2020 Integrated Networks to Deliver and Sustain Evidence-Based Chronic Disease Self-Management Education Programs

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2020 Integrated Networks to Deliver and Sustain Evidence-Based Chronic Disease Self-Management Education Programs
Opportunity ID
Primary CFDA Number
Funding Opportunity Number
Funding Instrument Type
Cooperative Agreement
Expected Number of Awards Synopsis
Length of Project Periods
Project Period Expected Duration in Months
Eligibility Category
State governments,County governments,City or township governments,Special district governments,Independent school districts,Public and State controlled institutions of higher education,Native American tribal governments (Federally recognized),Public housing authorities/Indian housing authorities,Native American tribal organizations (other than Federally recognized tribal governments),Nonprofits having a 501(c)(3) status with the IRS, other than institutions of higher education,Private institutions of higher education
Additional Information on Eligibility
Foreign entities are not eligible to compete for, or receive, awards made under this announcement.

Foreign entities are not eligible to compete for, or receive, awards made under this announcement.
Estimated Award Date
Funding Opportunity Description

The Administration for Community Living’s (ACL’s) mission is to maximize the independence, well-being, and health of older adults, people with disabilities, and their families and caregivers. ACL’s programs provide individualized, person-centered home and community-based services and supports, as well as invest in research and best practices, to make community living a reality for millions of people. [i] Delivered through the national aging and disability services network and their partners, ACL supports effective and efficient programs and services that address the social and behavioral determinants of health for millions of older adults and persons with disabilities each year. [ii][iii] The social determinants of health (SDOH) “…reflect the social factors and physical conditions of the environment in which people are born, live, learn, play, work, and age. [iv] Individual behavioral determinants of health (BDOH) can also significantly affect health; even making a small change – such as exercising a little more or choosing healthier foods – can make a big difference.
One of ACL’s greatest strengths is a nationwide aging and disability network. It reaches into every community across the nation and is staffed and run by people who live in those communities. For more than 50 years, organizations in the nationwide aging and disability network have functioned as experts in identifying and responding to social determinants of health, serving as trusted “eyes and ears” of a person’s home and community environments. Examples of programs and services addressing SDOH include congregate and home-delivered meals, transportation, assistive technology, information and resources on home and community-based services, care transition support, and evidence-based health promotion and disease prevention programs. When the most basic SDOH needs are unmet, such as access to adequate nutrition or safe housing, we know that this puts older adults and adults with disabilities at greater risk for chronic disease and other threats to their health and independence.
Over nearly two decades. ACL’s Administration on Aging has built an infrastructure to increase access to, and the sustainability of, evidence-based programs that help older adults make positive changes to maintain and/or improve their health. This portfolio of programs includes interventions focused on chronic disease self-management, behavioral health, medication management, physical activity, falls prevention, and other important areas. These proven programs, alongside the other services and supports the aging and disability networks provide, are essential in helping older adults and older adults with disabilities live healthy and independent lives.
In the United States, approximately three out of four older adults have multiple (two or more) chronic conditions, such as diabetes, arthritis, heart disease, chronic pain, and depression. [v] This burden places older adults at greater risk for premature death, poor oral health, poor functional status, unnecessary hospitalizations, adverse drug events, and nursing home placement. [vi],[vii] Chronic conditions also impact health care costs: 95% of health care costs for older Americans can be attributed to chronic diseases. The cost of providing health care for an individual aged 65 or older is three to five times higher than younger counterparts. [viii] Additionally, adults with disabilities experience health disparities when compared with the general population. For example, adults with disabilities are more likely to have chronic health conditions such as heart disease, diabetes, and stroke than adults without disabilities. [vi]
Evidence-based chronic disease self-management education (CDSME) programs can help mitigate the chronic disease burden by empowering participants to better manage their conditions. The acronym, CDSME, is being used in this announcement as an umbrella term for community-based education programs specifically designed to enhance patient self- management of chronic illnesses, 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. [v]
AoA has supported CDSME and other evidence-based health promotion programs for many years through grants, as well as collaborations on various federal initiatives. For example, Prevention and Public Health Fund initiatives in 2018 and 2019 supported 21 CDSME grantees. Additionally, Older Americans Act Title III-D funding supports a broader portfolio of evidence-based disease prevention and health promotion activities. For more information about ACL’s CDSME Program, including profiles of current grantees, please visit: https://www.acl.gov/programs/health-wellness/chronic-disease-self-manag….
This funding opportunity has two goals:
Goal 1: Strengthen integrated state or regional networks that address the social and behavioral determinants of health of older adults and adults with disabilities.
These networks should have:

the capacity to strategically incorporate evidence-based chronic disease self-management education (CDSME) and self-management support programs within a broader integrated health context that includes other programs/services related to the social determinants of health (e.g. nutrition, transportation, care coordination, etc.); and

the ability to deliver and embed evidence-based CDSME/self-management support programs into an integrated, sustainable program network.

For the purposes of this funding opportunity, an integrated, sustainable program network is a state/regional/tribal-level approach to providing older adults and adults with disabilities easy access to supports and services that address the social and behavioral determinants of health and must include the following:

Formal partnerships with aging and disability network organizations that have the capacity to provide a range of supports and services. This should include state level partnerships (i.e., State Units on Aging, Public Health, etc.) and local level partnerships (i.e., AAAs, Centers for Independent Living, etc.).
Sustainability strategies including, but not limited to, a business plan with clear strategies, contracts, and/or other means to secure and expand sustainable financing (including non-federal funding), infrastructure to receive reimbursement for services, and information technology solution(s) that allows for referral management (including closed loop referrals), participant tracking across interventions, and outcome measurement.
Strategic partnerships with other entities involved in evidence-based CDSME/self-management support program work.
Multi-site delivery partners who have the delivery infrastructure/capacity to increase access to evidence-based CDSME/self-management support programs with a defined geographic or population base, and a commitment to embedding these programs into their routine operations and budget.
Coordinated public awareness, education, marketing, and recruitment processes.
Ongoing quality assurance efforts including fidelity monitoring and continuous quality improvement.

Goal 2: Significantly increase the number of older adults and adults with disabilities who participate in evidence-based CDSME and self-management support programs to empower them to better manage these chronic condition(s).
All programs proposed to be implemented using ACL funding must be on the list of pre-approved interventions in Appendices B and C.
Applicants must propose to implement a minimum of two of the approved CDSME/self-management support programs. At least one of the proposed programs must be a CDSME program listed in Appendix B.

[i] U.S. Department of Health and Human Services, Administration for Community Living. (2019). FY2016 Report to Congress: Older Americans Act.
[ii] World Health Organization (2019). Social Determinants of Health, Accessed October 2, 2019 from https://www.who.int/social_determinants/en/.
{iii] ACL Office of Performance and Evaluation (2019). Program Evaluations and Reports. Accessed October 2, 2019 from https://acl.gov/programs/program-evaluations-and-reports.
[iv] U.S. Department of Health and Human Services, Office of Disease Prevention and Health Promotion (2019). Healthy People 2020: Social Determinants, Accessed October 2, 2019 from https://www.healthypeople.gov/2020/about/foundation-health-measures/Det…- Health#individual%20behavior.

[v] Gerteis J, Izrael D, Deitz D, LeRoy L, Ricciardi R, Miller T, Basu J. Multiple Chronic Conditions Chartbook. AHRQ Publications No, Q14-0038. Rockville, MD: Agency for Healthcare Research and Quality. April 2014.
[vi] Parekh, A.K., et al. 2011. Managing Multiple Chronic Conditions: A Strategic Framework for Improving Health Outcomes and Quality of Life. Public Health Rep. 126(4):460–71.
[vii] Kramarow E. et al. 2007. Trends in the Health of Older Americans,1970–2005. Health Affairs (Millwood). Sep-Oct;26(5):1417 25.
[viii] Centers for Disease Control and Prevention. The State of Aging and Health in America 2013. Atlanta, GA: Centers for Disease Control and Prevention, US Dept of Health and Human Services; 2013.

[vi] Centers for Disease Control and Prevention (CDC), Vital Signs, Adults with Disabilities, May 2014.
[v] Brady, T.J. 2012. Strategies to Support Self-Management in Osteoarthritis.” American Journal of Nursing 112(3), S54-60.

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Last modified on 09/21/2020

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