NH Chronic Disease Self-Management Program Better Choices-Better Health Sustainability Plan May 2012 Program Description: The Better Choices, Better

NH Chronic Disease Self-Management Program Better Choices-Better Health Sustainability Plan May 2012 Program Description: The Better Choices, Better Health Program (BCBH) is the NH version of the Chronic Disease Self-Management Program, an evidence-based program developed by Stanford University. Its purpose is to teach individuals and caregivers, who are coping with one or more chronic conditions/illnesses, how to better manage symptoms and improve their day-to-day living. The program is licensed and contains strict fidelity monitoring requirements. Individuals attend a series of six weekly sessions, facilitated by two trained leaders who also have a chronic disease or illness. Each session is 2 ½ hours long and participants develop an action plan for coping with their illness/disease going forward. Unlike other evidence-based programs, BCBH is not disease-specific but addresses common issues and challenges presented by a variety of conditions. The BCBH Program does not contradict the medical care and guidance that individuals receive. It complements disease-specific education programs and medical care given by providers. Individuals can easily take part in the BCBH Program before, after, or in conjunction with participation in disease-specific programs. Purpose of Sustainability Plan: The purpose of this Sustainability Plan is to outline direction, objectives, and known funding sources to carry forward the NH project developed under a two-year grant from the US Administration on Aging. The grant enabled the Department of Health and Human Services (DHHS) Division of Public Health Services (DPHS) and Bureau of Elderly and Adult Services (BEAS) and its key community-based partners to develop and solidify an organizational structure to deliver BCBH throughout the state. The grant period closed on March 31, 2012, but certain components of the project, including a statewide license to conduct BCBH workshops, statewide marketing materials and a trained leader network are well established and sustainable. Leaders are committed to continuing to recruit participants, secure sites and provide ongoing workshops, and DHHS staff have incorporated BCBH into their work responsibilities. Statement of Need: In the 2010 US Census data, NH was ranked the fourth oldest state in terms of its median age. Of great significance is that all of the New England states rank in the top 10 of all states in terms of oldest median age. This is a very significant demographic and may present opportunities for the New England states to collaborate on a broader level to address the prevention needs of this rapidly expanding population on a larger regional basis. With the aging of the population and accompanying burden of chronic disease in NH, the need for effective management of costly chronic conditions is increasing rapidly. The evidence-based BCBH Program represents one compelling opportunity to address this need. National research has shown decreases in both outpatient visits and hospitalizations among those who complete BCBH workshops. The program has been proven to decrease anxiety, frustration and fatigue and to improve overall health. In the years since Stanford developed the program, participants surveyed at various intervals after taking the classes consistently report a higher level of confidence in coping with their conditions, more effective communication with others about their needs, ability to take actions to avert or alleviate symptoms, and being more satisfied with the quality of their lives. History of Work in NH: The Diabetes Education and Asthma Control Programs, both funded by the Centers for Disease Control and Prevention (CDC) and located in the NH DPHS started exploring the possibility of building capacity for BCBH. 1

Two statewide meetings were convened in 2008 and 2009 for health care providers and community organizations interested in learning about BCBH and to begin planning how to bring the program to NH. Sufficient interest led to collaborating with the Vermont Department of Health, which already offered CDSM as part of its Blueprint for Health, to conduct a CDSM Master Training in the fall of 2009 for people interested in conducting CDSM consumer workshops and training leaders. Nine people in NH and ten in Vermont completed the training. Subsequently, the NH group established a BCBH Network and began holding consumer workshops in order to complete the requirements for qualifying as master trainers. Concurrently but separately, BEAS designated a small portion of its state general funds to develop and deploy mini-grants to a number of the State s senior centers to help them to develop infrastructure for wellness and prevention programs. In 2009, DPHS and BEAS collaborated on an Administration on Aging (AoA) grant application and a two-year grant was awarded in March 2010 to support BCBH capacity-building activities in NH. Current Status: The DPHS Chronic Disease Programs and BEAS are the state leads for the program. Key community partners are the Southern and Northern Area Health Education Centers (AHECS) and NH s senior centers. Representatives from these organizations comprise the project management team. The Southern Area Health Education Center holds and maintains the Stanford license and is responsible for the fidelity monitoring of the program. The AHECS have been responsible for the deployment of the program statewide, including coordinating all logistics of leader and participant recruitment, leader training, coordinating workshop sites, marketing, site development, conducting critical pre and post-participant surveys, data reporting and ensuring program fidelity. The Southern AHEC collaborated with the Institutional Review Board at Dartmouth to obtain formal approval of the pre and post surveys that are done with program participants. While national data exists to support the impact and success of the program, the project management team determined that acquiring NHspecific data was imperative to inform the further development, structure and sustainability of the program. NH s senior centers, Community Action Agencies and NH s ServiceLink Resource Center network (NH s designated Aging and Disability Resource Centers) have participated as key leader recruiters, participant recruiters, and workshop development sites and have promoted the program extensively in their communities throughout the state. In addition, hospital providers and health providers in community settings have enthusiastically promoted the program, trained leaders, hosted workshops and have provided significant commitment to the program. The project has been informed and guided by the involvement and dedication of numerous diverse community partners. In addition, the availability of the resources of the National Council on the Aging, including monthly technical assistance calls and a wealth of resource materials has been invaluable in shaping and guiding the program. The project management team established two working groups for Infrastructure and Marketing Development, spearheaded by the AHECS. These two groups have provided tremendous support to these two critical functions. In addition to participating in the monthly project management team meetings, the two groups have worked concurrently to develop and carry out all aspects of program development, deployment, marketing strategies and the development and dissemination of all marketing materials. In addition, an Advisory Committee was convened. The Advisory Committee is comprised of diverse representatives from the medical community, health insurers, agencies providing health education, aging services providers, AHEC and DHHS staff members. The Advisory Committee has guided the further development of the network and the development of this sustainability plan. In addition, regional and statewide networks of master trainers and leaders have convened and meet to share information, discuss challenges and share perspectives on working directly with participants. 2

With the AoA grant funds and resources from all of the network members, the BCBH program has been deployed through a diverse network of service providers and agencies. Over 400 individuals over the age of 60 have participated in the 6-week program in a variety of venues, and the program has been expanded throughout the state. The grant funding afforded the opportunity to establish connections between aging services, public health, community aging services providers and medical providers. This momentum has continued to develop. There are three key and overlapping components in this sustainability plan for the BCBH Program: Organizational, Community and Financial. The following section outlines NH s current status and capacity in these areas. Organizational Sustainability Components: XX Established mission, goals and objectives for communities served: Mission and goals for the statewide network were established for the 2-year AoA project period. At the close of this funding period the Management Team will set additional goals for the upcoming 2-year period. At this time it is anticipated that community host agencies will establish objectives for their own service areas. XX Management support of efforts: Management within NH DHHS, key collaborating partners, community partners and host agencies has been and continues to be very supportive. Management has facilitated the efforts of DPHS and BEAS staff to incorporate the project into ongoing programs. DPHS and BEAS staff will continue to provide leadership for the program. Management support for leader training among host agencies also continues to be strong, and community health centers and hospitals endorse the program, train leaders, subsidize publicity and offer workshops on site. XX Interventions embedded into menu of services offered: BCBH has already been embedded into a number of existing programs and activities. Examples include hospital community education programs, regular programs at senior centers, and inclusion in ongoing employee wellness programs. XX Staff time dedicated to efforts: As above, DHHS staff, key partners and agency staff are embedding BCBH into their work plans in their respective agencies. XX Established local partnership/coalition to support efforts: NH established a statewide BCBH network of leaders several years ago. Throughout the last two years this network has continued to meet regularly and has added members. Network logistics are managed primarily by the AHECs and the DHHS staff. All partners are committed to continuing this network. XX System in place to acquire needed program materials, resources, etc : Southern NH AHEC serves as the statewide coordinator for the bulk purchase of BCBH supplies, materials, and development and coordination of publicity. XX Effective marketing techniques in place: Central coordinators and network members have utilized a variety of marketing techniques and have customized the most effective methods to their communities. Outreach methods include brochures, news articles and ads, web sites, health provider publications, physician outreach and provider referrals. Coordinated techniques appear to be more effective, such as initial physician recommendation, reinforced by written and phone follow-up. Once a potential participant has expressed interest, personal follow-up call(s) from BCBH leaders have proven helpful for recruiting and retention. An important benefit of the BCBH network is the opportunity for workshop leaders to share successful marketing approaches and brainstorm ways to overcome challenges in recruiting participants. XX Sustainability plan written and shared with partners: This Sustainability Plan will be widely distributed among BCBH Network members, partners, community agencies, and key health care partners. 3

Community Sustainability Components: XX Reliable local partnerships with vested program interest and commitment: A pool of reliable and committed Master Trainers and class leaders has been established. Additional leader trainings are scheduled in 2012. Approximately half of the Master Trainers originally trained through DPHS regularly conduct leader trainings within the state as needed. To date the current capacity for Master Trainers has been sufficient to assure that an adequate number of new leaders are trained each year. XX Community capacity to maintain the established delivery system: The strength of the NH BCBH network has been its ability to integrate with community agencies that have interest and resources to sustain the program. NH has experienced particular success in establishing BCBH within its network of community health centers, senior services organizations, and local hospitals. XX Interventions accessible to majority of target populations: The Work Plan established for the AoA grant included an objective to expand BCBH to each of five geographic areas of the state. This objective has been met, with multiple host sites in most geographic areas. The west central part of the state remains an area in which BCBH capacity is still limited, so the BCBH Management Team will continue to encourage new BCBH activity in this area. XX Program champion/advocacy support in community: The BCBH network has a number of program champions from diverse provider and community backgrounds. Due to NH s small geographic size the most effective advocacy for BCBH has been through health and social service contacts and local channels. The project management team continues to advocate with insurers to consider including BCBH within applicable menus of covered benefits such as employee wellness provisions. Financial Sustainability Components: No single funding source is available to sustain the entire cost of coordinating and deploying the program. The program will be supported through blended funding. The project management team has outline discrete components of the current program and is identifying potential funding sources for each component: Title IIID: Under its AoA funding, BEAS receives an allotment under Title IIID to support evidence-based activities for older adults, such as substance abuse/misuse education and intervention. BEAS has committed a portion of its Title IIID annual allocation to provide funding for the BCBH program in the future. BEAS has affirmed its commitment to the program by its inclusion in NH s newly approved four-year State Plan on Aging. This is part of a larger DHHS strategy to increase and expand prevention and wellness initiatives that impact older adults, and to expand opportunities for public health, the medical community and the aging network to further collaborate. BEAS Choices for Independence Medicaid Waiver Program: BEAS has submitted its request for a new 1915 (C) Waiver for the Elderly and Chronically Ill, to be effective in July 2012. Due to a number of converging factors, no new service package changes have been requested in the new waiver application in light of the State s pending implementation of a Medicaid Managed Care Program. It is anticipated that the addition of BCBH will occur at a later date. NH Medicaid Managed Care Program: DHHS has procured three vendors to design and implement a Managed Care Program beginning in late 2012. The long-term care population will be brought into the program in its second phase of implementation on or after July 2013. The Managed Care Request for Proposals included language requiring the development of prevention and wellness initiatives, which will be further defined as the service package development process continues. 4

DPHS Coordinated Chronic Disease Prevention and Health Promotion Programs: The NH DPHS Diabetes Prevention and Control Program has provided significant leadership for the grant project. Funded by the Centers for Disease Control and Prevention since 1996, its objectives focus on activities to prevent the onset of diabetes and work with education health professionals and the public to improve diabetes management and reduce costly complications. In recent years the CDC has encouraged all state-based Diabetes Programs to support BCBH as an evidencebased approach to help people manage their diabetes and prevent problems, and the NH Diabetes Program has included objectives related to BCBHP in its work plan since 2009. The NH Diabetes Program is committed to incorporating BCBH in its on-going work and a portion of its federal funding will continue to help maintain BCBH activities across the state. In addition, the DPHS Asthma Control Program has provided leadership and active involvement support in the BCBH network. It has primarily provided financial support to the program. Currently, the Diabetes and Asthma programs maintain a joint contract with an external vendor to implement professional education and clinical quality improvement activities. For 2012-2014, the section on BCBH in the contract scope of services will be expanded to incorporate some of the coordination, logistical, data collection, and monitoring and evaluation functions that were funded under the AoA grant. At this time, the amount of funding the Asthma Program will commit to the program has not been determined. Other DPHS Program Areas: Going forward, other DPHS programs that could incorporate BCBH into their interventions include but are not limited to the Tobacco Prevention, Injury Prevention, Heart Disease and Stroke Prevention, Comprehensive Cancer Control, and the HIV/STD/Hepatitis/TB Prevention and Care Programs. These program areas need to be engaged to both expand the breadth and capacity of the BCBH Network and strengthen financial support for program sustainability. Coincidentally, DPHS is in the midst of strategic planning to achieve stronger cross-program alignment, integration and coordination. Current DPHS prioritysetting actions provide opportunities to make BCBH a priority and fundamental public health intervention that many programs can and should support. Medical Home and Accountable Care Organizations: Currently in NH there are a number of organizations either designated or seeking designation as Medical Homes or Accountable Care Organizations. Many of these are organizations are represented in the statewide BCBH Network, and have integrated BCBH into the services offered to their patients in primary care settings through the use of other public and private funding. Anthem Blue Cross Blue Shield: Anthem is the current Administrator of Medical Benefits for the State of NH Employee Health Benefit Program. As such, Anthem has designated a representative to serve wellness needs of this large group, which is approximately 40,000 members at this time. The Anthem representative has developed and submitted a proposal to include BCBH as a wellness program to state retired employees. If approved by the State Health Benefit Program, state employee retirees will be able to attend BCBH workshops without cost. At this time host organizations have been charging minimal registration fees; most run between $0 and $25 dollars. Most registration fees are optional and are waived for those who cannot afford to pay. Cigna Health and Harvard Pilgrim Health Care Plans: Both of these major health insurance companies have actively participated in the project advisory committee and have provided information and support throughout the project. The companies have created and incorporated a number of evidence-based wellness programs into their menus of covered services and are considering the inclusion of BCBH. Hospital-sponsored BCBH: A number of acute care hospitals in NH currently offer BCBH and include BCBH workshops in their menu of community health education sessions, as above, registration fees are minimal, optional or waived. Leaders are regular community health education staff employed by the hospital, so potential costs for leader stipend or room rental do not need to be covered. Often a nominal $15 registration fee 5

will go toward purchase of the BCBH book, and/or purchase of refreshments and supplies such as flip charts. Hospitals cover most or all workshop-related charges and include these in their annual Community Benefits (charitable care) filing with the State of NH Attorney General s Office. Community Health Center (CHC) sponsored BCBH: A number of CHCs in NH also have trained BCBH leaders on staff, who offer regular workshops on site as part of their community care and educational offerings. Costs in these organizations are handled in a manner similar to the hospitals. BCBH sponsored by Aging Services Organizations: Through the AoA ARRA grant, a number of senior centers, congregate meal sites, and senior housing sites have trained BCBH leaders and held workshops. While these organizations may not be able to absorb the entire cost of future participant workshops, they will have an opportunity to supplement registration fees with other funding from sources such as BEAS Title IIID and other federal, state, or community grants. In addition, these sites have affirmed their commitment to continuing to offer the program by offering in-kind contributions, including free space to hold workshops. Program Coordination Functions Connected to Financial Sustainability: The section below lists line items that represent various administrative functions of the BCBH project funded under the AoA grant. This Sustainability Plan identifies whether these functions will need to be sustained following the end of the grant period, and if so by what means each necessary function can be funded. As described in the report, some functions can be embedded in partner organizations going forward. Alternative funding sources have been, or will be, identified for others. Central Coordination Functions: Workshop Scheduling Web site maintenance Workshop Data Collection and Submission for Stanford Fidelity Monitoring for Stanford NH Statewide Pre-post data collection, analysis and publication Central Supply orders Development and distribution of statewide marketing materials Technical Assistance to local organizations Network Meeting Arrangements Collection and submission of workshop data to AoA Stanford License Fees Pre-post Survey - Data Collection and Data Analysis and Reporting Workshop Materials Bulk Purchase Costs Leader Training Leader Stipend Host Organization Support (mini-grants) Master Training Master Trainer Stipend Additional avenues to be explored for potential funding support and not previously described include: Philanthropic/charitable organizations Third party funding Healthcare organizations (Veterans Administration, Federally Qualified Health Centers, etc.) Employers (work sites, local health departments) Continuing education (community and state college support, Lifelong Learning Institutes) 6

Advocacy strategies (working to raise awareness for future legislation, etc ) Bequest marketing (acquisition of estate and late-life transfers of assets) Fee for service In-Kind support Lessons Learned and Next Steps: Numerous opportunities exist and will be pursued to continue to promote the availability and positive impact of the BCBH Program. Relationships developed and strengthened throughout the grant period and as part of the work of the Advisory Committee will continue, which include aging services providers, the ServiceLink Resource Center network, medical and community health providers, the Dartmouth Centers for Aging and representatives from the three major private health insurers providing coverage in the state. For DHHS, the receipt of the AoA grant provided a new opportunity for DPHS and BEAS to work together for a common goal. The development of new working relationships has extended far beyond the project, enabling BEAS to become engaged in other DPHS initiatives and DPHS to be connected to the aging network and initiatives that are addressing the rapidly expanding aging population. The receipt of the AoA ARRA grant funds has facilitated the widespread growth, development and support of BCBH statewide. The funds provided the catalyst needed to build the program s infrastructure and solidify BCBH as a key preventative program for NH s seniors. Going forward, the partners brought into the program are committed to its continuance and a goal will be to expand it to other populations. 7