NCCHW Chronic Disease Self-Management Support Scorecard (2019-2022)

This Scorecard reflects the Chronic Disease Self-Management (CDSM) Support Initiatives of the North Carolina Center for Health and Wellness, which are funded by the Administration for Community Living and build on the work of previous CDSM education program grants in North Carolina.

This Scorecard is a web-based platform for tracking and communicating the following:

RESULTS—the conditions of health and wellbeing we envision and are collectively working to achieve;

INDICATORS—the measures of population health and wellness we are using to track our progress towards achieving these results, often with a particular focus on differences in conditions and outcomes among groups (disparities) we are working to "turn the curve on" to contribute to greater equity;

STRATEGIES—the overarching sets of activities we undertake to create changes to help achieve our results; and

PERFORMANCE MEASURES—the measures of the quality and impact of our efforts, which we track by asking "how much" we did, "how well" we did it, and whether "anyone is better off?"

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Why Is This Important?

According to the NC State Center for Health Statistics, 81% of adults age 65+ have at least one chronic condition, and 51% of those have two or more chronic diseases. Among participants who have enrolled in NC CDSME programs since 2010, the top three health conditions reported include hypertension, diabetes, and arthritis, with over half participants reporting two or more chronic conditions.

Diabetes is the seventh leading cause of death in both the United States and NC. Over 50,000 NC adults are diagnosed with diabetes annually, and only half of those diagnosed with diabetes have taken a class to manage the chronic disease. The disease has many co-morbidities and complications, and a large proportion of adults are unable to work as a result. The prevalence of diabetes is higher among African Americans as compared to Whites, and it is the 5th leading cause of deaths for African Americans. Diabetes death rates are highest in rural eastern NC communities, where there is a high need for diabetes management programs that are culturally appropriate and support populations with low literacy.

Diabetes alone costs $3.8 billion in direct and indirect costs among the population age 65+ in NC,6 including $2.2 billion in Medicare costs and over $700 million in Medicaid costs. NC’s Medicaid Program incurred nearly one-third of the estimated annual diabetes-attributable medical costs among people age 65+ in 2013 (https://www.diabetesnc.com/diabetes-management/management-facts/).

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29%
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Strategy

NCCHW established Healthy Aging NC (HANC) as the state’s network hub for evidence-based programs (EBPs) in January 2016, with the goal of centralizing support for technical assistance, data management, data reporting, and communication. Since its inception, HANC has: centralized statewide coordination for programs and data collection/analysis; supported the expansion and continuum of chronic disease management programs, walking programs, and evidence-based falls prevention programs; and increased EBP visibility. This centralization has been progressing toward providing support for healthcare investments. The staff supports the integrated and sustainable EBP network in a way that didn’t exist before HANC. Centralized statewide data collection provides a sharper image of EBP impact, while dedicated staff improves responsiveness to program needs. In addition, our well-designed communications platforms such as www.healthyagingnc.com have received national recognition through media honors such as the Gold 2016 Marcom Award.

BUILD CAPACITY

  • NCCHW, through its HANC initiative, partners with the Centralina Area Agency on Aging (AAA) to maintain a statewide Chronic Disease Self-Management Education (CDSME) programs Training Academy. The training academy ensures the training of high-quality leaders in the suite of evidence-based CDSME  programs (chronic disease, chronic pain, and diabetes), and adherence to fidelity to ensure health outcomes and benefits.

  • NCCHW, through HANC, leads a learning collaborative to assist 8 NC-based AAAs in becoming accredited for the Diabetes Self-Management and Education and Support (DSMES) program with the goal of reimbursement from Medicare for the services provided. Two of NC’s 16 AAAs maintain accreditation and often serve as contributors to the learning collaborative.

  • NCCHW staff, through HANC, reduces administrative responsibilities of AAAs by providing statewide access to data and resources through software, website, and media options. This includes the website www.healthyagingnc.com.

IMPACT POLICY

  • NCCHW, through HANC, assists AAAs in becoming accredited to offer DSMES as a billable Medicare service, creating non-traditional delivery and sustainability mechanisms for local government agencies. This also opens opportunities for older adults receiving Medicare to have more access to DSMES in an effort to increase uptake of the billable service. 

  • NCCHW, through HANC, creates opportunities for CDSME programs, which improve self-management skills of North Carolinians, to be reimbursed through value-based care investments.

  • NCCHW, through HANC, assists AAAs in setting up their agency’s contracting to provide the EBPs that have demonstrated value. 

IGNITE COMMUNITY INITIATIVES

  • NCCHW staff, through HANC, supports the scaling of CDSME programs in communities needing the programs. This is done through connecting referral systems, offering marketing and registration online via healthyagingnc.com, conducting research on program best practices and developing requested toolkits.

  • NCCHW, through its partner agencies, increases self efficacy for individuals leading to better patient-provider interactions and helping providers understand the value of CDSME programs. 

  • NCCHW contributes to building clinical and community connections across NC. This is done by providing community-based organizations with tools to connect with healthcare partners who would find value in CDSME programs, and providing healthcare partners with information on connecting to community-based organizations delivering valuable CDSME programs. 

What We Do

The North Carolina Center for Health and Wellness (NCCHW), housed at UNC Asheville, falls within the university’s Academic Affairs department. The mission of NCCHW is to develop equitable opportunities that lead to healthy NC communities. We impact policy, build capacity, and ignite community initiatives by working through a web of cross-sector relationships organized around building healthier places throughout the state.

The Chronic Disease Project Manager, serves as the point person for day-to-day activities of the Healthy Aging NC Chronic Disease Self-Management efforts, and manages subcontracts, prepares reports, and coordinates communication among partners. In addition to working closely with the Centralina AAA for fidelity and tracking efforts, and with the CDC Arthritis Project Manager, the Chronic Disease Project Manager serves as the facilitator on the DSMES accreditation learning collaborative. Chronic Disease Self-Management programs focus on three primary areas: chronic diseases, diabetes, and chronic pain. Partners engaged in this work include AAAs, state Department of Health and Human Services agencies such as the NC Division of Aging and Adult Services and the NC Division of Public Health, community-based organizations, and many health professionals. The 2019 ACL CDSME grant created opportunities to engage 8 AAA partners in the DSMES accreditation process including Medicare reimbursement through a learning collaborative approach.

The NCCHW Data Manager manages data collection, entry into a chronic disease self-management program database (housed by the National Council on Aging), storage, and reporting for evidence-based programs. The Data Manager is also responsible for managing the Healthy Aging NC website and email account, regularly updating class information and registration online, and supporting the inquiries and online referrals for programs.

NCCHW Healthy Aging NC efforts are supported by the Director of State and Community Collaboration and the Director of Partnership and Evaluation. These additional staff members collaborate with state, regional, and local leaders to prioritize community needs, develop collaboration opportunities, expand efforts, and evaluate efforts.

NCCHW embeds strategies that improve quality measures, raise awareness among clinicians and the public, and result in fewer fall related injuries and deaths among North Carolinians.

Story Behind the Curve

CHALLENGES

Effective 2019, the state has more people of age 60 and over than under 18 and by 2025 it is projected that 88 of NC’s 100 counties will have more population age 60 and older than ages 0-17.The projected 61% growth of the age 65 and older population over the next twenty years will likely result in a drastic rise in deaths, hospitalizations, and ED visits due to chronic diseases. Many older adults report receiving no additional education outside of the clinical setting due in part to physicians, hospital staff, and other clinicians often being siloed from community-based organizations (CBOs), creating gaps in patient care.

We also have the challenge of changing public perception to increase understanding that chronic diseases are manageable and not an unaddressable part of aging.

In May 2020, the COVID-19 pandemic swept through the world, including North Carolina, and the provision of evidence-based programs was dramatically affected. Providers navigated the switch to virtual programming, and some AAAs do not have this capacity. Those that decided to make this transition were required to perform a great deal of work to shift effectively. Priorities shifted to meeting direct and critical needs in the community such as providing meals, telehealth resources, referrals and addressing social isolation. 

 

How We Impact

Map of the Counties Impacted by Chronic Disease Self-Management Programs (Updated September 2020)

The North Carolina Center for Health and Wellness (NCCHW) maintains an integrated network of CDSME program providers through our Healthy Aging NC (HANC) Resource Center. We build capacity among the AAAs as the regional organizations delivering CDSME programs in NC by removingadministrative barriers and we ignite CDSME initiatives by expanding relationships between agencies across the state. Additionally, we guide AAAs in accreditation by the Association of Diabetes Certified Educators and Specialists (ADCES) and facilitate reimbursement of DSMES programs through Medicare and quality billing as a means to impact policy and ensure sustainability of programming. 

Systematically offering evidence-based chronic disease self-management prevention programs can offer significant healthcare cost savings by addressing many of the risk factors that result in emergency department visits and hospitalizations. In one study, participants reported better overall health as measured by feeling healthier, leading more active lives, experiencing less depression, fewer sick days, and overall better quality of life (Ory, M. G., Ahn, S., Jiang, L., Lorig, K., Ritter, P., Laurent, D. D., ... & Smith, M. L. (2013). National study of chronic disease self-management: six-month outcome findings. Journal of Aging and Health, 25(7), 1258-1274.). Participants also reported better care as measured by improved communication with providers, better medication compliance, and increased health literacy. From a financial perspective, there was an average cost savings of $714 per person for emergency room visits and hospital utilization and a net savings of $364 per person after the cost of the program ($350). This results in potential savings of $152 million by reaching 10% of North Carolinians with one or more chronic conditions. 

The Patient Activation Measure (PAM) is a 13-item survey that assesses a person’s knowledge and confidence in managing chronic health conditions. From January 2012 to May 2014, the Centralina Area Agency on Aging assessed Patient Activation Measures for more than 400 participants before and after they completed a Chronic Disease Self-Management Education program and found that after the workshops: CDSME programs increased participant knowledge of their disease and its causes, increased participant knowledge of disease prevention, and felt more empowered about their own health care. 

Additionally, we conduct data collection and dissemination for the Administration for Community Living and Centers for Disease Control and Prevention grant reports as requested. NC AAAs have been offering EBPs since 2007, and all currently send EBP data to NCCHW HANC. All 16 AAAs have delivered or built capacity to deliver EBPs, with metropolitan AAAs offering 20-30 workshops per year. NCCHW documents an average of 1,100 enrolled participants in CDSME workshops annually in NC since 2014 as seen in our performance measures of this scorecard. 

NCCHW’s completer rates (attendance of 4/6 workshops for all CDSME workshops) are on par with national averages. We anticipate consistent enrollment of participants in programs through our robust and successful network of AAAs offering programs with administrative support from NCCHW’s HANC initiative. 

 

Partnerships

NC Department of Health and Human Services (DHHS), Division of Aging and Adult Services (DAAS)

NC’s DAAS, the state unit on aging, works to promote the independence and enhance the dignity of North Carolina's older adults, persons with disabilities and their families through a community based system of opportunities, services, benefits and protections.Division staff are an integral part of the efforts to create more access and visibility of chronic disease self-management strategies and evidence-based programs in North Carolina. We collaborate to build capacity, impact policy, and ignite community initiatives among the state’s 16 AAAs and local service delivery sites (such as senior centers). Together, we make strategic choices and create guidance for the state on how to disseminate and operate evidence-based programs.

NC DHHS, Division of Public Health (DPH), Chronic Disease and Injury Section (CDIS) and State Center for Health Statistics (SCHS)

NC DPH, CDIS, along with local health departments and other partners, works to reduce death and disabilities related to chronic disease and injury, and NC DPH SCHS is responsible for data collection, health-related research, production of reports and maintenance of a comprehensive collection of health statistics. We collaborate to better understand chronic disease burden in NC, including diabetes, and to use data to focus and mobilize efforts. Within the CDIS, we collaborate with theCommunity and Clinical Connections for Prevention and Health (CCCPH) branch, to find linkages to each other’s work in the areas of diabetes and heart disease prevention, promotion of physical activity and healthy eating, and support for brain health and caregiving.

NC Association of Area Agencies on Aging (NC4A)

Area Agencies on Aging (AAAs) are offices established through the Older Americans Act that facilitate and support programs addressing the needs of older adults in a defined geographic region. In NC, the 16 AAAs are located within regional Councils of Government and all directly or indirectly offer  health promotion and disease prevention programs. Most AAAs offerChronic Disease Self-Management Education programs. NCCHW provides technical assistance and expansion support to facilitate program implementation, evaluation, and sustainability. Two of the 16 NC AAAs are accredited for DSMES and bill Medicare for DSMES services. Eight NC-based AAAs have undergone the DSMES accreditation learning collaborative, and 11 of 16 AAAs have a direct contract with NCCHW for Healthy Aging NC activities.

Multiple agencies that support Older Adults and/or Evidence-based programs (Area Health Education Centers (AHECs), UNC’s Geriatric Workforce Enhancement Program (GWEP), Osteoarthritis Action Alliance (OAAA), NC Medical Society, Federally Qualified Health Centers (FHQCs), and others))

All of these partners are further potential for increasing the visibility of our services and resources.

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