6 CDSME Sustainability Tool

OMB Control No. 0985-XXXX
Exp. Date XX/XX/201

CHRONIC DISEASE SELF-MANAGEMENT EDUCATION
INTEGRATED SERVICES DELIVERY SYSTEM ASSESSMENT TOOL
We designed this tool to help you evaluate your progress in building a sustainable infrastructure for Chronic Disease
Self-Management Education (CDSME) Programs and other evidence-based programs. The assessment covers six key
elements of an integrated services delivery system: 1. leadership, 2. delivery infrastructure, 3. partnerships, 4.
centralized and coordinated logistical processes, 5. business planning and financial sustainability, and 6. quality
assurance and fidelity. We think the tool can help to determine where you might invest resources to build a stronger
system.
Please remember to answer the survey questions from the perspective of your overall state–not areas within your state.
While we understand that there will be some variation within states, and that some localities may have individual
capacity, this tool is meant to ascertain the sustainability of the infrastructure and delivery system at the state-level.
Please feel free to use the “additional comments” space following each element to provide further information about
any areas you feel are unclear.
We ask that both of your state’s co-leads (state unit on aging and state health department) complete ONE tool together,
with input from other partners as time allows.
For questions about the assessment, please contact Emily Dessem at [email protected] or 202-479-6627.
Contact Information
Name of Primary Person Submitting the Survey
Agency Name
Email Address

Type of CDSME programs offered (Select all that apply)
o Chronic Disease Self-Management Program (CDSMP)
o Tomando Control de su Salud (Spanish CDSMP)
o Arthritis Self-Management Program (English)
o Arthritis Self-Management Program (Spanish)
o Chronic Pain Self-Management Program (CPSMP)
o Diabetes Self-Management Program (English)
o Diabetes Self-Management Program (Spanish)
o Positive Self-Management Program (HIV/AIDS)
o Better Choices, Better Health (Online CDSMP)
o Better Choices, Better Health for Diabetes (Online Diabetes)
o Better Choices, Better Health for Arthritis (Online Arthritis)
o Other:___________________________________________________________________
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According to the Paperwork Reduction Act of 1995, no persons are required to respond to a collection of information unless it displays a valid OMB control number. The valid OMB control number for this information collection is 0985xxx. The time required to complete this information collection is estimated to average 4 hours per response, including the time to review instructions, search existing data resources, gather the data needed, and complete and review
the information collection. If you have comments concerning the accuracy of the time estimate(s) or suggestions for improving this form, please write to: Administration for Community Living, 1 Massachusetts Avenue, N.W., Room
5203, Washington, D.C. 20001, Attention: PRA Reports Clearance Officer

ELEMENT 1: LEADERSHIP

Effective leadership and project management includes a strong state unit on aging and state health department
partnership, an integrated state vision, documented plan and mutually agreed-upon goals.
Please indicate which of the following is true in your state: (Select all that apply)
o Our state unit on aging and state health department have worked together to identify and target underserved
geographic areas.
o Our state health department and unit on aging have an integrated and documented vision for evidence- based
programming.
o Strategies to support CDSME or other evidence-based programming are included in our state unit on aging state
plan.
o Strategies to support CDSME or other evidence-based programming are included in our state health department
state plan.
o Strategies to support CDSME or other evidence-based programming are included in in another management
body's state plan.
o There is a management structure (e.g. steering group, coalition, partner team etc.) including public health and
aging that provides overall direction and leadership for CDSME in the state.
o Our state unit on aging and state health department have a signed agreement documenting responsibilities
related to CDSME.
o None of the above.
How often do your state unit on aging and state health department meet?
o Weekly
o Monthly
o Quarterly
o Semi-annually
o Annually
o Other, please describe: ________________________________________
Do you have any existing organizational charts or other graphics that describe your state's structure for managing and
delivering the CDSME program(s)?
o Yes.
o No.
Please select the key bodies that are involved in managing or directing CDSME activities at the state level:
o State unit on aging
o State health department
o State advisory council or other management team
o State coalition
o Foundation/ other oversight agency
o Other management body, please describe: _______________________________________
Which agencies are responsible for the following key functions?
(Select all that apply for each agency)

State unit on State health
aging
department
Develops plan for expanding CDSME
Convenes state advisory council/ other management
structure
Holds CDSME license
Coordinates master trainings
Develops and/or coordinates marketing/ promotional
activities
Manages website
Coordinates workshop calendar
Responsible for NCOA data entry
Conducts fidelity and performance monitoring
activities
Coordinates evaluation studies
Recruits major partners/ host sites
Seeks funding support
Provides technical support to trainers, leaders, sites
Designates Agency staff to work on CDSME
Recruits and trains T-trainers/MTs/Lay leaders

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Please indicate the extent to which the following statement is true in your state: Our state currently has a strong
leadership and project management team including public health and aging that will continue to lead CDSME efforts
after AoA funding ends.
o To a large extent
o To a moderate extent
o To a small extent
o To a very small extent
o Not at all
Any additional comments:

ELEMENT 2: DELIVERY INFRASTRUCTURE
To make certain that evidence-based programs are as “accessible as prescription medications” requires ensuring a
delivery infrastructure with an adequate workforce that can support the number of workshops needed to ensure that
programs can be delivered statewide to the targeted populations.

Which of the following elements are currently part of your CDSME delivery system?
(Select all that apply)
o An appropriate number of active CDSME master trainers to meet the needs for leader training.
o An adequate number of lay leaders to provide CDSME workshops across the state.
o A mechanism or system to track CDSME master trainers or leaders statewide.
o Ongoing communications, support, and other retention strategies for CDSME master trainers or leaders that are
implemented across the state.
o Appropriate Stanford licensing to cover all implementation sites and planned number of workshops and
trainings.
o A delivery structure in place that is capable of delivering CDSME programs throughout the state.
o None of the above.
How many active CDSME T trainers do you have in your state?

How many active CDSME master trainers do you have in your state?

How many active CDSME lay leaders do you have in your state?

What percentage of your state’s counties would you estimate currently have enough sites and leaders to provide CDSME
workshops at least twice a year?
o 100%
o 75-99%
o 50-74%
o 25-49%
o Less that 24%
o Don’t know/unsure
What approximate percentage of your state’s population is included in the counties where you are able to offer CDSME
workshops at least twice a year?
o 100%
o 75-99%
o 50-74%
o 25-49%
o Less that 24%
o Don’t know/unsure

Any additional comments:

ELEMENT 3: PARTNERSHIPS
To ensure that programs are as available as possible and are sustained over time requires establishing effective
partnerships with agencies that have effectively embedded CDSME and/or other evidence-based programs within their
systems (i.e., the organization has incorporated CDSME into their ongoing operations), have multiple implementation
sites throughout the state and/or can reach the targeted audiences.
Please indicate which of the following is true in your state:
(Select all that apply)
o We collaborate with agencies already reaching targeted underserved populations.
o Our partnerships include agencies with host sites with multiple implementation sites and/or capacity to scaling
up statewide.
o We are effectively coordinating and integrating with existing CDSME and other community-based
evidence-based prevention programs.
o We are coordinating with chronic care management programs and demonstrations being sponsored by
physician groups and hospitals.
o We have signed agreements documenting responsibilities with all of our major partners.
o None of the above.
What percentage of your Area Agencies on Aging (AAAs) are part of your CDSME delivery system?

How do you interact with the Aging and Disability Resource Centers (ADRCs) in your state?
(Select all that apply)
o They serve as CDSME host sites.
o They serve as CDSME referral sites.
o They serve as CDSME implementation sites.
o They have integrated CDSME into their Options Counseling program.
o They have integrated CDSME into their Care Transitions program.
o We do not have ADRCs in our state.
o Other, please describe: _________________________
Besides the AAAs/ADRCs, who are your other major partners who have embedded CDSMEs into their ongoing activities
or who have played other significant roles in helping you expand CDSMEs statewide?

(Select all that apply)
Embedded
program
Advocacy/support groups
Agencies that reach rural populations
Area health education centers (AHECs)
Assisted Living Facilities/Continuing Care Retirement
Communities (CCRCs)
Centers for Independent Living (CILs)(or other groups
working with people with disabilities)
Civic groups (e.g. Rotary Club, women’s group,
Kiwanis, etc.)
Cooperative extension centers
Corporations /for-profit groups
Department of corrections
Ethnic/minority agencies
Faith-based organizations
Federally Qualified Health Centers
Foundations
Groups working with people with disabilities
Health insurers/health plans
Hospitals/ health care systems
Mental/behavioral health care providers/clinics
Native American tribal organizations
Primary care practice/local health organizations
Quality Improvement Organizations
Retiree groups/ groups for adults 55+
Senior Community Service Employment Program
(SCSEP)
Senior housing
Substance Abuse Prevention/Treatment facilities
University/academic institutions
Veteran’s Administration
Worksite programs/employee benefits programs
YMCA’s and Recreation Centers

Referral
Source

Funding
source

License
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Are there other organizations in your state that hold a CDSME license who were not funded through your current AoA
grant?
o Yes
o No

Please list the agencies and describe how they have been integrated within your system (e.g. do they share workshop
data with you?):

Which of the following sources provide referrals to your evidence-based health program system? (Select all that apply)
o Aging and Disability Resource Centers (ADRCs)
o Tobacco cessation programs/quit lines
o State Health Insurance Assistance Program (SHIP)
o State Health Insurance Exchange
o Health care systems (including physicians, HMOs and Retiree Benefits Plans)
o Local public health agencies
o Cross-referrals from other evidence-based programs
o Medicaid
o Medicaid Waiver
o Medicaid Managed Care
o Medicaid Dual Eligible Plans
o Other, please specify:
Please indicate the extent to which the following statement is true in your state: We have at least two major partners/
host organizations (outside of AAAs/ADRCs) that have embedded the CDSME into their delivery system and are offering
the workshops in multiple implementation sites throughout the state.
o To a large extent
o To a moderate extent
o To a small extent
o To a very small extent
o Not at all
Any additional comments:

ELEMENT 4: CENTRALIZED & COORDINATED PROCESSES
Centralized and coordinated logistical processes need to be in place for optimal efficiency, to decrease costs and to
ensure that potential participants hear about and enroll in the program as easily as possible and receive consistent
service.
Which of the following are currently in place for CDSME in your state?

(Select all that apply)
o A statewide brand name for your evidence-based initiatives.
o A statewide brand name for your CDSME programs.
o An ongoing public relations plan with multiple promotional strategies.
o Standardized CDSME marketing materials
o A formal process for using former participants or other ambassadors to promote the program.
o A statewide website for CDSME.
o A statewide workshop calendar for CDSME.
o A statewide toll-free number for CDSME.
o A single or coordinated referral mechanism.
o At least one major partner using an electronic medical record referral system.
o Online registration for CDSME.
o A statewide mechanism for tracking wait time or a waitlist.
o A consistent or coordinated intake, enrollment and registration process.
o Ongoing activities to educate potential advocates and decision makers about CDSME in your state.
o Agency bulletin boards for CDSME.
o Mass mailings for CDSME.
o Bulk or coordinated ordering of CDSME materials for the state.
o Regular in-service or update training around CDSME.
o A listserve or other information sharing tool for CDSME personnel and stakeholders.
o Coordinated data reporting and entry procedures.
o None of the above.
Please share the statewide brand name for CDSME (if applicable):

Please share the web address for your CDSME website (if applicable):

Please share the web address for your Workshop calendar (if applicable):

Please share your states toll free number (if applicable):

Please describe if/how are referrals tracked/is there reporting back to referring organization when participants enroll?

Do you track the number of T-trainers, master trainers and leaders and their training and workshop activity?
o Yes
o No
Who does this tracking and how?

In addition to CDSME, do you cross-promote or use your CDSME distribution system to deliver any other evidence-based
health promotion and disease prevention programs?
(Select all that apply)
o A Matter of Balance
o Active Living Every Day
o Fit and Strong!
o EnhanceWellness
o EnhanceFitness
o Program to Encourage Active Rewarding Lives (PEARLS)
o Healthy IDEAS
o Arthritis Foundation Walk with Ease Program
o Arthritis Foundation Exercise Program
o Arthritis Foundation Tai Chi Program
o Other:

Please indicate the extent to which the following statement is true in your state: We have a coordinated, state-wide
process for program marketing, referral, and recruitment, including a plan for using multiple, ongoing, promotional
activities.
o To a large extent
o To a moderate extent
o To a small extent
o To a very small extent
o Not at all
Any additional comments:

ELEMENT 5: BUSINESS PLANNING AND FINANCIAL SUSTAINABILITY
To maintain their evidence-based programs, states must have a business infrastructure including an accounting/

financial system to document program expenses and have a demonstrated capacity to fund programs after the grant
period.
Which of the following are currently in place in your state?
(Select all that apply)
o A CDSME business plan (i.e., a management tool to guide planning for financial sustainability and to assist in
seeking support from other organizations)
o A CDSME sustainability plan (i.e., plan that focuses on the management and acquisition of fiscal and in-kind
resources to expand and sustain programming).
o A requirement that community partners complete a CDSME business or sustainability plan.
o Calculated and accurate operating costs for CDSME.
o An established per participant cost for CDSME.
o An established rate for programs using costs and local market information.
o An established annual operating budget for CDSME.
o Break-even analysis (calculation of how many workshops and participants you need to break even with income
and expenses).
o Cash flow management system established (includes accounts receivable and payable systems to track and
manage revenue and payment of expenses).
o Regularly monitored operational performance through monthly financial statements and accounts receivable
reports.
o Partnerships with healthcare organizations to provide CDSME.
o Use of a consumer survey or needs assessment in business planning.
o None of the above.
What are your calculated operating costs for CDSME (if applicable):

What is your established per participant cost for CDSME (if applicable):

What is your established “sell” rate at which you can provide programs using costs and local market information (if
applicable):

What is your established annual operating budget for CDSME (if applicable):

Are any of your sites currently charging a fee for participation in a CDSME program?
o No
o Yes. Please share the range of fees: _______________________________________________
Which of the following additional sources of funding (besides the CDSME grant funds) is your state using to support the
evidence-based program system?

(Select all that apply)
o Older Americans Act, Title IIID.
o Older American Act – Other.
o Affordable Care Act Initiatives.
o Medicare - DSMT.
o Medicare
o Medicaid Waiver.
o Medicaid Managed Care.
o Medicaid State Plan (Long-term Services and Supports).
o Medicaid Dual Eligible Plan.
o Foundation support or other non-ACL grants.
o Health plan.
o Fee for service.
o Accountable Care Organization.
o Care Transitions
o CDC – Arthritis.
o CDC – Diabetes.
o CDC – Heart Disease.
o CDC – Coordinated Chronic Disease.
o CDC – Injury Prevention.
o CDC – Communities Putting Prevention to Work.
o CDC – Other.
o CMS Innovation Funds.
o National Association of Chronic Disease Directors (NACDD).
o None of the above.
o Other, please specify:
Please identify your Medicaid waiver:
Please describe your other CDC funding:
Please identify your other Older Americans Act funding:

In which ways has your state been able to collaborate with Medicaid for evidence-based programs?
(Select all that apply)
o We are partnering on Affordable Care Act Initiatives related to evidence-based programs.
o We have reimbursement for program participation through a Medicaid waiver plan.
o We have reimbursement for program participation through the state Medicaid plan.
o We are working on reimbursement but have not yet received reimbursement for program participation.
o We have a good working knowledge about how our state Medicaid system works.
o None of the above.
o Other, please specify: _______________________________________

Please describe how you are partnering on Affordable Care Act Initiatives related to evidence-based programs:

Please indicate the extent to which the following statement is true in your state: We have an effective business or
sustainability plan and processes in place to fund CDSME after the grant period.
o To a large extent
o To a moderate extent
o To a small extent
o To a very small extent
o Not at all
What are you doing that seems to be most effective in helping you sustain the CDSME activities in your state (e.g.
policies, sustainability planning activities, financial sustainability efforts, plans for applying for grants, etc.)?

Any additional comments:

ELEMENT 6: QUALITY ASSURANCE & FIDELITY TO INTERVENTIONS
To ensure effective, quality programs and efficient delivery and distribution systems, states should develop quality
assurance (QA) plans and have ongoing data systems and procedures in place that address: 1) Continuous Quality
Improvement (CQI) and 2) Program Fidelity. CQI is a cyclical process that includes setting performance objectives,
monitoring, evaluating what is or is not working and problem-solving, and making corrective changes as needed.
Program Fidelity is one aspect of quality assurance that focuses on monitoring the extent to which an evidence-based
program is delivered consistently by all personnel across sites, according to program developers’ intent and design.
How would you describe your state’s current approach to fidelity?
o Our state program has implemented its fidelity monitoring plan.
o Our state program has a fidelity monitoring plan, which we have not yet implemented.
o Fidelity monitoring activities are taking place in some sites, without state-wide coordination or leadership.
o We have begun developing a state-wide fidelity monitoring plan, but we don’t currently have one.
o We do not have a fidelity monitoring plan, state-wide nor site-specific.
Which of the following are part of your state’s fidelity system and processes?

(Select all that apply)
o The Stanford Implementation/Fidelity Manual is used throughout the state.
o Fidelity standards are disseminated throughout the state.
o Standard fidelity check list forms have been developed for each week of the workshop and are used for all
fidelity checks.
o A system of regional mentors is in place to facilitate fidelity monitoring, coaching, and technical assistance.
o Training webinars are held for fidelity monitors.
o Fidelity checks are conducted for new leaders during their first workshop.
o New leaders are required to conduct a workshop within 4-6 months of training.
o Leaders sign an MOU agreeing to follow fidelity manual/fidelity protocols.
o Quarterly observation is conducted from a Master Trainer or trained fidelity monitor.
o Leaders are observed once per year.
o Annual master trainer reviews are held.
o On-site technical assistance visits are conducted with leaders.
o Workshop data is tracked to monitor potential fidelity issues.
o Leader evaluation forms are used to monitor fidelity.
o Enhanced leader training on fidelity process and tools is provided.
o Monthly, quarterly, or semi-annual reports on fidelity monitoring process and outcomes are collected.
o An online database is used to monitor quality, reach and effectiveness.
o Fidelity reporting is collected by an outside contractor.
o A fidelity group meets regularly to address fidelity issues.
o Fidelity monitoring tools are posted on the statewide CDSME website.
o New leaders are paired with experienced leaders to increase program fidelity.
o None of the above.
Which of the following are part of your state’s quality assurance/quality improvement system and processes?
(Select all that apply)
o A written quality assurance plan that addresses both CQI and fidelity monitoring.
o Identification of performance indicators developed with input from key partners and other stakeholders.
o Ongoing processes for leadership to review fidelity monitoring and performance indicators.
o Specification of designated roles, responsibilities and timelines for fidelity monitoring and other quality
assurance activities.
o Orientation of the team (program coordinators, host sites and partners) about the quality assurance plan and
system.
o A system for feedback to involved personnel and stakeholders.
o A system for making corrective changes as needed with the aim of improving overall performance and
enhancing participant satisfaction.
o A system for using metrics and data to continuously improve quality and system performance.
o None of the above.

Please indicate the extent to which the following statement is true in your state: We have a quality assurance plan and
ongoing mechanisms in place to monitor fidelity and to ensure continuous quality improvement.
o To a large extent
o To a moderate extent
o To a small extent

o To a very small extent
o Not at all
Are you conducting evaluation work or planning to do so?
o Yes
o No
Please describe your evaluation work:

Any additional comments: