Nancy Whitelaw

Successes of a National Study of the Chronic Disease Self-Management Program Meeting the Triple Aim of Health Care Reform

Background:Emerging health care reform initiatives are of growing importance amidst concerns about providing care to increasing numbers of adults with multiple chronic conditions. Evidence-based self-management strategies are recognized as central to managing a variety of chronic diseases by improving the medical, emotional, and social role management demands of chronic conditions. Objectives:To examine the effectiveness of the Chronic Disease Self-Management Program (CDSMP) among a national sample of participants organized around the Triple Aim goals of better health, better health care, and better value in terms of reduced health care utilization. Research Design:Utilizing data collected from small-group CDSMP workshops, baseline, 6-month, and 12-month assessments were examined using 3 types of mixed-effects models to provide unbiased estimates of intervention effects. Subjects:Data were analyzed from 1170 community-dwelling CDSMP participants. Measures:Triple Aim–related outcome measures: better health (eg, self-reported health, pain, fatigue, depression), better health care (eg, patient-physician communication, medication compliance, confidence completing medical forms), and better value [eg, reductions in emergency room (ER) visits and hospitalizations in the past 6 mo]. Results:Significant improvements for all better health and better health care outcome measures were observed from baseline to 12-month follow-up. The odds of ER visits significantly reduced from baseline to 12-month follow-up, whereas significant reductions in hospitalization were only observed from baseline to 6-month follow-up. Conclusions:This National Study of CDSMP (National Study) demonstrates the successful translation of CDSMP into widespread practice and its potential for helping the nation achieve the triple aims of health care reform.

Geriatric Interdisciplinary Team Training Program : Evaluation Results

Geriatric interdisciplinary team training has long been a goal in health education with little progress. In 1997, the John A. Hartford Foundation funded eight programs nationally to create Geriatric Interdisciplinary Team Training (GITT) programs. Faculty trained 1,341 health professions students. The results of the evaluation, including presentation of new measures developed to assess interdisciplinary knowledge, are presented, and the implications of the program as a model of interdisciplinary education are discussed. Evaluation data from 537 student trainees are presented. At posttest, GITT trainees demonstrated improvement on all measures of attitudinal change, no change on the geriatric care planning measure, and a change in some of the questions on the test of team dynamics that varied by discipline. Changes were greatest for all the attitudinal measures with the self-reported Team Skills Scale indicating the most significant change—a change that is significant across medicine, nursing, and social work trainees.

National study of chronic disease self-management: six-month outcome findings.

Objective: To investigate how the Chronic Disease Self-Management Program (CDSMP) changes health outcomes, lifestyle behaviors, and health care service utilization over a 6 month period. Method: The participants were 1,170 adults enrolled in the National Study of CDSMP in 2010-2012 (M age = 65.4 years). Six-month assessments were available for 903 participants. Linear mixed models and generalized linear mixed models were used to assess the changes between baseline and 6-month assessment for primary and secondary outcomes among CDSMP participants. Results: Social/role activities limitations, depression, and communication with physicians improved significantly from baseline to 6-month follow-up. Study participants reported significant improvements in more physical activity and less emergency room (ER) visits and hospitalization during that period. Discussion: Nationally, CDSMP not only improves health outcomes and lifestyle behaviors but also decreases costly ER visits and hospitalization. Geriatricians and other primary care providers should be encouraged to refer patients with chronic conditions to such self-management programs.

THE STRUCTURE OF SELF-REPORTED PHYSICAL HEALTH AMONG THE AGED IN THE UNITED STATES AND JAPAN

This article attempts to extend the generalizability of a three-dimensional model of self-reported physical health among the aged to a nonwestern culture. Consisting of three interrelated dimensions, chronic illness, functional status, and self-rated health, this model was empirically evaluated by using national data on the aged gathered in the United States and Japan. The three-dimensional specification was found to apply equally well to U.S. and Japanese elderly. In addition to examining the internal structure of this three-dimensional model, the study assessed the models relationships with a set of selected exogenous variables including age, sex, marital status, and education. The relationships between the selected exogenous variables and physical health dimensions are largely similar in both countries. However, clear differences appeared in at least three instances.

The structure of the OARS physical health measures.

This article proposes and evaluates two models for integrating self-reported health status measures for the elderly with dominant conceptualizations of physical health. Each model includes three dimensions of physical health: chronic illness, functional limitation, and self-rated health. In Model 1, the dimensions are linked in a causal framework, whereas in Model 2, a secondorder factor, labeled physical health status, is hypothesized to account for the relationships among the three dimensions. Each model was tested with data gathered in Cleveland (N = 1,834) and Virginia (N = 2,146) using the Older Americans Resources and Services Multidimensional Functional Assessment Questionnaire (OARS MFAQ). Analyses were further replicated by randomly dividing each sample. Both models fit the data well; their utilities will depend on the way in which physical health is conceptualized and on the nature of the research question at hand.

Self-Management at the Tipping Point: Reaching 100,000 Americans with Evidence-Based Programs

Baby boomers are crossing the traditional “aging” threshold. More than 10,000 baby boomers now turn 65 each day. In turn, there is an increasing prevalence of chronic conditions, and more importantly, older adults are ever more likely to be living with multiple chronic conditions. It is important to recognize that, despite advances in medical care, individuals with chronic conditions live the majority of their lives outside of the healthcare system. Thus, it is critical for healthcare providers to be aware of ways in which their patients are managing—or failing to manage—their chronic conditions in their everyday lives. This editorial highlights the benefits of community-based self-management programs, discusses the results of a national rollout for one widely disseminated evidence-based program, and reflects upon the synergistic partnerships that need to be developed between healthcare providers and community service practitioners to create a seamless infrastructure to help expand delivery capacity and sustain such programs. There is accumulating documentation about the success of evidence-based self-management programs in helping people with the medical, role, and emotional management demands associated with chronic conditions. One of the most widely disseminated programs, the Stanford University Chronic Disease Self-Management Program (CDSMP), has been shown in randomized trials to improve symptoms such as pain, shortness of breath, and fatigue; improve ability to engage in everyday activities; reduce depression; enrich communication with healthcare providers; and decrease costly health care such as emergency department visits. Drawing upon evidence-based principles of behavior change, CDSMP workshops consist of six 2.5-hour sessions delivered in small group settings (e.g., 10–16 participants) over a 6-week period. CDSMP is designed to help participants develop skills to manage symptoms and learn specific coping strategies using action planning and feedback, behavior modeling, problemsolving techniques, and decision-making. The program is well scripted, and two leaders who have successfully completed 4 days of training facilitate each workshop. Nevertheless, there is emerging concern about pervasive research-to-practice gaps in which programs developed in research settings fail to be translated into widespread practice in the “aging services network.” This phrase describes a network of state units on aging, area agencies on aging, tribal organizations, and more than 30,000 community-based organizations (e.g., senior centers, social service agencies, faith-based organizations, senior housing) that serve older adults. Working together alongside the U.S. Administration on Aging, state health departments, state Medicaid agencies, and other public agencies, the aging services network is responsible for planning, administering, and providing a wide array of social, long-term care, and health-support services. It is this network of providers that has recognized the importance of being able to bring community-based self-management programs to scale to reach diverse populations of older adults who can benefit from participating in such programs. After 20 years of development and evaluation, CDSMP-type programs have gained traction and are now ready to be introduced nationally. Toward this end, the American Recovery and Reinvestment Act of 2009 (i.e., Recovery Act) Communities Putting Prevention to Work: Chronic Disease Self-Management Program initiative, led by the U.S. Administration on Aging in collaboration with the Centers for Disease Control and Prevention and the Centers for Medicare and Medicaid Services, allotted

Effectiveness of a Generic Chronic Disease Self-Management Program for People With Type 2 Diabetes A Translation Study

32.5 million to support the translation of the Stanford program in 45 states, Puerto Rico, and the District of Columbia. The goal was to have 50,000 Americans complete at least four of six CDSMP sessions between 2010 and 2012 and to embed delivery structures into statewide systems. This editorial describes the first 100,000 participants who enrolled in this national initiative and reflects on what is needed for the continued widespread dissemination of evidence-based self-management programs. Within the first 24 months of this initiative, more than 100,000 middle-aged and older adults were reached through 9,305 workshops in 1,234 U.S. counties. Participants self-reported 2.2 chronic conditions, the most prevalent being hypertension (43.0%), arthritis (40.8%), diabetes mellitus (30.3%), and depression (19.5%). Participants were primarily female (77.7%), older (mean age 67; 31.7% aged 75), and from diverse ethnic and minority backgrounds. Approximately 17% self-identified as Hispanic, 66.4% as white, 21.5% as African American, 4.5% as Asian or Pacific Islander, and 1.6% as American Indian or Native Alaskan. Although the majority of participants attended CDSMP workshops delivered in English (89.3%), the program was also offered in Spanish, Chinese, Vietnamese, French, and Somali. Paralleling findings from the original randomized clinical trials, participation attendance was high, with approximately 75% attending at least four of the six sessions. Workshops were offered in many DOI: 10.1111/jgs.12239

National Study of Chronic Disease Self-Management Age Comparison of Outcome Findings

Purpose The purpose of the study was to determine the feasibility and efficacy of a generic chronic disease self-management program for people with type 2 diabetes. Methods English-speaking adults with type 2 diabetes who were part of a larger US national translation study of the Stanford Chronic Disease Self-Management Program (CDSMP) were invited to be part of the current study. In addition to completing self-report questionnaires, participants submitted blood samples at baseline, 6 months, and 12 months. Of the 114 participants, half had A1C values between 6% and 6.9% and half had values of 7.0% or more. Results Adults with diabetes successfully participated in CDSMP workshops in a community health setting. Participants demonstrated statistically significant improvements in health indicators and behaviors but no reductions in health care utilization. Participants with A1C of 7% and above had A1C reductions at 6 months, with smaller reductions at 12 months. Those with baseline A1C less than 7% had no changes in A1C at 6 or 12 months. Conclusions The results suggest that the CDSMP is a useful and appropriate program for lowering A1C among those with A1C above 7% and for improving health status for people with diabetes, regardless of their A1C.

Probabilities and lifetime durations of short-stay hospital and nursing home use in the United States, 1985.

Introduction. The adult population is increasingly experiencing one or more chronic illnesses and living with such conditions longer. The Chronic Disease Self-Management Program (CDSMP) helps participants cope with chronic disease-related symptomatology and improve their health-related quality of life. Nevertheless, the long-term effectiveness of this evidence-based program on older adults as compared to the middle-aged populations has not been examined in a large-scale, national rollout. Method. We identified baseline characteristics of CDSMP participants aged 65 years or older (n = 687, M = 74.8 years) in the National Study of CDSMP from 2010 to 2012. Comparisons were made to middle-aged participants aged 50 to 64 (n = 325, M = 58.3 years). Assessments were conducted at baseline and 12-month follow-up. Linear and generalized linear mixed models were performed to assess changes in primary and secondary outcomes, controlling the key sociodemographics and number of chronic conditions. Results. All primary outcomes (i.e., social/role activities limitation, depression, communication with doctors) significantly improved in both the older and middle-aged cohorts. Although improvements in illness symptomatology (e.g., fatigue, pain, shortness of breath, and sleep problems) were similar across both cohorts, only the middle-aged cohort benefitted significantly in terms of overall quality of life and unhealthy mental health days. Effect sizes were larger among the middle-aged population who were also more likely to enter the program in poorer health and be from minority backgrounds. Conclusions. The current study documented improved health outcomes but more so among the middle-aged population. Findings suggest the importance of examining how age and interacting life circumstances may affect chronic disease self-management.

Concordance between Self-Reports and Medicare Claims among Participants in a National Study of Chronic Disease Self-Management Program.

OBJECTIVES The authors present a four-state increment-decrement life table model from which estimates of the risk and duration of nursing home and short-term hospital stays in the United States are derived. METHODS Survival analysis was used to generate various transition probabilities while controlling for population heterogeneity. In addition, a newly developed algorithm was applied to construct the multistate life table specifically for health-care use. RESULTS The results reveal that in 1985, a US civilian is expected to spend 72.35 years in the community, 59.5 days in short-stay hospitals, and 2.28 years in nursing homes throughout his or her lifetime. CONCLUSIONS The single-year risk of nursing home and short-stay hospital use is shown to be an increasing function of age, especially for the older adults.