2021 Integrated Networks to Deliver and Sustain Evidence-Based Chronic Disease Self-Management Education Programs

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2021 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. Faith-based and community organizations that meet the eligibility requirements are eligible to receive awards under this funding opportunity 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. [1] 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. [2][3] The aging and disability networks reach into every community across the nation and function as the trusted “eyes and ears” of a person’s home and community environments. When essential social and behavioral determinants of health, i.e., adequate nutrition, safe housing, and access to health care services go unmet, 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. [4]

Across the nation, many aging and disability networks are engaged in community integrated health networks in an effort to provide older adults, individuals with disabilities, and other high cost, high need populations with streamlined access to services to help them remain healthy, in ways that respect individual preferences, goals, and interests. These networks are comprised of a group of visible and trusted aging and disability organizations, led by a Network Lead Entity (NLE), who have formal partnerships with health care and other relevant sectors to address health and social needs in a coordinated way. NLEs function as a one-stop-shop for contracting with health care entities, and often deploy a multi-payer strategy to ensure individuals have access to needed programs and services; beyond contractual arrangements with health care entities, other sources of financing that networks may draw upon are federal grants (e.g. Older Americans Act and discretionary) or other publicly-funded resources at the state or local levels, philanthropic support, private pay arrangements, and civic/community investment (e.g. local businesses, United Way, etc.). An important part of any robust community integrated health network is the inclusion of evidence-based health promotion and disease prevention programs. Indeed, results from the Aging and Disability Business Institute’s 2020 Request for Information indicate that evidence-based programs are the second most common service provided through contracts (behind case management/care or service coordination). A March 2020 Community Integrated Health Network Report provides more information about the intent, guiding principles, and function/structure of these networks, and an example of one network.

Over nearly two decades. ACL’s Administration on Aging has worked 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. [5] 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. [6],[7] Chronic conditions also impact health care costs: 95% of health care costs for older Americans can be attributed to chronic diseases.

Evidence-based chronic disease self-management education (CDSME) programs can help mitigate 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. [5]

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 2020 supported 11 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 state or regional Community Integrated Health Networks that address the social and behavioral determinants of health of older adults and adults with disabilities.

These Networks should have the capacity to deliver, strategically incorporate, and embed evidence-based chronic disease self-management education (CDSME) and self-management support programs within their broader context that includes other programs/services that address social determinants of health (e.g. nutrition, transportation, care coordination, etc.).

These networks should have:

A Network Lead Entity that is working in partnership with a variety of community-based organizations across a geography to provide a centralized, coordinated model for service provision, administrative functions, and quality improvement. The collective network should have the ability to provide a range of services, including CDSME/self-management support programs. Beyond the partnering community-based organizations, the network should also include state level partnerships (i.e., State Units on Aging, Public Health, etc.), local level partnerships (i.e., AAAs, Centers for Independent Living, etc.), and strategic engagement of health care entities.

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 infrastructure and 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 their chronic conditions.

Please refer to Appendix A (Glossary of Terms) for definitions of CDSME and self- management support programs.

Applicants for this funding opportunity must propose to deliver two or more CDSME/self-management support programs on the pre-approved lists in Appendix B and C of this funding announcement. At least one of the programs proposed must be a CDSME program from Appendix B.

All applicants must propose to implement at least one program that can be delivered in a remote format, i.e., by video conference, phone, mailed toolkit + phone, or some other format that does not have an in-person component.. The National Council on Aging (NCOA) maintains a website that tracks remote program guidance by program (https://www.ncoa.org/news/ncoa-news/center-for-healthy-aging-news/track…). However, all applicants should contact the program administrator(s) for any program(s) they are interested in delivering remotely to confirm that: 1) the programs are allowed for remote delivery; and 2) that training is readily available for applicants who need it. Note that the NCOA website includes programs on the pre-approved list in Appendix B and C, as well as other programs not on the list. For this funding opportunity, applicants may ONLY propose programs on the pre-approved lists in Appendix B and C.

All applicants who do not have adequate existing capacity for any in-person and/or remote program(s) they are proposing must include a letter from the program administrator in their application indicating that they will be able to get training in the program no later than three months after the start date of the grant (if selected for funding).

[1] U.S. Department of Health and Human Services, Administration for Community Living. (2019). FY2016 Report to Congress: Older Americans Act.
[2] World Health Organization (2019). Social Determinants of Health, Accessed October 2, 2019 from https://www.who.int/social_determinants/en/.
[3] ACL Office of Performance and Evaluation (2019). Program Evaluations and Reports. Accessed October 2, 2019 from https://acl.gov/programs/program-evaluations-and-reports.
[4] 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.
[5] 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.
[6] 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.
[7] Kramarow E. et al. 2007. Trends in the Health of Older Americans,1970–2005. Health Affairs (Millwood). Sep-Oct;26(5):1417 25

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Last modified on 12/14/2020

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