Advancing Strategies to Deliver and Sustain Evidence-Based Chronic Disease Self-Management Education Programs to Support Older Adult Behavioral Health

BackgroundChronic Disease and Behavioral Health Conditions Among Older AdultsChronic conditions, such as hypertension, diabetes, and arthritis, are prevalent among older adults. Approximately 95% of older adults have at least one chronic condition, and nearly 80% have two or more. [2] Behavioral health is the promotion of mental health and well-being, the treatment of mental and substance use disorders, and the support of those who experience and/or are in recovery from these conditions. As of 2022, an estimated 9.8 million older adults (12.5%) had a mental illness in the past year, and there were 7.1 million older adults (9.1%) who had a substance use disorder (SUD) in the past year. [3] Behavioral health conditions among older adults are often underrecognized and undertreated. [4] In addition to those who have been diagnosed with a behavioral health condition, research shows that stressful life events, such as the loss of a spouse, major illness, and loss of independence, are linked to the onset of depression. [5] In the United States, 90% of adults have been exposed to at least one traumatic event, and exposure to multiple traumatic events is common. As trauma survivors age, their trauma symptoms may resurface and evolve as they face stressful life events. [6]The behavioral health crisis was exacerbated by the COVID-19 pandemic. Since March 2020:Nearly one in five older adults have reported worse sleep, worse depression, or sadness,Nearly 30% have reported worse anxiety or worry, andMore than six in ten have reported experiencing social isolation. [7][8]Many older adults have co-occurring chronic conditions and behavioral health conditions. Research shows us:People who have a chronic condition are at a higher risk of developing depression due to anxiety, stress, or other challenges caused by the condition, brain changes, and medications.Individuals who have a chronic disease and depression tend to have more severe symptoms of both illnesses.People who have depression are at a higher risk for developing some chronic diseases like heart disease, diabetes, stroke, and osteoporosis. [9]As adults age, they often experience heightened sensitivity to substances, which can result in injury, complicate existing medical conditions, or interact with medications. [10]Coping with multiple chronic diseases and worsening behavioral health conditions is a considerable challenge for older adults, their caregivers, and their families. Efforts to address chronic conditions and behavioral health are more impactful when they include the community and are part of coordinated strategies across multiple sectors that include public health, healthcare, behavioral health, and other critical stakeholders. By addressing both chronic conditions and behavioral health, we can better meet the needs of the whole person.Chronic Disease and Behavioral Health Conditions DisparitiesRacial/ethnic disparities exist in the burden of chronic disease and behavioral health conditions. Underserved populations and communities, such as adults with disabilities, those living in rural areas, communities of color, Native American communities, members of the LGBTQ+ communities, and those adversely affected by persistent poverty, experience greater burden. The burden and management of chronic diseases among those underserved are further exacerbated by the social determinants of health (SDOH) such as their physical environment, history of trauma, economic status, access to healthcare and health-related resources, among other factors. [11] [12] Due to factors such as intergenerational trauma, discrimination, and barriers to services, American Indian and Alaska Native individuals experience disproportionately high rates of behavioral health conditions and psychiatric diagnoses such as post-traumatic stress disorder (PTSD), substance use disorder, and suicide compared to other racial and ethnic groups. [13] Older people from communities of color have also faced challenges due to racism, which has led to psychological distress and potential mistrust of health care providers. [14]Increasing Participation in Evidence-Based Community Programs to Mitigate the Chronic Disease and Behavioral Health BurdenEmpowering older adults to engage in evidence-based chronic disease self-management education (CDSME) programs to better manage their conditions can help mitigate the chronic disease and behavioral health burden. The acronym, CDSME, is used in this announcement as an umbrella term for community-based education programs specifically designed to enhance self-management of chronic diseases. These programs focus on building multiple health behaviors and generalizable skills – such as goal setting, decision-making, problem-solving, and self-monitoring – and are proven to maintain or improve health outcomes of older adults with chronic conditions. Similarly, a self-management support program is a community-based, behavioral change intervention that is proven to increase skills or behaviors relevant to chronic disease self-management, such as physical activity or medication management. [15]Evidence-based CDSME programs supported by the Administration for Community Living have been proven to improve health and well-being and reduce disease and injury. CDSME program participants experience improved health literacy, better psychological well-being, better health-related quality of life, improved physical activity, and reduced loneliness, social role limitations, and health distress. [16] [17] [18] Research has shown that CDSME programs are also associated with long-term improvements in depression. [19] Additionally, evidence-based programs such as Healthy IDEAS (Identifying Depression & Empowering Activities for Seniors) and PEARLS (Program to Encourage Active, Rewarding Lives) (see Appendix C for more information) are designed to combat depression among older adults.PurposeThis section provides details about the Target Population and Goals.The purpose of this funding opportunity is to develop and implement multi-faceted strategies that support the delivery and sustainability of evidence-based chronic disease self-management education (CDSME) programs for older adults (age 60 and older) and individuals with disabilities with one or more behavioral health conditions and older adults and individuals with disabilities with one or more stressors that are negatively impacting their behavioral health through a statewide initiative.Outcomes will include:Increase the number of individuals who participate in evidence-based CDSME programs, while reaching the grant’s target population.Increase partnerships and collaboration between the Aging and Disability Services Network, behavioral health providers, and other key organizations.Increase the knowledge of the field by developing and disseminating resources and learnings from your grant for other organizations to replicate similar projects in their communities.Target PopulationFor this project, the target population is:Older adults (60 years and older) and individuals with disabilities who have one or more behavioral health conditions, such as:DepressionAnxiety disordersBipolar disorderPTSDSubstance use disorder Older adults (60 years and older) and individuals with disabilities who have one or more stressors that are negatively impacting their behavioral health. Stressors are defined in this Notice of Funding Opportunity (NOFO) as:Experiencing a traumatic eventNew diagnosis of a chronic condition or disabilityBeing a caregiverA change in finances or work statusLoss of a loved one, including through divorceSudden change in housing status (i.e., homelessness)As noted above, minority populations and American Indian/Alaska Native (AI/AN) populations are at increased risk of behavioral health conditions and behavioral health stressors. Due to that evidence and in alignment with language stated in the Final Rule to Update Older Americans Act Regulations (released February 2024), which highlights the importance of Older Americans Act programs reaching those of greatest economic and social need and to improve the health of racial and ethnic minority groups and American Indian/Alaska Native (AI/AN) populations, applicants shall ensure targeted population for recruitment and reach reflect state demographics including recruitment of minority populations and American Indians/Alaska Natives/Native Hawaiians. Please note, nearly 70% of American Indians/Alaska Natives/Native Hawaiians live off-reservation in cities and towns across the United States. These individuals are not eligible for services under Title VI programs.The majority focus of your grant should be older adults 60 and older, but projects may serve some individuals under 60 with disabilities.Throughout the rest of the announcement, the term “target population” will be used to refer to these two groups, and applicants should reflect a statewide strategy to engage minority groups and American Indian/Alaska Native/Native Hawaiian individuals.GoalsThis funding opportunity has two goals:Goal 1: Through a statewide initiative, develop capacity (e.g., instructors, partnerships, and referral networks) to increase the number of older adults and adults with disabilities in the target population who participate in evidence-based chronic disease self-management education (CDSME) and support programs.Goal 2: Develop and disseminate 508-compliant resources specific to your grant learnings to enhance knowledge in serving the target population and aid in the sustainability of programs.To be considered for funding, the application must include the following components in the proposal to accomplish the goals of this funding opportunity.Applicants for this funding opportunity must propose to deliver one or more CDSME programs in Appendix B AND at least one self-management program in Appendix C. Explain how the programs selected will help improve the behavioral health of the target population. The programs proposed MUST be on the list of pre-approved interventions found in Appendices B and C of this funding opportunity. Please refer to Appendix A (Glossary of Terms) for definitions of CDSME and self-management support programs.Applicants are expected to begin delivering their proposed CDSME and self-management support programs within three to six months after receiving their Notice of Award, should they be funded.Applicants may propose to implement one or more of the identified programs in a remote format, i.e., by video conference, phone, mailed toolkit + phone, or some other format. Applicants should contact the program developer/administrator for any program(s) they are interested in delivering remotely to confirm that: 1) the programs are allowed for remote delivery; and 2) training is readily available for applicants who need it.All applicants who do not have adequate existing capacity (i.e., trained leaders, licensing, etc.) for any in-person and/or remote program(s) they are proposing must include a letter from the program developer/administrator in their application indicating that they will be able to get training in the programs no later than three months after the start date of the grant (if selected for funding). Information about each program can be found in Appendices B and C.Applicants must identify the total target number of older adults and adults with disabilities throughout the state that they will reach with this funding, define which behavioral health condition(s) and behavioral health stressor(s) listed above will be prioritized, and clearly propose how 50% of the program's total participant target will be from the target population.Applicants must show a statewide approach to reach the target population noted above, that is inclusive of minority populations and American Indian/Alaska Native/Native Hawaiian elders. If partnering with state or federally recognized tribes or tribal consortiums, applicants must also establish a collaborative agreement with tribal health leaders from those tribes or tribal consortiums to offer evidence-based CDSME programs to American Indian/Alaska Native/Hawaiian Native elders.The proposed project must include partnerships across the state to support this application. At a minimum two or more of those partnerships must specialize in serving older adults with behavioral health conditions and other key organizations.Delivery of evidence-based CDSME and support programs needs to be person-centered, trauma-informed, and culturally appropriate. To accomplish this, the awarded organization will provide training on these topics for grant staff and program leaders.Recruitment of participants for the evidence-based CDSME programs must include those older adults in greatest economic and social need consistent with the language stated in the Final Rule to Update Older Americans Act Regulations released in February 2024. For more details, see the Glossary in Appendix A.All proposed activity funded by the Administration for Community Living, or “federal financial assistance” as it is referred to, must abide by the Final Rule Implementing Section 504 of the Rehabilitation Act of 1973. The Rule defines new compliance requirements of recipients of federal funding of the Administration for Community Living that services must be provided in the most integrated setting appropriate to meet the needs of individuals with disabilities.To help regulated entities and community members understand the new final rule, the Office of Civil Rights (OCR), as the agency charged with implementing and enforcing Section 504, has published a fact sheet providing a summary overview of the rule’s provisions. The Section 504 of the Rehabilitation Act of 1973 Final Rule: Section by Section Fact Sheet for Recipients of Financial Assistance from HHS can be found on the OCR website.References[1] Urban Indian Health Commission. (2015, October 13). Invisible Tribes: Urban Indians and Their Health in a Changing World. Urban Indian Health Commission. www2.census.gov/cac/nac/meetings/2015-10-13/invisible-tribes.pdf[2] National Council on Aging. (2024, August 16). Get the Facts on Healthy Aging. ncoa.org. https://www.ncoa.org/article/get-the-facts-on-healthy-aging/[3] Substance Abuse and Mental Health Services Administration. (2024). Key substance use and mental health indicators in the United States: Results from the 2023 National Survey on Drug Use and Health (HHS Publication No. PEP24‑07‑021, NSDUH Series H‑59). Center for Behavioral Health Statistics and Quality, Substance Abuse and Mental Health Services Administration. https://www.samhsa.gov/data/report/2023-nsduh-annual-national-report[4] Mental Health America. (n.d.). Depression in Older Adults. Mental Health in Older Adults. https://mhanational.org/depression-older-adults[5] Schneiderman N, Ironson G, Siegel SD. Stress and health: psychological, behavioral, and biological determinants. Annu Rev Clin Psychol. 2005;1:607-28. doi: 10.1146/annurev.clinpsy.1.102803.144141. PMID: 17716101; PMCID: PMC2568977.[6] Center on Aging and Trauma. (n.d.). Aging and Trauma. 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SAMHSA. https://store.samhsa.gov/sites/default/files/tip-26-pep20-02-01-011.pdf…] Boersma P, Black LI, Ward BW. Prevalence of Multiple Chronic Conditions Among US Adults, 2018. Prev Chronic Dis 2020;17:200130. DOI: http://dx.doi.org/10.5888/pcd17.200130.[12] Shaw KM, Theis KA, Self-Brown S, Roblin DW, Barker L. Chronic Disease Disparities by County Economic Status and Metropolitan Classification, Behavioral Risk Factor Surveillance System, 2013. Prev Chronic Dis 2016;13:160088. DOI: http://dx.doi.org/10.5888/pcd13.160088.[13] Kwon SC, Kabir R, Saadabadi A. Mental Health Challenges in Caring for American Indians and Alaska Natives. [Updated 2024 Feb 12]. In: StatPearls [Internet]. Treasure Island (FL): StatPearls Publishing; 2024 Jan-. Available from: https://www.ncbi.nlm.nih.gov/books/NBK570587/[14] Jimenez DE, Park M, Rosen D, Joo JH, Garza DM, Weinstein ER, Conner K, Silva C, Okereke O. Centering Culture in Mental Health: Differences in Diagnosis, Treatment, and Access to Care Among Older People of Color. Am J Geriatr Psychiatry. 2022 Nov;30(11):1234-1251. doi: 10.1016/j.jagp.2022.07.001. Epub 2022 Jul 8. PMID: 35914985; PMCID: PMC9799260.[15] Brady, Teresa. “Strategies to Support Self-Management in Osteoarthritis.” AJN, American Journal of Nursing, vol. 112, no. 3, 2012, pp. 54–60., doi: 10.1097/01.naj.0000412653.56291.ab.[16] Smith ML, Chen E, Lau C, Davis D, Simmons J, Merianos AL. Effectiveness of chronic disease self-management education (CDSME) programs to reduce loneliness. Chronic Illness. 2022. DOI: 10.1177/17423953221113604[17] Kennedy A, Reeves D, Bower P, et al. The effectiveness and cost effectiveness of a national lay-led self-care support programme for patients with long-term conditions: a pragmatic randomised controlled trial. Journal of Epidemiology & Community Health 2007;61:254-261.[18] Muscat DM, Song W, Cvejic E, Ting JHC, Medlin J, Nutbeam D. The impact of the chronic disease self-management program on health literacy: A pre-post study using a multi-dimensional health literacy instrument. Int J Environ Res Public Health. 2019 Dec 19;17(1):58. doi: 10.3390/ijerph17010058. PMID: 31861752; PMCID: PMC6982295.[19] Ritter PL, Ory MG, Laurent DD, Lorig K. Effects of chronic disease self-management programs for participants with higher depression scores: secondary analyses of an on-line and a small-group program. Transl Behav Med. 2014 Dec;4(4):398-406. doi: 10.1007/s13142-014-0277-9. PMID: 25584089; PMCID: PMC4286546.