshops that 

the sites then submit to regional coordinators or state grantees, which in turn submit the data 

to NCOA’s database. Michigan has developed data collection forms that can be scanned 

electronically to minimize burden to sites providing CDSMP in the community. This approach 

enables the state to more efficiently obtain information from all sites that provide CDSMP 

across the state.

 

Most site-level respondents, while they were not queried directly on the topic, did not mention 

difficulties collecting and reporting data on workshops. However, a small number of 

respondents from the site visits and telephone interviews did note that meeting the CDSMP 

data requirements could be challenging in some settings. One grantee with oversight of a 

mature CDSMP network emphasized the difficulties data collection can pose for community 

programs, stating:

It [data collection] is time consuming, often confusing, very labor intensive, so the 

state is looking to identify essential elements to collect on an ongoing basis. 

Tomando [Control de su Salud] is especially difficult for data collection as staff 

must collect data one-on-one with participants, many of whom have limited 

Spanish (or English) literacy. 

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7.4 Data Use and Reporting

The process evaluation examined grantees’ use of data relating to their CDSMP programs with

particular attention to their use of required data elements, their collection and use of 

additional data, and whether and how grantees used data for their own program planning, 

monitoring and decision making. Data collected and used for state reporting is both qualitative 

and quantitative, and may incorporate surveys of participants and workshop leaders as well as 

administrative and secondary data sources.

Grantees varied widely in their use and reporting of CDSMP data. All 47 state grantees have 

been collecting and submitting participant and program data required by AoA to NCOA. 

Approximately one-third of grantees (14 of 47) reported collecting required data only, 31 

grantees reported some level of basic program management or process evaluation, and 17 

grantees reported conducting special studies including evaluation of health outcomes, cost or 

utilization (often in partnership with local universities (Exhibit 7.1). 

Exhibit 7.1. Data Use and Reporting

Source: IMPAQ International and Altarum Institute

7.4.1 NCOA-Required Data: State Grantees

Fourteen of the 47 state grantees report collecting only required data. While most just submit 

the data to the NCOA database, four of these grantees reported that they also combine the 

data with other information for planning and managing their CDSMP activities. 

14

31

17

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 Arkansas uses the NCOA-reported data with GIS mapping to review compliance with 

the “30/30 concept,” to ensure everyone in the state can access CDSMP within 30 

miles and within 30 days.

 Louisiana matches NCOA-reported data against survey data, including questions on 

substance use, and is exploring the utility of collecting data elements in addition to 

the NCOA-reported set. The state, with University of Louisiana-Monroe, has 

examined changes in participants’ health behavior, health status, health care 

utilization and costs; and qualitative information on program effectiveness with low 

income, rural, and African American populations. 

 Nebraska uses the NCOA-reported data internally for program review, shares the 

data with external partners, and engages a GIS specialist for data mapping. 

 Tennessee develops individual spreadsheets from NCOA-reported data for each 

ADRC, representing the areas they serve. This grantee requires implementation sites 

to telephone completers at 6- and 12-months following the workshops to administer 

a short survey about their ability to manage their chronic conditions. 

7.4.2 Program Management-Process Evaluation: State Grantees

An additional 31 states have included primary and secondary data from other sources and 

combine this with the NCOA-required data to conduct basic evaluation of their CDSMP 

operations and management. One example is the Maryland grantee and its partner, Towson 

University, which have added additional data elements to the required dataset to look for 

issues or gaps that may impede program delivery, and others that may make it more successful. 

This team is also conducting phone interviews with coordinators across the state to provide 

additional input to these assessment activities.

Program management evaluation approaches most frequently reported were participant 

satisfaction surveys, pre/post workshop surveys, and 3- and 6-month follow up surveys. 

Seventeen state grantees reported conducting pre/post surveys and/or follow up surveys. Most 

of these assessments are based on self reports of participants on knowledge and 

understanding, self-efficacy and health behavior changes. New Mexico reported using data on 

participant feedback, program reach, and completion for CDSMP program planning. The 

Georgia grantee has used survey questions from the CDC’s Behavioral Risk Factor Surveillance 

System and from nutrition classes offered apart from CDSMP workshops, delivered pre/post 

workshop and 6 months following completion, to assess their CDSMP workshops. 

Program administrative data describing numbers and locations of participants, workshop 

leaders and master trainers; workshop and training schedules; and other operational issues are 

sometimes analyzed and used to coordinate information across and within regions and 

statewide. This information can be made available online, as Arkansas has done, to facilitate 

information sharing. Program management evaluation also addressed fidelity issues. Currently, 

Georgia is piloting an approach for using evaluation data to refine its program fidelity. Michigan 

reported focusing program evaluation on fidelity issues using an online survey and phone and 
IMPAQ International, LLC Page 84 CDSMP Process Evaluation Final Report

face-to-face interviews. This evaluation has been conducted through a partnership with the 

Michigan State Geriatric Education Center.

7.4.3 Special Studies: State Grantees

Some grantees have initiated special studies of CDSMP that focus on unique populations or 

seek to provide information about program cost savings and impacts on health behaviors, 

health status, and utilization of health services. Seventeen grantees described studies of this 

type, often conducted in partnership with local universities. Most of these studies have been 

conducted independently, with each research team developing their own framework, measures 

and analyses. Many studies are currently in progress and have not yet produced final results; 

others have been completed and some, including studies conducted in Hawaii, already 

contribute to the growing evidence base about CDSMP.33 Example studies are highlighted 

below. Selected outcomes studies with findings to report are highlighted in the following 

section.

Exhibit 7.2. CDSMP Special Studies from Example States

State Special Studies

New Jersey In collaboration with the University of Medicine and Dentistry of New Jersey (UMDNJ) the 

state is moving forward with 3 studies aimed at different populations: (1) UMDNJ “SAVE 

Women and Men” related to New Jersey’s Cancer Education and Early Detection program, 

which will enroll 90 CDSMP participants and measure clinical outcomes; (2) UMDNJ is 

measuring outcomes in prisons where CDSMP has been conducted; and (3) an initiative at a 

Federally Qualified Health Center to examine integration of operations with data collection.

Texas The state recently completed a pilot study at a women’s prison and hopes to have a 

dedicated site for program delivery at the facility. The state also held a summit to discuss 

DSMP accreditation as a requirement for Medicare reimbursement. The state is conducting a 

pilot to demonstrate the ability to deliver DSMP and has identified Medicare partners 

including Federally Qualified Health Centers, a nursing school and a home health 

organization. (Methods and findings have not yet been reported.)

Vermont As part of a larger data collection effort in the “learning organization” of the state’s Blueprint 

for Health, the state collects and analyzes data on CDSMP. For many analyses Vermont has 

the ability to link CDSMP participation to clinical outcomes using electronic health records.

 

33 Tomioka M, Braun KL, Tanoue L. Adapting Stanford's Chronic Disease Self-Management Program to Hawaii's 

multicultural population. Gerontologist. 2012 Feb;52(1):121-32. Epub 2011 Jun 30. 

http://www.ncbi.nlm.nih.gov/pubmed/21719630. 

Tomioka M, Tom T, Higuchi P, Kidani S, Pendleton N, Yamashita B, Braun K. The Hawai'i Healthy Aging Partnership: 

partnership development - an investment for program success. Hawaii Journal of Public Health 2009 Vol. 2 No. 1 

pp. 20-31. http://hawaii.gov/health/hjph/Volumes/Volume2.1.pdf
IMPAQ International, LLC Page 85 CDSMP Process Evaluation Final Report

State Special Studies

West Virginia Through West Virginia University (WVU) and Marshall University, West Virginia has several 

studies underway. First, there is an outcomes study in progress based on the Ory model, 

which incorporated some questions from the Bureau of Public Health, as well as selfreported health, self efficacy, quality of life, communication, activities, pre-diabetes screen, 

pre-hypertension screen, cholesterol levels (all self-reported). They are training leaders to 

distribute the outcomes survey pre-class (so far 89 completions), a satisfaction survey at the 

end of the 6 week course and outcomes again at 3 and 6 month post program. Second, they 

are planning a leader survey to determine activity, barriers, needs, experiences and 

demographics (at this point, the survey has been drafted). Third, they are conducting 

telephone interviews of participants and non-participants by region, with proportional 

representation (CDSMP, DSMP, non-completers and completers). They aim to survey at least 

one participant per leader. At this point, the survey instrument is complete. In preparation 

for these efforts, this grantee restructured its ARRA grant to cover future data collection and 

pre-paid postage and made copies of data collection instruments to last for several months 

following the end of the grant. 

 Source: IMPAQ International and Altarum Institute

7.5 Evaluation Efforts

Several grantees have undertaken evaluation of CDSMP program outcomes that examine 

impacts of program participation on changes in health behaviors, health status, self-efficacy in 

managing chronic health conditions, utilization of medical care, cost and cost effectiveness. 

States that have initiated these studies, beyond basic submission of required data or program 

management monitoring and evaluation, typically have been in state agencies with more 

established infrastructure that have designated evaluation staff to support CDSMP or other 

aging or public health programs, or that have engaged in partnerships with local universities 

and their research groups. These evaluation activities are contributing to a growing evidence 

base about CDSMP as it is implemented in community settings, with older adults from diverse 

populations and settings. The research teams usually operate independently, and have 

generated considerable expertise and research supports, from measures and surveys to analytic 

approaches. Stanford University’s Patient Education Research Center has made available some 

basic suggestions for evaluating CDSMP in its “Primer for Evaluating Outcomes.”34 While many 

of the standard research approaches presented in the Primer appear to have been adopted 

(e.g., 3-, 6- and 12 month follow up), the extent to which grantees and their research teams rely 

on this resource is unclear. In fact, many teams have developed more detailed approaches and 

alternate methodologies (see Exhibit 7.4) to investigate their research questions.

Grantees and their research teams have examined pre/post and follow-up effects of workshop 

participation, with an eye to changes in participants’ knowledge, behavior, and perceived self 

efficacy. Research teams are examining both initial impacts of participation and longer term 

effects to assess whether and if participants experience longer term effects as a result of their 

participation in the workshops. Most studies use the conventional 3-, 6- and 12-month follow 

up periods and examine such items as satisfaction, self-reported patient health and social 

 

34 Lorig, K. and D. Laurent, “Primer for Evaluating Outcomes,” April 2007.
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behavioral measures. Grantees that report these measures generally find a statistically 

significant improvement among key measures related to self-efficacy and some measures of 

self-reported health status, particularly among participants with long-term chronic conditions. 

Grantees and partners with sophisticated data analytic resources were able to investigate 

CDSMP impacts on clinical outcomes such as BMI, Hemoglobin A1c, and measures of health 

status and functional abilities. The Alaska grantee has worked hard to implement clinical 

outcomes for diabetes patients enrolled in CDSMP programs with the most typical outcomes 

being changes in blood pressure and A1C hemoglobin levels- tangible evidence that the 

underlying conditions are being controlled. Alaska has implemented a case-control design to 

separate changes that may occur in participants due to other external factors and changes that 

occur directly due to program participation. Louisiana is seeking clinical partners in order to 

gauge CDSMP’s impact on health care utilization and cost, and to explore potential payment 

support from public and private payers. Although there have not been robust studies 

conducted with medical outcomes, a recent survey has shown statistically significant 

improvements for individuals dealing with diabetes in blood pressure and hemoglobin levels. 

7.5.1 Evaluation Partnerships

Resources to carry out a formal evaluation, both financial and technical, are not always 

adequate or available for evaluation at the state and local levels. To bridge the gap, some 

grantees partnered with local academic institutions to assist with evaluations. Twelve grantees 

reported partnering with universities for evaluation purposes. Due to different state capabilities 

and existing evaluation infrastructure, however, universities played different roles in facilitating 

evaluations. 

Some partnerships focused on developing tools that would ultimately lead to a more thorough 

evaluation: New Hampshire tapped the Dartmouth Prevention Research Center to establish a 

pre-post outcome survey that was later used to evaluate CDSMP across the state. Grantees also 

tapped university research centers to help evaluate CDSMP programs aimed at specific 

populations in non-traditional settings. New Jersey partnered with the University of Medicine 

and Dentistry of New Jersey to evaluate CDSMP as it was administered in prison settings. The 

Hawaii grantee partnered with the University of Hawaii to evaluate how the adaptation of 

CDSMP fared across different ethnic populations in the state. 

Grantees also partnered with universities to carry out detailed evaluations of program delivery 

and efficacy. Maryland partnered with Towson University and Massachusetts with the 

University of Massachusetts’ Donohue Institute to examine issues related to program delivery 

and process evaluation. Finally, Oregon partnered with Oregon State University to produce 

perhaps the most sophisticated CDSMP program evaluation to date. The report entitled 

“Program Impact Report: Oregon’s Living Well With Chronic Conditions” (available at 

http://public.health.oregon.gov/DiseasesConditions/ChronicDisease/LivingWell/Documents/Re

ports/statedata12.pdf) not only provides analysis of program participants’ change in four 

domains (health behavior, health status, self-efficacy, and health utilization), but the report also 
IMPAQ International, LLC Page 87 CDSMP Process Evaluation Final Report

provides sophisticated estimates such as the number of Quality Adjusted Life Years (QALYS)

35

the program has added for participants, and the cost savings of the program in reduced health 

utilization by participants (a brief summary of this research is provided in Exhibit 7.4). 

7.5.2 Evaluation Topics, Measures, and Findings

State-based program evaluations address a wide range of different topics and outcomes. 

Exhibit 7.3 summarizes the measures and outcomes respondents interviewed for the process 

evaluation identified for their studies.

 

35 The QUALY is an internationally recognized measure of the value of health outcomes that attempts to combine 

length of life and quality of life into a single index number.
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Exhibit 7.3. CDSMP Evaluation Measures and Outcomes: Grantees and Partners

Evaluation Measures and Outcomes

Clinical

 Body Mass Index

 LDL Cholesterol

 Blood pressure

 Hemoglobin A1c

 Health status 

 Health distress

 Levels of fatigue, pain, stress, sleep

Self-Reported

 Self-rated health status

 Self-reported physician visits

 Ability to cope with symptoms

 Physical activity

 Time spent engaging in stretching/strengthening and aerobic exercise

 Communication with physicians

Social-Behavioral

 Self efficacy

 Health behaviors

 Symptom Management

 Patient Activation Measures (PAMs)

 Social and role activity limitations

 Activities of Daily Living (ADLs)

Satisfaction

 Participant satisfaction

 Leader satisfaction

Health Care Utilization and Cost

 Health care utilization (physician services, ER visits)

 Health care costs

 Quality Adjusted Life Years (QALYs)

 Medicare Cost Savings

Source: IMPAQ International and Altarum Institute
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Several states reported evaluation and other research studies were underway, and some have 

been able to report findings. Exhibit 7.4 highlights study findings from states reporting them 

during the ARRA funding period.

Exhibit 7.4. CDSMP Study Findings from Example States

State Study Findings

Hawaii Hawaii has conducted a formal evaluations focusing on the modification of CDSMP to 

different ethnic groups. The state, with the help of the University of Hawaii, conducted a 

study looking at the adaption of CDSMP to Caucasian, Asian, and the Asian Pacific Islander 

(API) population groups. The study took baseline and 6-month measures for the three 

populations (584 completers, baseline data for 422 including 53 Caucasians, 177 Asians, 

and 194 Pacific Islanders), and found that all three groups realized significant decreases in 

social and role activity limitations and increases in communication with physicians. In 

particular, the API group realized significant increases in self-rated health and time 

engaging in stretching/significant exercise; Asian respondents reported significant 

reductions in health distress and self-reported physician visits and increases in time spent 

in aerobic exercise. The study results suggested that CDSMP could be successfully adapted 

to different cultures without losing its behavioral change focus using supplemental 

materials and additional staff time to support participants. 

Idaho Idaho has conducted a formal evaluation of the impact of CDSMP on rural populations, 

particularly among women of a lower socioeconomic status. The state partnered with 

Boise State University to evaluate the “Living Well Idaho” program. A survey was 

administered once to measure pre-intervention (before the program) and again six-months 

after the program ended in the domains of self-efficacy, health status, health care 

utilization, and health behavior. The study population of 298 was primarily white Caucasian 

females above the age of 65 residing in rural areas with 1 or more chronic condition. A 

majority of participants claimed annual income less than $24,999 and an education level at 

or below high school. 

Overall, there were significant changes in health status, and among those individuals of 

lower incomes, there were also changes in days affected by physical or mental health and 

improved communication with physicians. On the negative side, participants of lower 

social status reported higher utilization and ER visits; they also reported lower selfmanagement skills after the program ended. These respondents also reported higher 

utilization of physician visits, which may ultimately lower long-term costs if the visits 

allowed respondents to handle health issues with their physicians before they escalated 

and required hospitalization. Further research is needed on the role of physician visits.
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State Study Findings

Massachusetts Massachusetts, in cooperation with the University of Massachusetts, published a pilot 

outcomes evaluation of the state’s programs in March 2012. Between March 1, 2010 and 

March 2, 2012, a total of 2,720 adults participated in 251 chronic disease self-management 

workshops with 2,132 completing four out of six workshop sessions for a completion rate 

of 78%. Of the total number of participants, 83% attended “My Life, My Health” (CDSMP) 

and “Mi Vida, Mi Salud” (Tomando Control de su Salud) workshops. 

The outcome study included a pre-workshop health survey prior to the program’s 

initiation; the same survey was then given to participants after the sixth session and six 

months after the program ended. Overall, the evaluation found that completers 

experienced improvements in self-reported general health, levels of fatigue, pain, stress, 

sleep, physical activity, and communication with their physicians. There were also 

marginally smaller decreases in health care utilization levels. The completers aged 64 and 

younger had more significant reported health improvements than those 65 years and 

older, although completers between 65 and 74 years of age had slightly higher decreases 

in health care utilization than other groups.

New 

Hampshire

New Hampshire has developed a survey instrument with the help of Dartmouth Prevention 

Research Center. The survey instrument shares many of the same foci and question types 

as already used in Maine and Vermont. The state has already conducted an evaluation of 

the existing programs, and expects a summary report to be available in late spring 2012.

North Carolina North Carolina conducted a formal evaluation of the state’s Living Health Chronic Disease 

Self-Management Program (CDSMP) in the fall of 2009. The evaluation targeted 

participants who attended a CDSMP workshop from November 2009-March 2010; the 

survey questions were in four main domains: general health, physician communication, 

symptom management, and daily activities. The questions were asked pre-program and a 

year after the program finished. A total of 113 participants participated in both surveys. A 

series of Repeated Measures ANOVAs were run to examine the changes in scores from preto post-test. Statistical trends were found in the four self-reported health domains. 

Specifically, increases in physician communication, daily activities, and symptom 

management were found as well as improvements in general health.

Oregon Oregon conducted perhaps the most comprehensive and complex evaluation with its 2010 

impact report. The report evaluated a number of unique metrics for the 3,919 participants 

in 376 workshops from 2005-2009. Although the state did not conduct a state-wide prepost survey of participants, it did collect extensive qualitative information from workshops 

that showed improvements in participants’ attitudes and self-reported conditions in a 

range of domains including quality of life, health and functional status, disability, and 

overall confidence levels. Perhaps more notable, Oregon is the first state to conduct a 

formal cost-effective analysis of the program’s impact on health spending: The report 

found that the participants saved 107 quality adjusted life years (QALYS) through the 

program, had 557 fewer visits to the ER that resulted in avoided costs of $634,090 and 

2,783 avoided hospital days that avoided costs of $6,501,088. The report also made 

estimates of enrolling 5% of eligible Oregonians in CDSMP that would result in 2,138 

gained QALYS, 11,119 avoided ER visits avoiding $12.6 million in costs, and 55,593 avoided 

hospital days that would save $129.9 million dollars. 

Wisconsin Evaluation has largely focused on cost savings associated with the program. In addition, 

evaluation efforts have measured fidelity adherence, leader motivation, and retention.

Program evaluation conducted in November 2010 reported a nearly 1.5 million dollar 

savings in health care expenditures based on the same utilization indicators of emergency 

room and hospital days used by Stanford in their original evaluation of the program.

Source: IMPAQ International and Altarum Institute
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7.6 Post-ARRA Changes

For many grantees, the completion of ARRA funding for CDSMP on March 30, 2012, raises 

questions about potential impacts on data collection, analysis and evaluation activities as well 

as the future of CDSMP programs overall. Of particular interest to AoA, is understanding the 

extent to which grantees will continue to collect data required for submission to NCOA under 

the ARRA grant. Although grantees will not be funded for this activity, NCOA on behalf of AoA, 

has requested that grantees continue to do so. Nearly half of the grantees received extensions 

on their grants, and are expected to continue to collect and submit data throughout this period, 

which may extend as far as one year. Completion of ARRA funding for CDSMP has occurred 

concurrently with difficult economic situations for states and local areas. It is important for AoA 

to understand and access data from its grantees, maintained by its technical assistance 

contractor NCOA, to enable AoA to track and monitor the CDSMP programs it funds over time 

and evaluate the impact of this funding nationwide. Members of the evaluation team explored 

related questions with grantees during site visits and phone interviews. 

Exhibit 7.5. Post-ARRA Data Submission

Source: IMPAQ International and Altarum Institute

As shown in Table Exhibit 7.5, approximately half of the state grantees (24 of 47) reported plans 

to continue collecting and submitting data to NCOA. As a whole, these grantees tended to have 

established programs and data management infrastructure in place, and often incorporated 

collection of NCOA-required data with other state data collection, analysis and evaluation 

activities. Oklahoma reported that the state Department on Aging’s in-house evaluator would 

continue to submit the data, which the state views as a valuable program asset for refining the 

24

18
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program and reporting its benefits to stakeholders. Vermont will continue to submit data 

because reporting is integrated within their state Blueprint for Health and CDSMP data are 

collected routinely.

Five states reported that they did not plan to continue data collection after funding ended. One 

grantee reported that the part time position supporting CDSMP data activities would be 

eliminated when funding ended. Another grantee reported that sending data to NCOA is a 

burden given the grantee’s other responsibilities.

Several state grantees reported they were not aware of the request to continue providing data 

after funding had completed, but stated they would be willing to do so. Grantees also 

cautioned that, while they were willing to submit data at the state level, they could not speak 

for their host or implementation sites and their capacity or willingness to comply. The Texas 

grantee reported that the state will continue its data collection and monitoring as usual after 

funding ends, and has been encouraging local partners to submit data as well. However, 

because these activities are no longer a requirement of funding, participation would likely vary 

by organization. 

Eighteen grantees stated they did not know how the completion of ARRA funding would impact 

their data collection and reporting, or how data collection would likely be affected by state and 

local budget cuts. In Nevada, the state hopes to obtain funding from other sources to continue 

CDSMP data-related activities. 

Grantees were also uncertain of the post-funding impact on data collection and analysis for 

program management and basic studies. Some grantees have squarely incorporated evaluation 

into their public health and aging activities, and surmised that their current activities would 

continue or expand. Others expressed uncertainty tied to state and local budget negotiations 

and their impact on their CDSMP programs. 

7.6.1 Data, Analysis, and Evaluation Needs

While some states are more data driven and sophisticated in their use of evaluation than 

others, grantees appear to have their basic needs for program management data and 

evaluation met. The gap identified by most was the lack of state-level information about 

CDSMP program outcomes including information about health care costs and utilization, health 

status and return-on-investment. A common refrain was ... legislators, health plans and 

employers want to know about CDSMP in OUR state. National studies are not sufficient at state 

and local levels. 

 The state unit on aging in one state called for Medicaid claims studies to prove the 

cost effectiveness of the program. 

 According to one grantee, the physician community wants to see state-specific 

outcomes. Insurers will also want to see outcomes data for the participants they 

refer to CDSMP.
IMPAQ International, LLC Page 93 CDSMP Process Evaluation Final Report

 Another state grantee is planning to expand their current evaluation framework to 

support some type of cost effectiveness analysis.

7.7 Future Plans

The future of data collection and evaluation at the state and local levels appears uncertain and 

quite variable with the completion of ARRA funding for CDSMP. About half of grantees plan to 

continue collecting and submitting data to NCOA after funding ends, and the remaining 

grantees are either uncertain or do not plan to submit data on their CDSMP programs. 

Some grantees and host and implementation sites have been able to plan for the end of ARRA 

funding and sustain their data collection, analysis and evaluation by integrating core activities 

with those of other public health and aging programs, in states where this capacity is present. 

Partnerships with local universities have helped to sustain capacity for evaluation, particularly 

where special studies are conducted. Grantees have also sought to develop multiple funding 

streams from federal and state grant programs. Funding from CDC’s Community 

Transformation grants and CMS, as well as AoA’s Title III-D and new grant opportunities for 

CDSMP continuation and expansion are among the sources grantees have identified to help 

sustain this capacity. 

Grantees’ capacity to sustain CDSMP data collection, analysis and evaluation typically depends 

on the assessment of competing priorities for resources at the state level, as well as the 

capacity and willingness of regional and local sites to collect and submit data. Successful 

strategies for sustaining these capabilities include integrating CDSMP data collection and 

analytic activities with those of other public health or aging programs. States vary in their 

capacity for and use of data for program management and decision making. Grantees in states 

with data-driven cultures and established data analytic infrastructure are more likely to report 

intentions to continue to collect and report required data as well as program management 

evaluation and special studies than grantees in states with less developed resources. Special 

studies conducted through partnerships with universities were often funded by grants and 

contracts unrelated to ARRA funding for CDSMP. As a result, these studies were less likely to be 

affected by the end of ARRA funding. 

The evaluation team identified several areas where efficiencies could be achieved or additional 

information provided to improve grantees abilities to sustain CDSMP. These are listed below.

1. Grantees have become involved with various types of program management evaluation 

and special studies, and are gaining experience with diverse measures and methods as 

they conduct CDSMP-related research. These activities are usually conducted 

independently, without inter-state collaboration. Sharing measures, methods, findings, 

and experiences conducting CDSMP-related research among grantees and their research 

partners across states enables peer-to-peer learning and development of the evidence 

base for CDSMP as delivered by community-based organizations to older adults.
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2. Several grantees mentioned that they provide data and analysis to external stakeholders 

including individuals in other state agencies, legislators, employers, health plans and 

Medicaid. Grantees emphasized the importance of this state-level information to 

support CDSMP adoption and sustainability. Many would have liked to have more statelevel information about health care cost, health care utilization, health status and 

return-on-investment to facilitate their efforts to obtain third party payers including 

Medicaid.

3. Grantees with advanced research agendas developed in-house and with university 

researchers, are developing experience merging CDSMP program data with other data 

sets such as BRFSS, Medicaid claims, and surveys of participants and leaders. Hawaii and 

Oregon are two examples of states that have developed considerable experience in this 

area. Grantees in four states have added GIS mapping to their data analytics to support 

CDSMP planning and management.

Data collection at local sites can be challenging given the many competing priorities of 

workshop leaders and program staff, especially when funding and resources are limited. 

Innovations including the scannable forms developed in Michigan show great promise in 

reducing the burdens associated with data collection, and could be replicated in other states.
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CHAPTER 8: SUSTAINABILITY OF CDSMP

Research Question 5: Have the grantees built sustainable statewide distribution and delivery 

systems which increase the availability of evidence-based self-management programs and 

provide an ongoing distribution channel for other evidence-based programs that may be 

delivered by community-based organizations?

Key Findings

1. Strong leadership and vision at the state level will be a key factor in program sustainability. 

Whether a state opts for centralized or decentralized oversight or a centralized or decentralized 

delivery system, state-level commitment to CDSMP will be critical. Leaders at the state level who 

ensure that CDSMP is integrated into statewide strategic planning, actively support implementation 

at the local level through technical assistance and other supports, and advocate for statewide 

standards for fidelity monitoring are likely to be rewarded with stronger, more sustainable 

programs.

2. A symbiotic partnership between the state unit on aging and the public health department 

benefits CDSMP implementation and sustainability. Aging brings access to a state’s aging network, 

which is important for reaching older adults and, increasingly, persons with disabilities (through 

ADRCs). Public health brings a commitment to evidence-based health promotion and prevention 

programs and established delivery systems. States in which aging and public health collaborate 

effectively tended to have stronger CDSMP delivery networks, even though the aging-public health 

partnerships vary significantly in structure and function across the states.

3. Agency leaders at the state level will not be successful in advocating for and sustaining CDSMP 

unless they are able to effectively communicate the program’s benefits to the governor’s office, 

legislators, and other stakeholders. Many grantees reported that state officials and legislators 

want evidence of program benefits and cost-effectiveness before considering broader support for 

CDSMP.

4. While strong leadership is needed at the state level, regional and local leadership is also 

important to sustainability. Regional or local leaders committed to CDSMP, as well as “embedded” 

agency staff who are trained as CDSMP leaders, can bring stability and continuity at the local level. 

Embedded leaders can also reduce dependence on volunteers. Many sites reported that recruiting, 

training, and sustaining an all-volunteer corps of workshop leaders can be challenging and costly.

5. With their boundless energy and tenacity, state and local champions often play a pivotal role in 

launching successful programs; however, sufficient attention must be given to building a strong 

delivery system and broad support for the program. Otherwise, a program may not be able to 

weather the loss of a champion or a change in leadership.

6. Strong infrastructure is key to sustainability, whether at the state level (centralized models) or 

the regional level (decentralized models). Some grantees advocated for centralized infrastructure 

to support multi-site, multi-program licenses and data collection and support for community-based 

organizations. Others advocated for decentralized approaches, making efforts to have communitybased organizations take on program responsibilities to ensure sustainability of CDSMP in the event 

of state budget cuts or reorganizations that might impact capacity to support ongoing program 

activities. There is not strong evidence for one approach over the other as a sustainability strategy.
7. Simultaneous pursuit of multiple strategies to promote sustainability can be beneficial in a 

program’s start-up phase, but a focus on the most effective strategies is ultimately the best 

approach. “Let a thousand flowers bloom” was the mantra of a number of ARRA grantees in their 

quest for sustainability; however, those who systematically evaluate the various strategies and 

ultimately focus only on those likely to result in the greatest benefit will be most successful over 

the long term.

8. Outsourcing program oversight and technical assistance can be an effective strategy as long as 

there is funding to do so. Grantees such as California and New York have been able to build 

strong programs by outsourcing program development responsibility to other organizations. 

However, this is a sustainable model only if there is a dedicated source of funding for these 

organizations (e.g., grant funding or a state budget line) or program revenue streams that can 

support them (e.g., technical assistance fees).

9. Perhaps most challenging for grantees was developing effective referral networks and few 

“best practices” emerged. While all but one grantee met their goals for workshop participation, 

virtually all reported difficulty recruiting participants. Developing more effective recruiting 

strategies will be an important factor for ensuring long-term sustainability of CDSMP. 

10. “Smart” investment of program development funds can help to build sustainability. Many 

grantees avoided using ARRA funds to support state and/or local staff salaries, understanding 

that it would be difficult to find replacement funds when the ARRA grant came to an end. Instead, 

investing in infrastructure building was more likely to position a program for sustainability over 

the long term (e.g., developing marketing materials and Web sites, training program coordinators 

and leaders, establishing processes for fidelity monitoring).

11. Long-term sustainability is likely to depend on integration of CDSMP into new delivery system 

and financing models. States cannot rely on public or private grant funding to sustain CDSMP, 

which can ebb and flow as budgets and priorities change. Incorporating CDSMP into medical 

home models, large medical practices like Kaiser Permanente, and public and private managed 

care programs is likely to be a more sustainable strategy.

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8.1 Introduction

In their ARRA grant applications, each state was to provide “a vision for long-term sustainability 

of CDSMP as part of its overall approach to helping older adults remain independent and living 

in their own home and communities.”36 AoA endeavored to support states in developing 

strong, sustainable delivery systems for CDSMP that would continue to thrive after federal 

funding came to an end. 

In announcing funding opportunities for chronic disease self-management education programs 

and structuring technical assistance for grantees, AoA promotes these key elements for an 

integrated, sustainable service delivery system:

 

36 ARRA grant RFP, page 16.
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1. State-level aging and public health leadership. Regardless of which agency is the lead 

for CDSMP implementation, AoA seeks to encourage states to develop effective 

collaborations between the state unit on aging and the public health agency.

2. Effective partnerships to embed CDSMP into statewide health and long-term services 

and supports systems. AoA encourages states to strategically recruit and partner with 

organizations that can embed CDSMP into their ongoing operations, with priority to 

delivery system partners with multiple delivery sites, the capacity to reach large 

populations, and a commitment to offering workshops on an ongoing basis beyond the 

grant period.

3. Delivery infrastructure/capacity to provide programs throughout the state. AoA 

expects states to develop adequate capacity to deliver CDSMP workshops throughout 

the state.

4. Centralized or coordinated processes for recruitment, intake, referral, and 

registration/enrollment. AoA expects states to develop centralized or coordinated 

outreach and marketing efforts and to coordinate with ADRCs in the state. 

5. Quality assurance program and ongoing data systems and procedures. States are 

strongly encouraged to have a strong quality assurance programs to ensure fidelity and 

facilitate continuous quality improvement, as well as data collection systems to support 

these functions.

6. Business planning and financial sustainability. States are expected to develop and 

execute business plans that will ensure financial sustainability beyond the grant period, 

working with government agencies, foundations and corporations, health care 

providers, employer groups, and public and private insurers.

In addressing Research Question 5, AoA expressed interest in better understanding the 

approaches state grantees have taken to ensure sustainability of their CDSMP delivery systems

and whether there is evidence to suggest the relative effectiveness of various approaches in 

achieving this goal. Our examination of this question centered on the six key elements listed 

above for an integrated, sustainable service delivery system. We found considerable variation 

in grantees’ approaches to the interconnected dimensions of sustainability, reflecting each 

state’s unique historical, political, and organizational features. Yet, even with this variation, 

common challenges, opportunities, and themes became evident. 

Below we discuss eight strategies state grantees are using to promote program sustainability: 

integrating CDSMP into existing service delivery networks, organizational strategies, partnering 

with strong organizations, building provider referral systems, educating students in the health 

professions, leveraging grant funding, building billing capability, and integrating CDSMP into 

health reform initiatives. The “Key Findings: Sustainability” listed at the beginning of this 

chapter are based on our review of these strategies together with the analysis of program 

implementation in Chapter 5.
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Data sources consulted in conducting the following analysis of sustainability include site visits 

and telephone key informant discussions conducted by the research team, grantee progress 

and final reports, and program data and reports from NCOA, the technical assistance 

contractor. The research team also reviewed states’ responses to the Sustainable Infrastructure 

and Delivery System Self-Assessment administered by AoA in collaboration with NCOA in 2011.

8.2 Deliver CDSMP through Existing Networks 

In developing their CDSMP delivery systems, grantees have taken advantage of six existing 

networks developed with support from Federal partners: the aging network promoted by AoA; 

the public health network sponsored by CDC; AHECs and Federally Qualified Health Centers 

(FQHCs) sponsored by the Health Resources and Services Administration (HRSA); cooperative 

extension services sponsored by the Department of Agriculture; and the Department of 

Veterans Affairs’ medical centers (Exhibit 8.1). These networks offer established channels for 

program delivery with regional offices and partners throughout the state. States with stronger 

existing networks on which to build CDSMP initiatives tended to have more robust programs 

that are likely to be sustainable over the long term.

Exhibit 8.1. Federally-Sponsored Networks Used by CDSMP Programs

Sponsor Network

Administration for Community 

Living (ACL)/Administration on 

Aging (AoA)

Aging Network

Centers for Disease Control 

and Prevention (CDC)

Public Health Network

Health Resources and Services 

Administration (HRSA)

Area Health Education Centers 

(AHECs)

Health Resources and Services 

Administration (HRSA)

Federally Qualified Health Centers 

(FQHCs)

Department of Agriculture Cooperative Extension System

Department of Veterans Affairs Veterans Administration Medical 

Centers

Aging network: In most states AAAs, a key component of the aging network, have assumed an 

important role in the delivery of CDSMP. AAAs function as host sites and frequently take an 

active role in other aspects of program development and management, such as seeking out 

new partners for program delivery and provider referrals, training and managing leaders, 

program marketing and registration, and conceiving and testing new strategies to promote 

sustainability. Senior centers are an important component of the aging network and serve as 

CDSMP host and implementation sites. Many AAAs partner with ADRCs, which are often an 

important source of consumer referrals to CDSMP. 
IMPAQ International, LLC Page 99 CDSMP Process Evaluation Final Report

Public health network: CDC’s Arthritis Program has been funding state arthritis programs 

managed by state health departments since 1999. The programs focus on building capacity to 

disseminate and deliver evidence-based interventions. Many of these programs incorporate 

CDSMP into their program offerings. CDC’s National Diabetes Education Program also promotes 

the diabetes self-management program. Many states have used these programs as a base for 

expanding CDSMP.

Area Health Education Centers (AHECs): AHECs aim to improve access to health care in 

underserved areas through interdisciplinary/inter-professional community-based professional 

training, continuing education, and outreach. New Hampshire has engaged AHECs to deliver 

CDSMP and the state’s lead AHEC organization holds the CDSMP license. New Mexico, with its 

vast rural and frontier areas, has an established network of AHECs that have also helped to 

implement CDSMP. 

Federally Qualified Health Centers (FQHCs): The nation’s network of FQHCs provides 

comprehensive health services to medically underserved populations. Thirty-five grantees 

reported collaborating with state primary care associations (which represent FQHCs) and 

FQHCs to provide CDSMP. The Missouri grantee reports that FQHCs are now actively referring 

patients to CDSMP and are also program delivery partners. A New Jersey FQHC, Southern Jersey 

Family Medical Centers, Inc., has trained leaders and is now offering CDSMP and DSMP. In New 

Hampshire, the FQHCs are exploring the feasibility of inserting a CDSMP referral “button” into

their electronic medical record. 

Cooperative Extension System: Land-grant universities in each state operate a county network 

of local offices that provide research-based information to agricultural producers, small 

business owners, and consumers. The K-State Research and Extension at Kansas State 

University trains staff members in local offices as CDSMP leaders, and these leaders market and 

manage CDSMP workshops in their areas. Local offices of the University of Missouri Extension 

partner with the Missouri Department of Health and Senior Services and the Regional Arthritis 

Centers to provide CDSMP as well. 

Veterans Administration (VA) Medical Centers: Twenty-five state grantees reported 

developing partnerships with local VA facilities to offer CDSMP to veterans. For example, 

Michigan reported training VA health system staff so that they can offer CDSMP to returning 

veterans and Ohio has helped VA facilities in Cincinnati and Columbus to launch CDSMP 

programs. 

8.3 Organizational Strategies

States reported a variety of organizational strategies aimed at building sustainable CDSMP 

programs and delivery systems. 

1. Embed the program in state and local agencies, including training local agency staff as 

leaders. A number of grantees reported training state and local agency staff as master 
IMPAQ International, LLC Page 100 CDSMP Process Evaluation Final Report

trainers and workshop leaders as a way of building and sustaining program capacity. 

Grantees reported having leaders employed by state-level agencies as well as host and 

implementation sites. This way responsibility for leading workshops becomes part of the 

job description for paid staff and, in the case of master trainers, training new leaders. 

These grantees must still rely on a cadre of volunteer leaders to help lead workshops, 

but states maintained that having leaders on staff—many of whom become CDSMP 

champions—makes the program less vulnerable to resource reductions during or 

following grant funding. For example, the state-level program coordinator in Kansas was 

a trained leader, as were staff of ADRCs in Tennessee, staff at senior centers in 

Arkansas, and extension agents at Kansas State University. 

2. Centralize responsibility for evidence-based programs in one agency or department. 

Many grantees reported having established state-level departments for evidence-based 

programming and offering all of their evidenced-based programs through this one 

department. The location of these hubs for evidence-based programs varied widely 

across states, reflecting political and historical funding relationships, including 

departments of aging or public health, or executive level umbrella agencies such as 

departments of health and human services. Concentrating evidence-based 

programming in one department has obvious advantages for program development, 

marketing, staffing, fidelity monitoring, and continuous quality improvement. Some 

states offer a number of these programs; others have decided to offer just one or two 

so as not to “dilute” their efforts around program development (e.g., New Hampshire 

offers just CDSMP and Puerto Rico only offers Tomando Control de su Salud and DSMP). 

Respondents often linked the decision to offer fewer or more programs to availability of 

funding for evidence-based programs within and across state departments or agencies. 

States with more decentralized regional delivery models centralized responsibility for 

evidence-based programs at the regional or local level rather that the state level. 

A number of local agencies reported establishing evidence-based program 

departments and offering “suites” of programs. The ElderLink AAA in Fairfax, VA, 

takes this a step further, linking A Matter of Balance (targeted at falls management) 

to CDSMP. The AAA is encouraging clients to complete both programs and combines 

program participation with additional supports such as home inspections, with the 

goal of preventing avoidable hospitalizations. 

3. Develop tools to support local delivery of CDSMP. Many states with decentralized 

delivery systems are working to empower their local sites to develop sustainable 

programs. The Missouri Arthritis and Osteoporosis Program garnered extensive input 

from experts and stakeholders to develop a sustainability manual for local sites. Entitled 

Self-Management Education Programs for People with Chronic Conditions,

37

 

the manual 

offers sites comprehensive, practical guidance on sustainability planning, including 

37 Available at http://www.moarthritis.typepad.com/Final%20-%20Missouri%20Sustainability%20Toolkit.pdf.
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chapters on revenue generation, marketing, referral networks, service operation, 

community support, and advocacy. The manual is now the centerpiece of local technical 

assistance efforts. Oregon’s Living Well Sustainability Toolkit discusses marketing and 

financial sustainability strategies for local sites, including recruiting partners, guidance 

on using traditional marketing approaches and the new media, and targeting and 

making the case to prospective funders.38 Utah developed a financial model to help sites 

calculate the number of workshops that can be convened with available funding. The 

Connecticut and Maryland programs engaged sustainability consultants to work on 

sustainability planning with local agencies. 

Maryland issued a Request for Proposals for a sustainability consultant charged with:

 Fostering partnerships Medicaid and Medicare health plans to pursue 

reimbursement for CDSMP.

 Providing technical assistance to local CDSMP programs on sustainability and 

third-party reimbursement.

 Providing materials for and participating in regional quarterly meetings with 

local CDSMP sites.

 Regular reporting to the Maryland Department of Aging and the Department of 

Health and Mental Hygiene on sustainability efforts statewide.

Source: CDSMP Sustainability Consultant. State of Maryland, Request for Proposals, Solicitation No. MDoA 12-

002, July 25, 2012.

4. Develop broad-based support for CDSMP through coalitions and collaboratives. A 

number of states have established new collaboratives or coalitions or are working 

through existing ones to develop and sustain their CDSMP initiatives. Involving coalitions 

and collaboratives as CDSMP supporters helps to embed CDSMP at the community level 

and encourages broad ownership of the program at the state, regional, or local levels. 

Examples are shown in Exhibit 8.2.

Exhibit 8.2. State Collaboratives for CDSMP

State/Collaborative Description

Arizona

Arizona Living Well Institute

Launched in 2010 through a grant from the Administration on 

Aging, now supported by multiple grant sponsors and partners. 

Works collaboratively with community-based organizations, 

healthcare systems, community health centers, senior centers, 

tribal and minority leaders, parks and recreation centers, 

employers, and providers. It will take the volunteers, staff, and 

providers within these organizations to help spread the word 

about the benefits of CDSMP workshops. (http://www.alzwi.org). 

 

38 Available at 

http://public.health.oregon.gov/DiseasesConditions/ChronicDisease/LivingWell/Documents/Toolkit/lwtoolkit.pdf. 
IMPAQ International, LLC Page 102 CDSMP Process Evaluation Final Report

State/Collaborative Description

Colorado 

Be Well Colorado

Established in 2011 by the Colorado Department of Human 

Services, the Department of Public Health and the Environment, 

and the Central Colorado AHEC. Sponsors a CDSMP website 

targeted at consumers and providers that describes the program, 

presents success stories, and lists upcoming workshops and 

contact information (www.bewellconnect.net). 

Massachusetts

Healthy Living Center of 

Excellence

Includes the Department of Public Health, the Executive Office of 

Elder Affairs, and six regional coalitions. Working to establish a 

“center of excellence” that will foster local networking and 

sharing of leaders and other resources, as well as provide a 

centralized billing capability to support provision of CDSMP as a 

reimbursable service (http://www.healthyliving4me.org).

Minnesota

Minnesota Live Well at Home

CDSMP has become part of the Minnesota Live Well at Home 

framework that promotes community-based living for older 

adults and features the CDSMP workshop schedule on its website 

(http://www.mnlivewellathome.org). 

Mississippi

Mississippi Delta Health 

Collaborative

Mississippi CDSMP has teamed with the Mississippi Delta Health 

Collaborative 

(http://msdh.ms.gov/msdhsite/_static/44,0,372.html), an 

established collaborative sanctioned by the Mississippi State 

Department of Health. The collaborative works to promote 

healthy communities in the Delta, including clinical initiatives to 

increase access to care for treatment for heart disease and 

stroke and community initiatives to create environments that 

promote heart healthy lifestyle choices. 

Rhode Island

Chronic Care Collaborative

Rhode Island CDSMP has become involved with the Department 

of Health’s Chronic Care Collaborative 

(http://www.health.ri.gov/partners/collaboratives/chroniccare/), 

established more than a decade ago to address diabetes 

prevention and now working to develop standards for patientcentered medical homes. 

Wisconsin

Wisconsin Healthy Aging 

Institute

Launched in 2010 to help the state’s citizens live healthier lives 

through evidence-based prevention programs. Includes 

university and community-based partners to implement, 

maintain, and test programs for older adults. 

(https://wihealthyaging.org/). 

5. Outsource responsibility for program development and technical assistance to a 

university or nonprofit organization. Some states have established university-based 

technical assistance centers for CDSMP. Others outsource technical assistance 

responsibilities to new or existing nonprofit organizations. The scope of responsibility of 

these organizations varies. Respondents shared that this arrangement enabled their 

programs to make available highly skilled staff and resources while protecting the 

CDSMP programs from state legislative actions—e.g., funding or hiring freezes or 

redirection—that could threaten program continuity and reach. Examples are provided 

in Exhibit 8.3.
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Exhibit 8.3. University and Nonprofit Organizations Responsible for Technical Assistance

State/Organization Description

University-Based Centers University-Based Centers

New York

Quality and Technical 

Assistance Center (QTAC)

The New York State Evidence-Based Health Programs Quality and Technical 

Assistance Center (QTAC) is based at the Center for Excellence in Aging & 

Community Wellness at the University at Albany School of Social Welfare

(www.ceacw.org). QTAC’s mission is to help build and sustain local capacity 

in New York State to deliver evidence-based health promotion and disease 

prevention programs. The state contracts with QTAC to support statewide 

infrastructure development, collect and manage program data, and monitor 

program quality. QTAC is funded through state allocations, grants, 

contractual work (e.g., for technical assistance, training), and in-kind 

contributions from partner organizations. QTAC has been an important 

factor in the success of New York’s CDSMP program with its knowledgeable, 

entrepreneurial, university-based staff dedicated to program expansion and 

sustainability.

Missouri

Missouri Arthritis and 

Osteoporosis Program

Missouri’s seven Regional Arthritis Centers (RACs) have been operating since 

1985 when they were written into statute and began receiving funding from 

the Department of Health and Senior Services. CDC has also provided core 

funding to the RACs. The RACs are managed by the Missouri Arthritis and 

Osteoporosis Program (MAOP) based at the University of Missouri

(http://health.mo.gov/living/healthcondiseases/chronic/arthritis/index.php). 

The RACs offer CDSMP and four other evidence-based programs. MAOP 

provides technical assistance to local programs and produced and distributes 

a sustainability manual entitled Self-Management Education Programs for 

People with Chronic Conditions (see

http://www.moarthritis.typepad.com/Final%20-

%20Missouri%20Sustainability%20Toolkit.pdf).

West Virginia

Marshall University 

Center for Rural Health

In West Virginia, the Center for Rural Health at Marshall University holds a 

statewide license for CDSMP, trains leaders, recruits partners, and assists 

local sites with program implementation

(http://www.selfmanagementonline.org/About-CDSMPs/about-chronicdisease-self-management.html). Marshall University also provides technical 

assistance for DSMP. West Virginia University collects and manages program 

data and monitors fidelity.

Kansas

Wichita State University

In Kansas, Wichita State University partners with a CDSMP collaborative in 

Wichita (Sedgwick County) to provide marketing and administrative support 

for the local CDSMP initiative. Unpaid graduate student interns from Wichita 

State develop marketing and workshop materials, recruit implementation 

sites, and develop provider referral networks under the direction of a faculty 

member in the College of Health Professions.

Nonprofit Organizations Nonprofit Organizations
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State/Organization Description

Arizona

Arizona Living Well 

Institute

The Arizona Living Well Institute (www.azlwi.org) is a public-private 

partnership launched in 2010 to promote delivery of evidence-based 

programs. It currently offers CDSMP and several other programs. The 

Institute was established with ARRA grant funding and is currently supported 

by the Arizona Department of Health Services, a private foundation, and an 

AmeriCorps grant. The Institute coordinates workshop delivery, trains 

leaders, and collects and reports program data. The Institute is one of an 

array of health and wellness initiatives housed by Empowerment Systems, 

Inc., a nonprofit organization that promotes health and human services in 

rural and underserved areas of Arizona.

California

Partners in Care 

Foundation

In California, technical assistance to local sites is provided through Partners 

in Care Foundation (www.picf.org), which has been in operation for 75 years 

and is the legacy foundation of the Visiting Nurse Association of Los Angeles. 

Partners in Care develops, tests, and disseminates new models of care for 

health and social services. The State reported that allocating funding to and 

providing technical assistance through Partners in Care has helped to shield 

CDSMP from state budget cuts and legislative action that might otherwise 

compromise the sustainability of CDSMP.

Wisconsin

Wisconsin Institute for 

Healthy Aging

The Wisconsin Institute for Healthy Aging (www.wihealthyaging.org) is a 

nonprofit organization established in 2010 through a public-private 

partnership with leadership from the state Office on Aging. The Institute’s 

mission is to promote healthier lives through evidence-based prevention 

programs and it currently administers CDSMP, Tomando Control de su Salud, 

and two falls prevention programs. The Institute maintains a list of 

workshops and a registry of leaders, monitors fidelity, and collects program 

data. Under development by the Institute is the Community Academic Aging 

Research Network (CAARN), which aims to bring together academic 

researchers and community partners to conduct clinical trials and 

disseminate research related to healthy aging.

Planned Entities Planned Entities

Massachusetts In the early stages of development is a “center of excellence” in 

Massachusetts that will promote collaboration the Department of Public 

Health, the Executive Office of Elder Affairs, and six regional coalitions and 

facilitate reimbursement for CDSMP. 

Nevada Under development in Nevada is a statewide center for evidence-based 

programs that the State anticipates funding with CDC grants and tobacco 

settlement money. The center will provide technical assistance and conduct 

quality monitoring of CDSMP and other community-based programs.

8.4 Partner with Strong Organizations

States partner with a variety of community-based organizations to offer CDSMP. Partners often 

offer established channels for program delivery and, in many cases, marketing outlets, 

electronic registration systems, venues for workshops, provider referrals, experienced program 

coordinators and workshop leaders, easy access to targeted populations, and administrative 

services. Contractual arrangements with partners vary. In some cases the state contracts with 

partners or executes memoranda of understanding (MOUs), other partners are funded through 
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public or private grants, and some provide services in-kind. Partnerships enable states to avoid 

“reinventing the wheel” and help them leverage existing delivery channels.

Some of the strongest partners are those who are sustaining the program by incorporating 

CDSMP into their own programs or networks—i.e., training and embedding leaders, recruiting 

participants, hosting workshops, and in some cases, purchasing their own CDSMP license. For 

example, the VA Medical Center and Jewish Family Services in Ohio have opted to purchase 

their own CDSMP licenses and taken responsibility for managing their own CDSMP programs. In 

Colorado and California, Kaiser Permanente has incorporated CDSMP into its delivery system in 

order to serve Kaiser members. In Puerto Rico, Triple S, a Blue Cross-Blue Shield health plan, 

has embedded leaders on staff who provide CDSMP to members. A number of states reported 

that hospitals have built internal capacity to provide CDSMP on an ongoing basis.

Partners such as community colleges, YMCAs, and libraries can provide a stable venue for 

CDSMP, offering classrooms for workshops, advertising workshops through their course 

catalogs, and managing registration through existing electronic systems. For example, Idaho has 

partnered with a community college, Puerto Rico with the YMCA, and Oklahoma with libraries. 

However, partners such as these do not generally train and embed their own leaders so must 

rely on others to supply leaders. 

In some cases states have made grants to local organizations to jump-start CDSMP initiatives 

targeting new populations that are likely to lead to larger, sustainable initiatives. For example, 

In New Jersey, the Office of Minority and Cultural Health granted funds to the Sickle Cell 

Association of New Jersey to provide CDSMP. The State reported that CDSMP has helped many 

young adults with sickle cell disease to transition from pediatric to adult care and the New 

Jersey Association is now promoting CDSMP in collaboration with the national association. 

8.5 Build Provider Referral Systems

Building strong provider referral networks is key to recruiting consumers most in need of 

CDSMP and ensuring a continuous flow of participants into workshops. While many participants 

self-refer, others need that nudge from a physician to take their chronic disease seriously and 

enroll in CDSMP. States consistently reported that building referral networks with physician 

practices and health plans was one of the most daunting tasks they encountered in striving to 

build a sustainable CDSMP program. Among the most promising referral systems reported by 

states were those that involved panel management, Medicaid referrals, and partnerships with 

medical home initiatives.

Panel management: Vermont has worked with physician groups to promote panel 

management whereby physicians mail letters to patients with a body mass index (BMI) above a 

certain threshold who might benefit from CDSMP. The letters advise patients of workshop 

locations and dates. Coming from a trusted source (a physician), these letters have motivated a 

number of consumers to enroll in CDSMP. Some states report working with hospitals and 
IMPAQ International, LLC Page 106 CDSMP Process Evaluation Final Report

FQHCs to incorporate a CDSMP referral button into the electronic medical record (EMR), but 

these electronic referrals systems are not yet operational.

Medicaid referrals: Michigan has been educating Medicaid managed care plans about CDSMP 

and some are now making referrals to the program. In California, L.A. Care Health Plan, which 

covers dual eligibles through its Medicaid plan and Medicare Advantage Special Needs Plan for 

dual eligibles (D-SNP), refers members to county CDSMP providers. In Delaware, the United 

HealthCare Medicaid managed care plan and Delaware Physicians Care, an Aetna Medicaid 

managed care plan, refer members to DSMP offered by the State and provide monetary 

incentives to members who complete the program. In Missouri, CDSMP staff trained coaches 

for the state-operated MOHealth.net information and referral hotline to refer Medicaid clients 

to CDSMP. Coaches regularly referred callers to CDSMP until the State discontinued 

MOHealth.net about two years ago because of funding cuts.

Medical homes: Community Care of North Carolina, which provides medical homes for 

Medicaid beneficiaries, Medicare-Medicaid enrollees, and privately insured individuals through 

14 local networks, refers members to CDSMP. A New Jersey AAA is partnering with a large 

physician practice on a care transitions program in which physicians are encouraged to refer 

patients to the AAA’s CDSMP program. Once the program is fully operational, the AAA will 

participate in revenue sharing and anticipates using these funds to help support CDSMP.

8.6 Educate Students in the Health Professions

Educating professionals about the value of evidence-based programs in health promotion and 

disease prevention is another strategy states are using to institutionalize programs like CDSMP. 

For example, educating nursing students about the CDSMP curriculum and who is most likely to 

benefit from it will prepare nurses to incorporate CDSMP into clinical practice and/or make 

referrals to community programs. It is too early to tell what the impact of this strategy will be 

on the quality and supply of CDSMP leaders, but the states pursuing this strategy believe it will 

raise awareness of CDSMP among professionals and contribute to the pool of qualified leaders.

Examples of training programs incorporating CDSMP:

 The University of Medicine and Dentistry of New Jersey (UMDNJ) School of Nursing 

developed and implemented a curriculum for undergraduate nursing students to 

educate them about evidence-based programs, how to integrate these programs 

into nursing practice, and how to refer patients to programs such as CDSMP with the 

goal of graduating advocates for these programs. 

 In Ohio, the Miami University School of Nursing trains nursing students as workshop 

leaders. 

 In Kentucky, independent study students in the University of Louisville School of 

Social Work are trained as leaders and facilitate workshops. 
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 In Illinois, Rush University College of Nursing trains master’s level nursing students 

as CDSMP and DSMP leaders and is considering incorporating this training into the 

curriculum for undergraduate nursing students. 

8.7 Leverage Grant Funding

While a dependence on grant funding is not likely a sustainable funding strategy over the long 

term, a number of grantees have taken advantage of multiple public and private grant 

programs to build and expand CDSMP and other evidence-based programs. Grantees cited 

these federal grant programs:

 ACL: Systems Integration Grants;39 ADRC grants; Community Living grants

 CDC: Arthritis Program, Coordinated Chronic Disease Program; Community 

Transformation Grants; other grants to support diabetes self-management programs

 CMS Center for Medicare and Medicaid Innovation (CMMI): Funding for Accountable 

Care Organizations (ACOs), medical homes, Medicaid health homes, the Communitybased Care Transitions Program, and demonstrations for Medicare-Medicaid 

enrollees

State grantees have also turned to a variety of local funders, including private foundations and 

health plans. These sources typically provide small grants and time-limited funding for program 

development and implementation and cannot generally be relied on for long-term support. 

One partnership with a private foundation stands out. The Health Foundation of South 

Florida launched the Healthy Aging Regional Collaborative in 2008 with $7 million in 

foundation funds. The foundation holds a CDSMP license and supports training for Ttrainers, master trainers, and lay leaders. Classes and programs have been attended by 

17,000 older adults in south Florida. The foundation is what is known as a “health 

conversion foundation,” formed by conversions of nonprofit hospitals to for-profit 

enterprises. Federal law requires that the proceeds of sales of tax-exempt entities be 

directed to charitable purposes. About 200 local and regional foundations have been 

created in this way since the 1990s. The mission of many health conversion foundations 

centers around community health and disease prevention, so these foundations could be a 

promising source of funding for evidence-based programs. 

8.8 Build Third-Party Billing Capability

 

39 Also called “Accelerating Integrated, Evidence-Based, and Sustainable Service Systems for Older Adults, 

Indiviudals with Disabilities, and Family Caregivers.”
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State grantees recognize the importance of building a third-party billing capability for CDSMP 

services but have had very limited success in accomplishing this. Fee-for-service payment 

requires a business model that is vastly different from a delivery system that is funded through 

grants and/or state budget allocations. It will require a significant investment of resources as 

well as major cultural change in the way these grantees’ networks operate.

To bill for CDSMP services, a state must first determine the actual cost of providing a workshop 

or workshop session in order to price the service correctly and not operate at a loss. On the one 

hand, pricing should incorporate the costs of product development, marketing, service 

provision, quality assurance, and indirect expenses; on the other hand, the price of the service 

must be affordable for purchasers. States have experienced difficulty in striking this balance, 

particularly in serving low-income populations. In addition, many prospective purchasers are 

inquiring about the return on investment (ROI) for CDSMP, which will require outcome studies. 

Second, a state must have an accounting system to manage accounts receivable (i.e., to bill 

health plans, employers, consumers, and other purchasers) and accounts payable (i.e., to pay 

leaders, workshop sites, and other vendors for services provided). 

States have been working with public and private insurers to explore different strategies for 

financing CDSMP. Fee-for-service reimbursement or capitated payment is the ultimate goal but, 

as an interim strategy, some states have negotiated lump sum payments (or grants) from health 

plans to help defray the state’s costs for providing CDSMP to individuals referred by the plans. 

Virtually all the states understand the advantages of moving to fee-for-service reimbursement 

by Medicaid, Medicare, and private health plans, but are experiencing difficulty in effecting 

what would be a major transformation in service provision within the aging network. 

Below we discuss several approaches states are pursuing: Medicaid waivers, Medicare 

reimbursement, Medicaid reimbursement or allocations, coverage under Medicaid managed 

care, and coverage under integrated care programs for Medicare-Medicaid enrollees. 

Medicaid home and community-based services (HCBS) waivers: Medicaid HCBS waivers are 

authorized under Section 1915(c) of the Social Security Act and enable states to provide 

Medicaid-financed long-term services and supports (LTSS) to eligible individuals. Individuals 

meeting a state’s Medicaid financial eligibility requirements and assessed to need a nursing 

facility level of care can participate in HCBS waiver programs. Each state establishes its own 

criteria for determining the need for a nursing facility level of care, but typically an individual 

must have deficits in two or three activities of daily living (ADLs). Older adult Medicaid waiver 

clients are typically very frail and often homebound.

States must obtain approval from CMS for their HCBS waiver programs. The approval process 

includes a review of services and supports that the state proposes to offer under the waiver. 

States seeking to offer CDSMP as a waiver service in a new or existing waiver program must first 

obtain approval from CMS.
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Vermont and Washington are currently the only states approved by CMS to provide CDMSP as a 

service under a 1915(c) Medicaid HCBS waiver and can serve as models for other states. As an 

example, Washington offers CDSMP under its Community Options Program Entry System 

(COPES) waiver for older adults. As opposed to being a distinct waiver service, CDSMP is 

provided under a broader service category entitled “Caregiver/Recipient Training Services.” The 

definition for this service is:

“Recipient training needs are identified in the CARE assessment or in a 

professional evaluation. This service is provided in accordance with a therapeutic 

goal in the plan of care and includes for example, adjustment to serious 

impairment, maintenance or restoration of physical functioning, self 

management of chronic disease [emphasis added], acquisition of skills to 

address minor depression, management of personal care, and development of 

skills to work with care providers including behavior management ...”40

The waiver application goes on to list “Chronic Disease Self-Management Trainer” as one of 14 

approved providers for “Caregiver/Recipient Training Services.” The waiver application 

authorizes both “individual” trainers and “agency” trainers. In this way trainers (or the agencies 

they work for) can bill and be reimbursed for services by the State Medicaid agency. The State 

reports that about 100 individuals have taken advantage of CDSMP as a waiver service, with a 

per session reimbursement rate of $50.

California, working with the Partners in Care Foundation, conducted pilots in 2010 and 2011 in 

which care managers for the Multipurpose Senior Services Program (MSSP) Medicaid HCBS 

waiver referred waiver clients to CDSMP. Medicaid provided reimbursement of $60 per 

workshop session attended by the Medicaid client, as well as reimbursement for transportation 

($24 per hour for each two-and-a-half-hour session). The State found that many waiver clients 

were too frail or encountered other barriers in completing the workshops and the pilots have 

been discontinued.

Medicaid reimbursement and FQHCs: Oregon, which has partnered with FQHCs to deliver 

CDSMP, reported that efforts to obtain reimbursement for Medicaid beneficiaries participating 

in CDSMP offered by FQHCs failed due to a billing technicality. Medicaid payment rates for 

FQHCs use a federally-defined methodology and are based on a per visit rate. FQHCs were 

required to bill each CDSMP session as a separate visit (at an estimated rate of $900 to $1,500 

per patient), making the total cost of a six-week CDSMP workshop financially unfeasible. A 

single billing for the entire six-week workshop was not allowable under federal rules. 

Medicare reimbursement for DSMP: Section 4105 of the Balanced Budget Act of 1997 

authorized Medicare coverage for diabetes self-management training services furnished by a 

certified provider who meets certain quality standards. Services are covered by Medicare only if 

the treating physician or a treating qualified non-physician practitioner who is managing the 

 

40 State of Washington Application for 1915(c) HCBS Waiver: WA.0049.R06.00, April 1, 2009.
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beneficiary’s diabetic condition certifies that such services are needed. Medicare rules provide 

further specifications for eligible beneficiaries and training requirements. Training programs 

must be approved by a national accreditation organization.41 AoA has been working with the 

American Diabetes Association (ADA) and the American Association of Diabetes Educators 

(AADE)—both approved accrediting organizations—to increase the availability of communitybased training programs using Stanford University’s DSMP model. Up until now, most training 

programs have been offered in clinical settings. AoA has provided technical assistance to sites. 

Providers of DSMP must first be accredited by ADA or AADE and collaborate with a Medicare 

provider who is recognized by CMS as a diabetes self-management training provider. Providers 

must also have the infrastructure in place to bill Medicare.

A site in Massachusetts has been accredited to receive Medicare reimbursement for DSMP as a 

result of a collaborative effort by Hebrew Senior Life, a provider of elder housing, health care, 

and LTSS, and Elder Services of the Merrimack Valley, an AAA. To be accredited, a registered 

nurse, dietitian, or pharmacist must conduct a one-on-one assessment with the Medicare 

beneficiary, develop an individualized plan, and then refer the beneficiary to DSMP. Workshop 

leaders are supported by the nurse, dietitian, or pharmacist, and then each beneficiary is 

required to have a follow-up with a nurse, dietitian, or pharmacist at the conclusion of the sixweek workshop. The State has convened its first DSMP workshop for which it will be claiming 

Medicare reimbursement for eligible participants (the workshop included a mix of eligible and 

non-eligible individuals). The partners believe that if they can build the infrastructure for 

program management and reimbursement, it could be a replicable model for helping older 

adults to manage chronic conditions. The “center for excellence” that the Massachusetts 

partners envision (see description above) would be the framework for this infrastructure. 

AgeOptions, the AAA for suburban Cook County in Illinois, was close to submitting their 

application for DSMP accreditation to AADE at the time the research team conducted the 

telephone discussion with Illinois. The State is exploring how to “brand” the program and 

whether to have workshops solely for Medicare beneficiaries or mixed workshops that include 

non-Medicare beneficiaries. 

Allocations from Medicaid to support CDSMP: Colorado reported that the Medicaid agency 

made a grant to the Division of Aging and Adult Services to help support the provision of 

CDSMP to Medicaid clients. Some of the 14 local networks that comprise Community Care of 

North Carolina—which provides medical homes for Medicaid beneficiaries and others—make 

lump sum payments to local AAAs to help support CDSMP.

Coverage of CDSMP under Medicaid managed care: A majority of the states receiving ARRA 

funding have Medicaid managed care programs. The number and scope of Medicaid managed 

care programs continues to grow as states seek greater cost predictability, accountability, and 

 

41 Department of Health and Human Services. CMS Manual System: Pub. 100-02 Medicare Benefit Policy, 

Transmittal 13, May 28, 2004. Accessed at www.cms.gov/Regulations-andGuidance/Guidance/Transmittals/downloads/R13BP.pdf. 
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quality improvement. These programs aim to provide high quality, cost-effective care by 

assigning enrollees a medical home with a primary care provider, promoting care coordination, 

and investing in health promotion and disease prevention. Medicaid health plans—typically 

called managed care organizations or MCOs—receive capitated per-member-per-month 

payments from the Medicaid agency to provide care to members. The scope of benefits 

provided by MCOs varies by state and ranges from primary and acute care only to plans that 

cover primary and acute care as well as behavioral health, dental care, and/or LTSS. 

Grantees reported exploring a variety of methods for covering CDSMP through Medicaid 

managed care but, to date, there are no reported community-based CDSMP providers (i.e., 

AAAs or other local providers) who are receiving reimbursement from Medicaid managed care 

plans. In northwest Missouri, CDSMP is being integrated into an Aetna Medicaid pilot program 

(as well as into an Aetna plan for employees of Heartland Health, an integrated delivery system, 

and Heartland Health’s new Accountable Care Organization), but arrangements for Medicaid 

reimbursement have not yet been developed. Oregon reported that one AAA has arranged for 

a lump sum payment from a health plan that comes from the plan’s community benefit 

program budget. WellCare of Texas pledged $100,000 to the East Texas Coalition to support 

expansion of CDSMP and DSMP in the Houston area. Maryland and several other states 

reported that MCOs and the Medicaid agency must first be convinced of the cost-benefit of 

CDSMP before they will agree to provide reimbursement for Medicaid members, so they are 

discussing outcome studies with health plans that would involve a comparison of health care 

expenditures for Medicaid members who participated in CDSMP versus a similar group of 

Medicaid members who did not. States reported major barriers to conducting outcome studies 

such as this (e.g., securing health plan participation and research partners, availability of claims 

data, developing a defensible study design, funding for the study). 

Reimbursement under Medicare-Medicaid integrated care programs: A long-standing 

integrated care program for dual eligibles in Minnesota reimburses CDSMP providers. Under 

this program, members are enrolled in a Medicare Advantage D-SNP for their Medicare benefits 

and most receive their Medicaid benefits from the same plan that offers their Medicare 

benefits. This incentivizes plans to better manage the care of these dually-eligible beneficiaries 

across the two programs. Medica, one of the health plans that participates in Minnesota’s 

Senior Health Options program for dual eligibles, reimburses CDSMP providers $120 per 

workshop for each participating individual. Medica operates in 38 of Minnesota’s 87 counties. 

The State reports that because Senior Health Options members tend to be very frail, 

recruitment and retention can be challenging.

8.9 Integrate Evidence-Based Programs into Health Reform Initiatives

States reported considering a number of potential approaches for incorporating CDSMP and 

evidence-based prevention programming in general into state health policy aimed at health 

reform. Most approaches were in the early stages of discussion and will require extensive 

development and collaboration across state agencies and with the federal government.
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Vermont is one state where CDSMP has been integrated into health reform. Vermont’s 

Blueprint for Health is built around a statewide network of patient-centered medical homes 

coupled with local Community Health Teams (CHTs) that provide care coordination, counseling, 

transition assistance, and self-management and health education. AAAs offer CDSMP and CHTs 

refer consumers to the program. Community hospitals anchor services under the Blueprint, 

providing a highly stable delivery infrastructure and resources. Vermont’s Blueprint for Health 

originated as a community-based chronic care model. CDSMP has been an important part of 

the Blueprint since it was launched in 2003. Medicaid beneficiaries participate in the Blueprint 

for Health through a Section 1115 demonstration waiver authorized by CMS. 

Federal and state policies can encourage states and local agencies to build and sustain 

evidence-based programs. Under the Older Americans Act, states are required to submit fouryear State Plans on Aging to ACL to document accomplishments and future plans. Arkansas now 

requires each AAA region to offer at least one ongoing evidence-based program. 

This has incentivized a number of AAAs to focus on evidence-based programming. States 

reported that ACL’s new rules requiring states to use Title IIID funding for evidence-based 

programming has helped with program sustainability. 

CMS reports a record number of states pursuing Section 1115 demonstration waivers for 

Medicaid reform. Each state’s strategy varies, but typically states are seeking 1115 waivers to 

enable them to bring all or most Medicaid populations and services under one global waiver. 

These waivers typically involve a managed care model that uses a single enrollment and 

assessment process, provides care coordination, and emphasizes wellness and prevention. A 

number of states recognized opportunities for incorporating CDSMP, but reported limited 

involvement by their agency in the state’s Medicaid reform initiatives.

Several grantees cited the federal demonstrations targeting dual eligibles as a potential 

opportunity to offer CDSMP. The Center for Medicare and Medicaid Innovation (CMMI) 

awarded design grants to 15 states in 2010 to develop innovative service delivery and financing 

models for dual eligibles. In 2011, CMS announced two new financial alignment models for dual 

eligibles and 26 states have expressed interest in pursuing one of these models. Michigan 

received a design contract and the State reported exploring with the design contract team ways 

in which CDSMP might be incorporated. 

Grantees also reported interest in incorporating CDSMP into Accountable Care Organizations 

(ACOs), medical/health homes, and Care Transitions programs. Minnesota reported that an 

AAA is partnering with a health home that will include patient self-management supports under 

that state’s Integrated Systems Grant. Georgia reported that a CDSMP referral mechanism is 

being built into a CMS-funded Community-based Care Transitions Program demonstration in 

that state.
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Nevada expressed interest in promoting CDSMP to health plans offering products in the 

individual and small-group markets in the State’s health insurance exchange, due to begin 

operation on January 1, 2014, as required by the ACA. The State also sees the possibility of 

creating a chronic disease registry working through the exchange. 
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CHAPTER 9: BEST PRACTICES AND RECOMMENDATIONS

Our analysis of data collected during site visits and telephone discussions with grantees 

suggests a number of “best practices” for developing and sustaining CDSMP programs for older 

adults. Federal and state policies and state health reform initiatives can significantly influence 

CDSMP development and sustainability. States demonstrated creativity and tenacity in seeking 

innovative ways to recruit and retain leaders, market CDSMP to consumers and providers, and 

integrate CDSMP into broader delivery networks and systems. Best practices are discussed 

below, followed by recommendations for incentivizing continued development of strong, 

sustainable CDSMP programs. 

Ensuring long-term sustainability will require multiple strategies, but the evaluation team 

believes that positioning states to diversify their funding streams and receive third party 

payment should be a goal shared by all states and stakeholders. This will require documenting 

the effectiveness and efficiency of CDSMP delivery, conducting cost finding and establishing 

payment rates and approaches for delivering the program, and working with private health 

plans, Medicare Advantage plans, and Medicaid managed care organizations to incorporate 

CDSMP as a billable service for members. The time is right, with public and private health plans 

actively embracing health promotion, care coordination, and medical home models and states 

adopting more expansive managed care for public beneficiaries.

9.1 Best Practices

Best Practice 1: Infrastructure Development and Support

In accordance with AoA’s promotion of integrated, sustainable service delivery, grantees 

developed strategic partnerships and infrastructure to support the statewide delivery of 

CDSMP. Grantees reported wide variation in the development and use of infrastructure to 

support CDSMP program operations. Often, CDSMP was housed with other evidence-based 

programs for older adults in departments of aging or public health. In states like New Jersey 

and Ohio, CDSMP programs benefited from established state government programs and 

infrastructure, often extending to data collection and evaluation. Other states provided CDSMP 

as free-standing programs, offering basic program supports. Clearly, embedding CDSMP with 

other programs creates a stronger infrastructure and increases the likelihood of program 

sustainability. While there are no firm parameters for the most efficient or effective resource 

levels for statewide CDSMP programs, states with established infrastructure and support are 

clearly advantaged in implementing and sustaining their programs. 

Resource levels: Not surprisingly, grantees that were able to garner substantial resources 

and infrastructure to support their programs tended to have stronger programs with more 

offerings, and were better able to withstand reductions in funding when ARRA grant funding 

came to an end. Grantees with less developed program operations were more vulnerable, 

both during program implementation and following ARRA grant funding. State grantees with 
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fewer resources were more likely to report the need to discontinue or scale back activities 

such as leader training, recruitment and outreach, marketing, data collection, and 

evaluation. In some cases staff positions were eliminated. 

Best Practice 2: State Health Reform and Public and Private Community-Based Initiatives

Several grantees have been able to incorporate CDSMP into state health reform, public health 

initiatives, and other programs, thereby helping to expand program availability and ensure 

sustainability. These efforts have aligned with AoA’s promotion of embedding CDSMP into 

statewide health and long-term service and supports systems. Some states have included 

CDSMP as a prominent component of statewide programs, including Medicaid and CDC 

Community Transformation grants. Grantees have also successfully embedded workshop 

leaders into public agencies and included CDSMP training and workshop development as part of 

staff positions. This helps to ensure a stable workforce of leaders and positions CDSMP 

advocates and experts within the agency. Many of these staff positions are non-grant-funded or 

“regular” positions, so tend not to be affected by downturns in grant or discretionary funding. 

This approach also establishes multiple funding streams for CDSMP, which helps to sustain the 

programs when federal funding declines or comes to an end. Examples include:

Vermont Blueprint for Health: AAAs offer CDSMP as an integral part of Vermont’s innovative 

Blueprint for Health, a statewide network of patient-centered medical homes that 

emphasizes care coordination, transition assistance, health education, and selfmanagement. 

Community Care of North Carolina: This nationally acclaimed system of medical homes for 

Medicaid beneficiaries, Medicare-Medicaid dual eligibles, and privately insured individuals 

partners with local AAAs to provide CDSMP to members.

Embedded CDSMP trainers and workshop leaders: A number of states reported that paid 

staff in state and local agencies and/or partner organizations have been trained as CDSMP 

leaders. Private health plans have also used this approach. Triple S, a Medicaid plan in 

Puerto Rico, trains staff as leaders and delivers CDSMP to members in its Medicaid health 

plan directly. Kaiser Permanente also trains leaders and conducts its own workshops for 

members. 

Best Practice 3: Partnerships to Expand Reach and Extend CDSMP to Special Populations

AoA expects states to develop adequate capacity to provide CDSMP workshops throughout the 

state to all residents. State grantees reported success working with a wide range of public and 

private partner organizations and groups, including local coalitions and collaboratives, state and 

local agencies and organizations, and employers to support AoA’s vision. Partnerships have 

enabled access to special populations (e.g., cultural/ethnic minorities, inmates, individuals with 

specific diseases or conditions), expanded program referrals, and enhanced the resource base 

available to grantees and their host and implementation sites. Partners may refer to 
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community-based workshops or hold their own licenses and convene their own workshops. 

Partners play an important role in diversifying resources for and sustaining CDSMP programs 

outside direct federal funding streams.

Coalitions and collaboratives: States engaging with existing collaboratives or starting up 

new ones to support development and dissemination of CDSMP generally reported that the 

collaboratives made a difference in bringing stakeholders on board and generating broad 

support for CDSMP. Strong collaboratives already in existence with complementary missions 

to promote health and disease prevention seemed to be advantageous. 

Place-based partners: Partnerships with senior housing complexes enable states to “bring 

the program to the consumer” and alleviate the need for transportation to workshops. 

While our data showed residential sites to have among the lowest completion rates across 

settings, some host sites reported that residential settings enabled delivery of CDSMP to 

individuals with multiple chronic conditions for whom travel and logistics could be barriers 

to participation. Several states reported partnering with their departments of corrections to 

offer CDSMP to inmates. Oklahoma has established CDSMP as a peer educator program and 

inmates who complete CDSMP receive credit toward reducing their sentences. Oklahoma 

also partnered with libraries in rural areas to reach individuals in these locales.

State service and community education programs: State grantees reported partnering with 

community hospitals, YMCAs, community colleges, local four-year colleges, county parks and 

recreation programs, local fire departments, and libraries to take advantage of these 

established resources. Ohio is working with the State’s Rehabilitation Services Commission, 

convening CDSMP workshops that “wrap around” employment supports provided to 

consumers with disabilities. The goal is to enable persons with disabilities to better manage 

their chronic conditions so that they are able to work and be independent. One AAA in 

Washington is pursuing a partnership with that State’s Division of Vocational Rehabilitation. 

A variety of community partners offer classroom space for educational programs as well as 

established marketing vehicles (e.g., mailings, Web sites) with electronic registration and 

billing systems. 

Workplace programs: Several states reported offering CDSMP to state or local government 

employees, giving release time from work for the first hour or hour-and-a-half of each 

workshop session. Other states were exploring similar partnerships with private companies. 

Several grantees expressed interest in expanding program reach to private employers and 

worksites, but have been struggling to establish payment arrangements.

Best Practice 4: Establish Referral Networks 

AoA promotes a coordinated process for recruitment, intake, referral, and 

registration/enrollment. One strategy state grantees and host sites have used to facilitate 

participant recruitment and target individuals likely to benefit from CDSMP is to establish 

referral networks through public and private partnerships. While some grantees reported 
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difficulties collaborating with physician groups, others reported that partnerships to establish 

referral networks with healthcare practices were particularly effective for recruiting 

participants. Electronic health records have been used to support panel management to target 

individuals likely to benefit from CDSMP workshops in some settings. Other referral sources 

states have used include FQHCs, state AHEC networks, and ADRCs associated with AAA 

networks. 

Physician practices and health plans: Host sites in Vermont and Rhode Island have reached 

out to local physician practices and have established referral arrangements for CDSMP 

workshops. A host site in Vermont recounted an effort to encourage a local physician group 

to mail letters to patients with a body mass index above a certain threshold to encourage 

them to enroll in a local CDSMP workshop. A letter from a physician proved to be a powerful 

force for convincing consumers to participate in CDSMP, although the site cautioned that 

communications must be carefully crafted to balance tact and confidentiality. While some 

sites reported that outreach to physicians and health plans was challenging, others have 

successfully reached out to physicians and health plans serving Medicaid and Medicare 

Advantage members to encourage the plans to refer members to CDSMP.

FQHCs: Several states reported partnering with state primary care associations to offer 

CDSMP through FQHCs. One FQHC network is considering including a CDSMP referral button 

in their electronic medical record. Others have trained staff as CDSMP leaders and host 

workshops. FQHCs offer an opportunity to reach low-income populations and many are 

pursuing medical home models of health care delivery.

ADRCs: Some states reported that ADRCs are an important source of consumer referrals to 

CDSMP. New Mexico’s ADRC (there is one statewide ADRC in New Mexico) uses a tool to 

screen callers that includes a chronic disease indicator so that ADRC staff can refer 

appropriate callers to CDSMP. Rhode Island’s ADRC—The POINT—refers callers to CDSMP. 

Arizona reports ADRC referrals as well. Idaho is actively seeking to collaborate with ADRCs 

for marketing and referrals. Nevada envisions their online ADRC portal that is now under 

development as a mechanism for consumer information and registration, provider referrals, 

and communications with leaders.

Medicaid consumer hotlines: Although no longer in operation because of budget cuts, an 

information and referral hotline for Medicaid beneficiaries in Missouri trained health 

coaches to screen and refer callers to CDSMP.

Electronic health records and registries: While there were significant variations in scope and 

quality, electronic health records and registries are under development in a number of states 

for provider referrals and so that leaders can more easily be monitored and recruited for 

workshops.
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Best Practice 5: Technical Assistance and Evaluation

As part of its key elements to an integrated, sustainable service delivery system, AoA strongly 

encourages grantees to develop quality assurance programs and ongoing data systems and 

procedures. Many grantees have partnered with local colleges and universities for technical 

assistance, data collection, and evaluation support and report that these are valuable, 

productive relationships. Partnerships such as this can help states access special skills and 

resources. In some cases grantees reported that contractual relationships for technical 

assistance provided by a partner organization can help ensure continuity of services in the 

event of legislative impasses that may otherwise affect the program. Technical assistance for 

some grantees also included training leaders and monitoring fidelity. We include these as a best 

practice for their contributions to CDSMP program support and success. Some examples 

include:

University Partnerships: New York, Missouri, and West Virginia are some of the states that 

have partnered with universities for technical assistance, data collection, and program 

monitoring and evaluation. New York contracts with the Quality and Technical Assistance 

Center at the State University of New York at Albany for assistance with infrastructure 

development, data collection and management, and quality monitoring. The Missouri 

Arthritis and Osteoporosis Program at the University of Missouri provides technical 

assistance on program implementation and sustainability to local programs, as does 

Marshall University’s Center for Rural Health in West Virginia.

Other Technical Assistance Partnerships: California partners with a nonprofit, Partners in 

Care Foundation, for technical assistance and CDSMP program oversight. The California 

Department of Aging focuses on policy and, through an ongoing contract, delegates 

responsibility to Partners in Care for implementation of all evidence-based prevention 

programming. The Arizona Living Well Institute is a new nonprofit established to coordinate 

CDSMP workshop delivery, train leaders, and manage program data.

Best Practice 6: Evaluation for Program Planning and Management

Under the ARRA grants and as part of AoA’s vision for long-term sustainability, grantees were 

required to submit data on CDSMP enrollment, participation, and completion to NCOA. Many 

grantees reported using these data for program planning. In many cases states supplemented 

these data with pre- and/or post surveys of participants addressing satisfaction with CDSMP 

and changes in knowledge and/or behaviors (see Chapter 7 for more information on evaluation 

efforts by grantees). Grantees also used other state and program data to monitor and evaluate 

their programs, identify gaps in services, assess availability of leaders, target demand for 

workshops, and more. Several grantees reported collecting basic program data to monitor 

fidelity. Evaluation support was built into some programs; in others, the grantees relied on 

evaluators of other state programs or on external evaluators from universities. Grantees 

generally agreed that evaluation is a useful program management tool that provides a 

foundation for program planning, monitoring, and performance improvement. About half of 
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grantees reported that they intend to continue collecting, reporting, and using these data to 

support CDSMP delivery. For example, the in-house evaluator in the department of aging in 

Oklahoma will continue to collect and report data, as will Vermont, whose data reporting is 

integrated into the state’s Blueprint for Health. 

Best Practice 7: Third-Party Payment for CDSMP

AoA promotes working with public and private insurers to ensure financial sustainability 

beyond the grant period. Grantees are in widespread agreement that third-party payment

arrangements are needed to successfully sustain and expand CDSMP. However, progress in this 

area has been limited to the experience of a small number of grantees and host sites that are 

exploring how such arrangements could work and be scaled broadly. Great variation in cost 

structures and capabilities across AAAs and other host sites, most of which have traditionally 

operated as grant-funded organizations, has resulted in pricing that is variable and often 

impractically high for fee-for-service payment. Bundled rates as part of the patient-centered 

medical home, flat-rate grants or payments, and cost- or rate-based fee-for-service payment 

are among the possibilities under consideration. Many are examining Medicare reimbursement 

requirements for DSMP as an example. Two significant efforts in this area include:

Medicaid reimbursement: As discussed in Chapter 8, Washington has successfully 

demonstrated how CDSMP can be reimbursed as a service under a 1915(c) HCBS Medicaid 

waiver in its COPES waiver for older adults. Washington’s strategy could be used as a model 

for other states.

Programs for Medicare-Medicaid Eligibles (“dual eligibles”): One of the health plans that 

participates in Minnesota’s Senior Health Options program for dual eligibles reimburses 

CDSMP workshop providers. 

Best Practice 8: Federal and State Policy to Promote Evidence-Based Programming

In its key elements for long-term sustainability, AoA strongly supports effective policies and 

partnerships to embed CDSMP into statewide systems. There are many opportunities for states 

to promote availability of CDSMP and other evidence-based programs through federal and 

state policies. Grantees have used state policy mechanisms and recent provisions to advance 

prevention and wellness under federal health reform to make available and sustain these 

community-based programs. For example: 

State legislative change: Arkansas reported that they now require AAAs to include at least 

one evidence-based program in their four-year State Plans on Aging. Other states have 

pursued similar strategies to advance CDSMP.
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From the Arkansas State Plan on Aging: “The state unit on aging will require all AAAs to 

implement at least one Evidence-Based Disease Prevention (EBDP) program in all senior centers 

in their PSA. Implementation will begin with SFY 2008 and will be phased in over a four-year 

period with all senior centers participating by 2011. The AAA may address one of the following 

prevention areas: chronic disease self-care, physical activity, fall prevention, nutrition and diet, 

and depression and/or substance abuse ... Each AAA [must provide] ... a strategy for phasing in 

the EBDP program over the four-year period ... and to assess all EPDP programs at least 

annually.” 

Source: Arkansas State Plan on Aging, pp. 34-35. Retrieved at http://www.daas.ar.gov/pdf/arstateplanonaging08.pdf. 

Title IIID funding: The FY 2012 Older American Act Congressional appropriations required, 

for the first time, that Title IIID funding be used only for programs and activities which are 

evidence-based. A number of state grantees reported that this requirement has promoted 

the adoption of CDSMP by giving the state unit on aging new authority to direct local 

agencies to use Title IIID funds for evidence-based programs. 

Medicare reimbursement for DSMP: Section 4105 of the Balanced Budget Act of 1997 

authorized Medicare coverage for diabetes self-management training. While authorization 

for reimbursement does not extend to CDSMP or other self-management programs, 

coverage for DSMP represents an important opportunity for states to embed DSMP into 

their community-based evidence-based programming. Massachusetts was recently approved 

for reimbursement and Illinois expects to follow soon. Experience with Medicare 

reimbursement for DSMP could be useful in helping states to establish payment rates and 

billing practices for CDSMP.

9.2 Recommendations

To continue to build and expand CDSMP, the evaluation team offers the following 

recommendations to ACL.

Recommendation 1: Support Grantees in Communicating the Benefits of CDSMP to State 

Policy Makers

Time and again state grantees remarked that in order to convince state legislators and agency 

leaders of the importance of building and sustaining a strong CDSMP program, they must be 

able to demonstrate the benefits of CDSMP for residents of their state. Grantees stressed the 

importance of having data on both improved health outcomes and demonstrated cost savings. 

The peer-reviewed literature includes a number of evaluation studies in which improvements in 

health behaviors, health status, and health service utilization have been documented through 

self reports by CDSMP participants as well as more rigorous studies of impact and outcome 

including the original clinical trials that establish the evidence base for CDSMP by Stanford 

University. Grantees could benefit from guidance on which research studies could best support
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their advocacy efforts at the state level, as well as how to “message” research findings to 

convince policy makers that similar outcomes could be expected in their state. 

ACL and CMS should continue to pursue studies of cost effectiveness using Medicare and 

Medicaid fee-for-service administrative data. In addition, cost-effectiveness studies in managed 

care settings could help persuade health plans to either provide CDSMP directly or offer 

members access to state programs. Several grantees reported interest from Medicare 

Advantage plans, Medicaid managed care plans, and private insurance plans. Health plans 

active in multiple states may be interested in multi-state demonstrations and evaluations. Once 

cost-effectiveness studies are completed, grantees will need assistance with messaging findings 

so that their applicability can be understood by state policy makers. 

Grantees should also be supported in their efforts to continue collecting and monitoring 

program performance data, either through technical assistance and/or grant programs to 

support data collection activities. It will be important for grantees to monitor participation and 

completion rates, participant satisfaction, leader performance, and fidelity in order to help 

convince state policy makers that program dollars are well spent and to continue funding the 

program. To support data collection efforts, ACL should continue to allow grantees to enter 

data into and receive reports from the NCOA database even if they are no longer receiving AoA 

funding. Technical assistance could also be provided to states interested in collecting additional 

data. Encouraging grantees to partner with local university-based research centers to collect, 

analyze, and report performance data could be beneficial as well. 

Recommendation 2: Assist States with Determining the Cost of CDSMP and Preparing for 

Third-Party Payment

States are eager to seek payment for provision of CDSMP from diverse funding sources but 

have no established methodology for determining the true cost of the program. NCOA provides 

a cost calculator developed by the Lewin Group that states can use to estimate the costs of 

program delivery. However, more sophisticated state and region-specific information is needed 

to determine the actual per capita cost of providing a CDSMP session to ensure that the service 

is priced correctly and the program does not operate at a loss. As in any business model, the 

cost calculation should include product development, marketing, service provision, quality 

assurance, and indirect costs. States would benefit from a sophisticated model developed by a 

reputable accounting firm, as well as technical assistance in applying the model. Having 

defensible estimates for per capita cost will be important in negotiating payment with 

providers, third-party payers, and employers. Payment options range from fee-for-service 

payment per workshop or workshop session, to per capita completion payments, bundled 

rates, or global payments from health plans, patient-centered medical homes, accountable care 

organizations, and other purchasers. 

The transformation from grant-funded programs to a third-party payment business model will 

require the capability to bill for services. A technical assistance program that aids states in 

developing billing system requirements, issuing procurements to prospective vendors, 
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implementing new billing systems and linking them to other systems (e.g., Medicaid MMIS, 

electronic registration systems), and training staff to manage billing functions would be 

welcomed by states. Grants to states for purchase and implementation of systems would also 

be beneficial.

Certification processes and programs for Medicare reimbursement for community-based 

delivery of DSMP are now available and several respondents in the evaluation interviews 

suggested that DSMP could well provide a model for CDSMP. ACL and CDC should continue to 

provide grants and technical assistance to states seeking to become certified to receive 

Medicare reimbursement for DSMP. In addition to expanding access to DSMP, this will help 

states to build the capacity to bill for self-management programs, which will in turn support 

state efforts to bill health plans and Medicaid. Additionally, ACL and CMS should evaluate the 

DSMP experience and consider the prospects for statutory change that would permit Medicare 

reimbursement for CDSMP. 

Recommendation 3: Promote Peer Learning Among Grantees

State grantees are eager to learn from the experiences of other grantees. Creative peer learning 

opportunities in which grantees are “matched” with other grantees to provide peer technical 

assistance could spur more rapid program expansion through the use of proven 

implementation strategies. This could be coupled with a Web site that organizes resources 

supplied by grantees (i.e., manuals, organizational charts, marketing plans and materials, 

legislative reports, sample contracts, requests for proposals, Medicaid rules, survey 

instruments, evaluation reports) around implementation topics (e.g., delivery system oversight 

and organization, outreach and marketing, recruitment and retention of leaders, building 

referral networks, fidelity monitoring, program evaluation). Mini-case studies on best practices 

and peer technical assistance that had a significant impact on program implementation could 

also be shared. Activities such as these are currently provided by NCOA. ACL should continue to 

support current and expanded options for peer knowledge transfer.

Recommendation 4: Develop an Electronic Registry for Leaders

Few states have electronic systems for registering leaders, scheduling leaders for workshops, 

and monitoring leader certification. An electronic registry could facilitate efficient training and 

leveraging of leaders within and across states and regions, including providing interstate access 

to leaders. ACL could sponsor the development of a web-based electronic registry that could be 

used by all states. The registry could be designed for states to use individually (i.e., each state 

would only have access to their own data, but all states could use the system) or by groups of 

states (e.g., smaller states in the northeast that may want to share leaders across state lines). 

Alternatively, ACL could sponsor the development of registry software that could be 

downloaded and customized for use by individual states (i.e., a freeware or shareware 

program). 
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Recommendation 5: Educate Health Professionals about Self Management

Universities in New Jersey, Ohio, and Illinois have incorporated education about selfmanagement and evidence-based health promotion programs into their nurse training 

programs. In some states, health professions students are being trained as CDSMP leaders and 

are referred to organizations that are seeking volunteer leaders. While this strategy is not likely 

to significantly increase the leader workforce in the immediate future, educating health 

professionals about the importance of self management could, over time, have an impact in 

practice settings. ACL could work with professional societies such as the American Association 

of Colleges of Nursing to develop curricula on self-management education that could be 

adopted by other nurse training programs. Curricula could also be developed for practicing 

professionals that could be offered online or at professional meetings, with continuing 

education unit (CEU) credits awarded to professionals completing the programs. 

Recommendation 6: Assist Grantees in Developing More Effective Strategies for Building 

Referral Networks for Recruiting Participants 

Grantees reported that building an effective referral network for recruiting participants was 

perhaps the most daunting challenge they faced. Given the pressures on today’s medical 

practices, getting physicians to directly refer patients was rarely a successful strategy.42

However, some grantees reported success with special mailings generated by physicians’ offices 

(signed by the physician) to patients whose medical records indicated they might benefit from 

CDSMP. Other grantees reported efforts to incorporate a “button” in the electronic medical 

record that could trigger a patient referral. Additionally, some health plans were identifying 

members who might benefit from a self-management program through medical record 

reviews—and in some cases, providing cash rewards for participation. Strategies such as these 

warrant further exploration. In addition, more research is needed to identify the personal, 

social-behavioral, and clinical characteristics of individuals most likely to participate, complete, 

and benefit from the program and how to effectively target these individuals using electronic 

medical records. 

With the growth of ADRCs, ACL has a unique opportunity to encourage referrals within the 

aging and disability services networks. ADRCs in some states are referring consumers to 

CDSMP, but the practice is not yet widespread. ACL’s technical assistance contractor could 

develop a training module for ADRC staff on incorporating self-management program referrals 

into the ADRC screening and options counseling processes. This could include developing 

several questions related to chronic disease management that could be integrated into the 

initial screening questions ADRCs use when a consumer calls for the first time, as well as 

developing guidelines for building self-management program counseling and referrals into 

options counseling. Nevada’s vision for integrating CDSMP into their ADRC Web site—using the 

 

42 This is consistent with findings from other studies. See Lorig KR, Hurwicz ML, Sobel D, Hobbs M, Ritter PL. A 

national dissemination of an evidence-based self-management program: a process evaluation study. Patient 

Education and Counseling, 59 (2005), 69-79. 
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portal for consumer information, workshop schedules and registration, communications with 

and reporting by leaders, and on-line leader training—could be promoted to other states 

through webinars and presentations at ADRC grantee meetings, as well as through technical 

assistance on implementing these functions.