new jersey sustainability & business plan€¦ · evidence of the value of the program in a new...
TRANSCRIPT
New Jersey Sustainability
& Business Plan
December 2012
2
Acknowledgements DP Consulting LLC would like to thank the following organizations for participating in the NJ Department of Human Services (NJDHS) Business and Sustainability Plan for the Chronic Disease Self-Management Program (CDMSP): Camden Area Health Education Center Community Services Inc. of Ocean County Complete Care Health Network (FQHC) Horizon NJ Health (Medicaid Managed Care Org) Jewish Federation of Greater Metro west New Jersey NJ Department of Health Division of Family Health Services NJ Department of Health-Office of Minority & Multicultural Health NJ Department of Human Services-Division of Aging Services NJ Prevention Network Ocean Health Initiatives (FQHC) Robert Wood Johnson Center for Health & Wellness Saint Peter's University Hospital Sickle Cell Association of New Jersey Sussex County Office of Senior Service University Correctional Health Care University of Medicine & Dentistry of NJ-Department of Preventative Medicine & Community Health UMDNJ School of Osteopathic Medicine Institute for Successful Aging
3
Executive Summary
BACKGROUND
New Jersey has established goals for the Chronic Disease Self-management Program - CDSMP program
(described in the state as Take Control of Your Health) in the areas of reach, adoption, capacity and
securing funds for sustainability. Targeted populations are those with a chronic condition over 60 years
or with a disability (reach); continuation of the program by existing aging network agencies and greater
involvement by health systems, insurers and community based organizations within health disparity
communities (adoption); staffing and infrastructure to deliver and ensure quality in delivery in CDSMP in
every county of the state, and similar infrastructure for the Diabetes Self-Management Program (DSMP)
and Tomando Control du su Salud delivery in selected counties(capacity); and statewide management
structures, dedicated funding, embedding in care transitions and waiver programs and corporate and
philanthropic support so that programming will continue when ACL/AoA funding ends.
CURRENT CAPACITY
The NJ Department of Human Services is funding 2.40 FTE staff dedicated to CDSMP/DSMP overseeing
day-to-day project activities including technical assistance, quality assurance and communication to
agency partners; leading data collection, entry and reporting; and managing fidelity assurance activities.
CDSMP is now available statewide with 100 master trainers (28 for DSMP and 5 for Tomando) and 200
peer leaders providing programs in all 21of the state’s
counties. There are identified program coordinators in
many counties and a growing number of people are
being reached with rates now of 168 participants per
month. Support from the Office of Disease Prevention
and Control (Chronic Disease Prevention) and the Office
of Minority and Multicultural Health have also facilitated
effective targeting of persons with Cardiovascular
Disease and Stroke, Asthma, and Diabetes, and outreach
to racial/ethnic and rural communities.
CDSMP is now available
statewide with 100 master
trainers (28 for DSMP and 5
for Tomando) and 200 peer
leaders providing programs
in all 21of the state’s
counties.
4
CHALLENGES
Local delivery is still largely supported by small grants from the Department of Human Services and its
State partners, some philanthropic and corporate support and the contributions of the 65 agencies that
either provide sites or support program coordinators. Further expansion of reach into communities and
to individuals who will benefit from the programs and increased adoption of the programs by
community agencies, physician groups, health networks and insurers is desired. This will require more
evidence of the value of the program in a New Jersey context. This may include identification and
securing of funding and revenue sources as well as establishing a level of delivery that will attract both
referrals and resources. These actions and similar ones, will assure partners that the revenue needed for
program delivery is secured and lead to the commitment, on their part, of the required level of delivery
and staffing needed to coordinate efforts.
BUSINESS STRATEGIES
Utilizing existing resources from the Department of Human Services and its State partners, additional
resources now available from the Administration on Community Living and in order to realize new
resources from Care Transitions, MCO and Waiver programs the New Jersey program will:
1. Maintain the commitment of the Department of Human Services and its State partners to support
the staff positions currently funded and maintain the roles of these staff in overseeing day-to-day
project activities including technical assistance, quality assurance and communication to agency
partners; leading data collection, entry and reporting; and managing fidelity assurance activities.
2. Build local capacity throughout New Jersey using existing and new partners able to reach 3000
participants over three years
3. Embed referrals to CDSMP in the array of services supported in several funded care transitions
programs
4. Partner with four managed care organizations in New Jersey to a) encourage referrals by their
affiliated nurse case managers to the programs, b) assess impact of CDSME on members from
clinical and financial perspective; and, c) evaluate CDSMP as a health promotion option for which
members may be reimbursed.
5. Include CDSMPs among programs that may be funded under New Jersey Medicaid Long Term
Services and Support. Operationalize the process including ensuring that partners meet
requirements to qualify for reimbursement.
5
6. Continue to include CDSMP in Community Mobilization Initiatives which will further help to embed
the program into the grassroots’ expectation of health care services and its active involvement in
sustaining the program through a long-term commitment.
ANTICIPATED OUTCOMES
A statewide delivery network for CDSMP at a level likely to a) foster reimbursements, b) be integrated
into key health related initiatives (e.g., care transitions and Waiver services), c) expand needed supports
for persons with specific chronic conditions, including Cardiovascular Disease and Stroke, Asthma, and
Diabetes and d) increase access for racial/ethnic groups and rural as well as urban and suburban
communities.
6
Business Plan Background
The New Jersey Department of Human Services (NJDHS) contracted with DQ Consulting to develop a
business plan for the sustaining of CDSME delivery in New Jersey.
METHOD
Data collected to support the development of this
business plan was gleaned from several things including:
a.) A review of grant proposals, contracts and existing
documentation related to delivery of the CDSMP, DSMP and Tomando Control du su Salud
interventions, b.) Research on chronic illness and health disparity challenges in New Jersey, c.)
Interviews with key State staff to understand where CDSMP fits within agencies’ overall missions and
priorities, d.) History of the State staff involvement in the programs and plans for the future, and online
focus groups with key partners to understand current delivery, infrastructure, marketing, quality
assurance, evaluation, and reach achievements and challenges.
A series of business planning questions emerged from these reviews to which State agency staff
responded, providing a basis for the development of a proposed business plan.
The plan reflects a comprehensive review of the existing infrastructure beginning with a series of
assumptions, which are based upon the data collected. These assumptions outline steps to be
undertaken during the three-year period of the currently funded CDSMP project that will lay the
groundwork for sustainability. The completion of these steps will demonstrate that:
There is ongoing State leadership support
CDSMP fits within key priorities for New Jersey agencies
The existing statewide infrastructure and planned expansions in another 10 counties is sustainable
Planned expansions will support greater collaboration with care transitions, managed care
organizations and waiver programs
State leadership will target the marketing, delivery, evaluation and quality assurance concerns to
various partners that will encourage program development and expansion.
CDSMP fits within key priorities
for New Jersey agencies.
7
CDSMP delivery will be a feature of waiver programs and Medicare reimbursement will be secured
for the DSMP.
Comprehensive Review Of Existing Infrastructure
VISION & MISSION
The New Jersey Department of Human Services (NJDHS) is
the largest state agency in New Jersey. Based in Trenton,
NJ, it serves approximately 1.5 million New Jersey
residents, or about one of every six state residents, and
employs about 15,000 people.
NJDHS serves seniors, individuals and families with low incomes; people with mental illnesses,
addictions, developmental disabilities, or late-onset disabilities; people who are blind, visually impaired,
deaf, hard of hearing, or deaf-blind; parents needing child care services, child support and/or healthcare
for their children; and families facing catastrophic medical expenses for their children.
NJDHS is made up of eight divisions, including the State Unit on Aging - the Division of Aging Service
(DoAS). Within the DoAS, programs like Take Control of Your Health (the Chronic Disease Self
Management Program) help older adults manage their health concerns and maintain themselves in the
community. These programs are offered in local sites through extensive partnerships with community-
based agencies.
Since 2006, the NJ DoAS has promoted and invested in infrastructure for delivery of the self-
management workshop, the Chronic Disease Self-Management Program (CDSMP). Known as Take
Control of Your Health in New Jersey, CDSMP was developed by Stanford University’s Patient Education
Research Center and has been endorsed as an evidence-based intervention by the Centers for Disease
Control and Prevention (CDC) and the U.S. Administration on Aging (AoA). CDSMP supports workshop
participants in community-based settings in developing self-management techniques to manage their
chronic conditions. The small groups meet for 2.5 hours per week for 6 weeks. There are also variations
on the core program targeting persons with diabetes (Diabetes Self-management Program - DSMP) and
persons who are Spanish speaking (Tomando Control de Su Salud and the DSMP for Spanish speakers).
Working with its community partners over the past several years, The State has been building an
infrastructure to initiate and expand access to the above evidence-based programs.
New Jersey’s success in the
delivery of these programs
can be directly attributed to
state-level leadership and
an array of strategic
partnerships.
8
9
Current Delivery Structure New Jersey’s success in the delivery of these programs can be directly attributed to state-level
leadership and an array of strategic partnerships.
The DoAS has committed significant resources to support a fully functioning Older Adult Health
Promotion unit within the Department’s Community Resources, Education and Wellness (CREW) office
that:
Provides leadership for program administration, strategic partnerships and visioning.
Holds a multi-site license with Stanford for statewide delivery of CDSMP, Tomando and DSMP.
Promotes programs through a State CDSMP webpage and toll-free number.
Maintains centralized data input.
There are 2.40 FTEs dedicated to CDSMP/DSMP: The DoAS Director of CREW, (50% CDSMP dedication);
Coordinator (100% CDSMP dedication) who oversees day-to-day project activities including technical
assistance, quality assurance and communication to agency partners; Data Collection Coordinator (90%
CDSMP dedication) leads data collection, entry and reporting; and three other staff persons who
participate in fidelity assurance activities (5-10% FTE CDSMP dedication). The state’s commitment to
fund staff salaries as outlined above will continue for the
foreseeable future.
A primary goal of the effort to date has been to build
capacity and infrastructure and much has already been
achieved. There is now a readiness to expand the reach
for CDSMP.
CURRENT CAPACITY
Three CDSME programs are currently delivered and one
additional version is contemplated:
The Chronic Disease Self-Management Program (CDSMP), developed at Stanford University Patient
Education Research Center, teaches skills to manage common problems related to having a chronic
The DoAS has committed
significant resources to
support a fully functioning
Older Adult Health
Promotion unit within the
Department’s Community
Resources, Education and
Wellness (CREW) office.
10
condition such as arthritis, diabetes, lung disease, and heart disease. The program has proven useful for
increasing a person’s self-confidence that they can manage their chronic condition(s). Classes meet 2
1/2 hours, once a week for a 6-week succession and are facilitated by two, trained peer leaders.
CDSMP is now available statewide with 100 master trainers and/or 200 peer leaders providing
programs in all 21 of the state’s counties.
Tomando Control de Su Salud (Tomando) is a workshop given two and a half hours, once a week, for six
weeks, in community settings such as senior centers, churches, libraries and hospitals. Spanish-speaking
people with different chronic health problems attend together. Workshops are facilitated by two trained
leaders. All workshops are given in Spanish without translators. The Program is not a translation of the
Chronic Disease Self-Management Program, but developed separately in Spanish to be culturally
relevant.
There are now 7 active master trainers covering 5 counties.
Diabetes Self-Management Program (DSMP), similar to the CDSMP but focused on the management of
Type 2 Diabetes was also developed by the Patient Education Research Center at Stanford University.
There are now 28 active master trainers covering 10 counties.
Better Choices, Better Health® (BCBH) is the online version of the nationally recognized Chronic Disease
Self-Management Program, developed and tested at the Stanford University Patient Education Center
and managed by the National Council for Aging. Frequently, BCBH is disseminated under contracts with
managed care organizations and other health systems. It does not require “real time” attendance and a
pair of trained peer facilitators moderates each workshop. Weekly over a 6-week period, participants
are asked to log on at least three times for a total of about two hours. Weekly activities include reading
and interacting via the Learning Center, making and posting a weekly action plan, participating in
problem solving and guided exercises on bulletin boards, and participating in any appropriate self-tests
and activities. Participants are encouraged to post chronic condition-related concerns on a bulletin
board which allows group members to express and share ideas with each other in a helpful manner.
In NJ, for the next three years, BCBH will be offered as part of a pilot project for members of four
managed care organizations.
11
LOCAL INFRASTRUCTURE
Sixty-five community-based agencies function as “lead agencies/host agencies,” and house master
trainers, oversee peer leaders and coordinate delivery at more than 300 implementation sites. Lead
agencies include Area Agencies on Aging (AAAs), hospital systems, Federally Qualified Health Centers,
community and faith-based organizations, Retired and Senior Volunteer Programs (RSVPs), health
departments and state health associations.
LANGUAGE
CDSMP has been offered in 6 languages in select geographic areas: Mandarin/Cantonese (3 master
trainers), French Creole (2 master trainers), Vietnamese (2 master trainers), Hindi (3 master trainers)
and Korean (3 master trainers).
ACHIEVED PROGRAM REACH
There has been a steady increase in the effective reach of the programs:
2007 – 2009 = 1,580 participants (24 months = an average of 66 new participants per month)
2010 = 1,418 participants (12 months = an average of 118 new participants per month)
2011- May 2012 = 2,863 participants (17 months – an average of 168 new participants per month)
KEY PARTNERSHIPS
While DoAS holds lead responsibility for CDSMP, two key
public health partners – the Office of Disease Prevention
and Control (Chronic Disease Prevention) and the Office
of Minority and Multicultural Health -have also
embraced the CDSMP. Both offices committed resources
to establish institutional knowledge by training staff and
allocating funds ($800,000+) to introduce the programs
into their service delivery systems, which include a focus
on Cardiovascular Disease and Stroke, Asthma, Diabetes, Minority Health Services and Rural Health.
Both offices have collaborated with DoAS to provide oversight and support for community partners.
Sixty-five community-based
agencies function as “lead
agencies/host agencies,”
and house master trainers,
oversee peer leaders and
coordinate delivery at more
than 300 implementation
sites.
12
The Office of Minority and Multicultural Health (OMMH)
has worked closely with DoAS for the last five years to
provide access to CDSMP within racial / ethnic minority
communities. During this time they committed both
staff and monetary resources to expand availability of
CDSMP and Tomando Control de su Salud across New
Jersey. OMMH also supported delivery of the Diabetes
Self-Management Program by committing resources to
two providers to encourage the expansion of this program. An OMMH staff person is overseeing grants
targeting minority populations, (25% dedication to CDSME).
DoAS also has focused on developing capacity in CDSMP in counties throughout New Jersey, targeting
persons age 60+, and/or with a disability and at least one chronic condition. As can be seen in Figure 1,
statewide capacity exists for CDSMP, and some regional capacity in the Diabetes Self Management
Program and in Tomando Control de Su Salud.
POTENTIAL REACH
As can be seen in Figure 1, New Jersey experiences rates of chronic conditions similar to levels reported
nationally:
Figure 1
Both offices committed
resources to establish
institutional knowledge by
training staff and allocating
funds ($800,000+) to
introduce the programs
into their service delivery
systems.
13
Heart disease accounted for 29% of deaths in New Jersey, while stroke caused 5% of deaths.
28% of adults in New Jersey reported having high blood pressure (hypertension) and 39% of those
screened reported having high blood cholesterol; 27% reported being diagnosed with arthritis.
The American Cancer Society estimates that 49,370 new cases of cancer were diagnosed in the
state.
Although specific local prevalence rates on chronic conditions are not easily available, the estimate is
that 80% of all individuals in New Jersey age 60+, and/or with a disability have at least one chronic
condition. Table 1 gives estimates of the numbers of persons who may be reached by CDSMP statewide
and in the 10 target counties. These estimates represent the potential target numbers of people in New
Jersey likely to benefit from CDSMP.
Table 1. Potential Reach population - New Jersey
Population Persons 60+ Persons with one or more
Chronic Conditions (60+) Persons with
Disabilities (60+)
New Jersey 1,666,535 1,333,228 376,112
Bergen County 190,092 152,074 26,000
Burlington County 88,110 70,488 20,893
Cumberland County 28,580 22,864 10,896
Essex County 129,272 103,418 Not Available
Hudson County 94,166 75,333 27,918
Mercer County 65,637 52,510 16,077
Middlesex County 140,202 112,162 26,431
Ocean County 157,064 125,651 Not Available
Passaic County 85,721 68,577 Not Available
Union County 95,107 76,086 19,892
14
HEALTH DISPARITIES
Disparities in risk, access and health outcomes are being targeted in New Jersey and are a particular
focus of The Office of Minority and Multicultural Health (OMMH). Data estimates for health disparities
based upon the Behavioral Risk Factor Surveillance System (BRFSS) for New Jersey include:
African-Americans have higher mortality rates from cardiovascular disease than do whites (Age-
adjusted death rates, 2001), and from colorectal cancer although the incidence rates for both
groups are similar.
In 2005, an estimated 24% of adults were diagnosed with hypertension with highest prevalence
among Non-Hispanic Black males and females. The age-adjusted stroke mortality rate for blacks is
53% higher than the rate for whites.
Non-Hispanic blacks had the highest age-adjusted prevalence rate of diabetes at 11.5%, followed by
Hispanics at 7.2%, and non-Hispanic whites at 5.3%.
In 2003, the age-adjusted breast cancer mortality rate was 28.6 for white women and 33.9 for black
women per 100,000 of population.
Incidence rates for invasive cervical cancer are higher for blacks than they are for whites (17.5
versus 9.0 per 100,000 women in 2000) and prostate cancer incidence rates are approximately 50%
higher for blacks than for whites. (Center for Health Statistics).
These estimates have encouraged ongoing targeting of health disparate populations in New Jersey with
future health disparity outreach efforts focusing on Diabetes through the expansion of the English and
Spanish DSMP programs. Other efforts will remain non-disease specific through the delivery of the
CDSMP and the Tomando Control de Su Salud. As a result, the State intends to maintain and/or build
capacity in its 21 counties partly through the expansion of infrastructure partners i.e. community
partners in all counties and also to see specific expansion
of delivery in Spanish.
CURRENT FUNDING
Over the last several years, NJDHS has shown a long-term
commitment to support the CDSMP. This has been
affirmed through a recently received Chronic Disease Self
Management Education (CDSME) grant from the
Administration on Aging (AoA). This three year grant contains a commitment of approximately $300,000
to support full and part-time state funded positions associated with the DoAS CREW.
Several local partners have
had success in securing
small grants from various
Foundations to support
delivery of CDSMP as part of
larger program initiatives.
15
In addition, the Office of Minority and Multicultural
Health has dedicated a portion of their state funds to
CDSMP for the past 5 years. For the period beginning
December 2012 this will represent approximately
$90,000; however this is not a static amount and will
vary annually. In past years, other State agencies/offices have dedicated funds (both state and federal)
to CDSMP including the Office of Rural Health and Primary Care, and the Heart and Stroke Program.
These funds tend to be one-time funds. Finally, NJ DoAS has paid for the current Statewide Stanford
License for the period February 2010 – February 2013, at a cost of $7000.00, or $2333.00 per year.
In the past partners have received mini-grants from DHS to support start-up costs. Partners are being
encouraged to seek funding sources to sustain the program. Several local partners have had success in
securing small grants from various Foundations to support delivery of CDSMP as part of larger program
initiatives (for example, the Robert Wood Johnson Foundation NJ Health Initiatives funds for Health
Literacy Projects.). Partners are continuing to seek such funds and to also look at possibilities for
corporate and health system/insurer supports.
Prior funding has allowed many partners to integrate CDSMP and related infrastructure into their
ongoing operations with master trainer, peer leader and project coordinator roles being incorporated
into larger job responsibilities. This has the advantage of removing the need for funding for these roles
but does mean that CDSMP is rarely the sole responsibility for the staff involved. The value of this
contributed time, of the time of volunteer peer leaders, and donated space varies among partners. To
date books and materials have been largely covered by awarded grants. Some partners have secured
other sponsors for these costs, while others charged a minimal participation fee. Very few partners
offer stipends to their peer leaders because, although done so by a few partners in the past, it was
demonstrated that it was not viable and didn’t result in increased peer leader retention.
NJ DoAS plans to work with partners in a variety of ways such as: Accessing Managed Care Organizations
funding under the Comprehensive Waiver for Medicaid Long-term Services and Supports; including
CDSMP in the developing Care Transitions Models being implemented by local coalitions; revenue
sharing with providers of wellness programs like the CDSMP; encouraging Area Agencies on Aging to
support these programs with AoA-provided Title IIID funding.
Over the last several years,
NJDHS has shown a long-
term commitment to
support the CDSMP.
16
There are some examples of success:
In one care transition program a CDSMP partner
is working with providers and hospital to reduce
frequency of re-admissions for Medicare
patients.
Some pharmaceutical companies have provided
short term, low level funding for delivery of
CDSMP.
DoAS has worked with partners interested in pursuing other grant funds providing a grant
template to agencies where there may not be staff able to independently submit a grant.
Work is underway with physicians groups who are using CDSMP and Care Transitions programs
to meet the Centers for Medicare and Medicaid Services (CMS) Quality Measures.
As more inroads are built and successes recorded around the inclusion of the CDSMP, additional State
offices/Divisions may become involved including Managed Behavioral Health, Division of Disability
Services, Mental Health and Addictions.
SERVICES
NJ DoAS and its partners have committed to the delivery of four programs: CDSMP, DSMP (with the
addition of the Spanish DSMP), and Tomando Control de su Salud.
MEASURES OF SUCCESS
Beyond effectiveness, typical metrics of success for evidence-based programs are expressed in terms of
the RE-AIM Framework (www.re-aim.org), which is designed to enhance the impact of public health
programs by paying special attention to the five
framework elements including REACH (meaning your
intended target population; people who will most benefit
from improvements in self-management) and ADOPTION
(by partners who will most benefit such as health
systems, insurers and local agencies who are working
with chronic conditions and who are seeking to improve
health outcomes, quality of life and costs of care).
Work is underway with
physicians groups who are
using CDSMP and Care
Transitions programs to
meet the Centers for
Medicare and Medicaid
Services (CMS) Quality
Measures.
NJ DoAS and its partners
have committed to the
delivery of four programs:
CDSMP, DSMP (with the
addition of the Spanish
DSMP), and Tomando
Control de su Salud.
17
The state will measure success in REACH in terms of continuing to reach groups currently being served
and in reaching new populations including people with disabilities and/or diabetes, Spanish speaking
populations, people recently discharged from hospitals, and people receiving Managed Long Term
Services and Supports.
COMPETITION
CDSMP is usually offered in environments in which there are other evidence-based programs or efforts
around health education, which may be seen as programs for competing health concerns and/or
competing priorities. The DoAS has made a choice to advance the CDSMP because of its proven
outcomes and because it is offered extensively throughout the state. Two things that no other program
currently on the market can tout. CDSMP will continue to be the program of choice in New Jersey as
long as the federal agencies like the Administration on Aging/Administration for Community Living and
the Centers for Disease Control and Prevention continue to focus on and fund the program.
CDSMP is being delivered at a time of rapid changes in the health care system in New Jersey (and the
country) and to the extent that CDSMP represents an opportunity to better bridge and engage
community and health resources and support activation of individuals then it is an attractive offering in
this changing health environment.
MARKETING
There are already developed materials available through the
State and other national partners as well as evidence for
their effectiveness. Since 2007, the state has reached over
5800 participants with these programs. The marketing
materials used include:
A professional brochure template developed highlighting cultural diversity and geared to senior
audiences.
Videos for television.
PowerPoint presentations developed for and given by graduates and staff to community and
professional groups.
The PowerPoint presentations have appeared to be the most successful marketing tool offering face to
face contact, linkages to diverse participant and professional (including physician) audiences and lending
The DoAS has made a
choice to advance the
CDSMP because of its
proven outcomes and
because it is offered
extensively throughout the
state.
18
themselves to start-up publicity, ongoing recruitment
and integration with other health related and partner
related marketing efforts.
Other strategies that have proven effective include:
Using quotes from program graduates inserted into
brochures, as teasers for upcoming workshops, in
agency newsletters, and featured on websites;
Outreach to health disparity communities featuring
quotes from local participants;
Recruiting leaders and other volunteers to do
community presentations;
Having CEO and other provider leaders “sell” the
program to physicians and other groups;
Finding sponsors for individual local classes;
Use of Eventbrite for registration and Facebook and Twitter for marketing.
A hallmark of these successful strategies is that they are all relatively low cost.
The State will continue to play a lead role in offering
templates, standards, and maintaining branding.
However, the local partners will personalize the materials
and target resources to media outlets most relevant for
their communities. The State recognizes that there must
be great flexibility in allowing its partners the freedom to
decide how the programs will be marketed to consumers
and the target community. The state’s percentage of marketing efforts will vary based upon the
particular point in time and the influence of environmental factors at that time, but will include
increasing individual referrals, engaging existing or new referral sources, and recruiting from existing
partners as well as attracting new funders.
CDSMP is being delivered at
a time of rapid changes in
the health care system in
New Jersey (and the
country) and to the extent
that CDSMP represents an
opportunity to better
bridge and engage
community and health
resources and support
activation of individuals
then it is an attractive
offering in this changing
health environment.
The state currently has a
workforce of about 200 peer
leaders made up of both
professionals and
volunteers with chronic
conditions.
19
ADDRESSING MARKETING CHALLENGES
There is evidence of success in reaching diverse communities, MCOs, health partners and physicians.
However, there is an identified challenge that true engagement with physicians and health partners will
likely require greater emphasis on demonstrated outcomes data. To date there has been a reliance on
evaluations conducted by Stanford and other published studies but there is feedback that more local
outcomes is required. The AoA/Administration for Community Living CDSME grant (commencing
September 2012) supports work with four managed care organizations including an evaluation
component that promises to yield New Jersey specific cost savings, utilization, and health outcomes
data. The Office of Minority and Multicultural Health is also requiring outcome measures (measures to
be determined) in the grants they award in the fall 2012 which will add to data available to support
marketing efforts.
The state will continue to emphasize national CDSMP
studies and the program’s well-documented outcomes
until state data is available.
OPERATIONAL
Local delivery of CDSMP and other CDSMP has relied upon a workforce comprising program
coordinators, master trainers, and peer leaders.
CDSMP Program Coordinators
Since the initial grant funding to develop local programming, there have been successful efforts to
integrate the role of Program Coordinator into the necessary components of program implementation.
This has been primarily accomplished by maintaining the Program Coordinator role within an existing
staff position.
Currently coordinators dedicate 10-50% time to advertising, marketing, recruitment, site selection,
making peer leader charts, calling participants who do not attend sessions, making quality checks and
attending first or last sessions related to data collection and thanking leaders. Some coordinators are
master trainers; others have access to a master trainer to support training and quality checks. Some
areas have seen turnover in master trainers and do not have as many resources as they have previously
depended on.
Since 2007, the state has
reached over 5800
participants with these
programs.
20
21
Master Trainers
Master trainers can, be but are not always, the program coordinator. Some challenges are being
experienced with master trainer turnover including master trainers not being able to maintain
certification because there are not sufficient peer leader training opportunities. The state believes that
the current complement of master trainers is sufficient to meet all training and quality monitoring
requirements if all stay involved in program activities. However, it is recognized that additional strong
leaders/volunteers/administrators are needed to take on some roles like regional/area coordination and
quality assurance.
Peer Leaders
The state currently has a workforce of about 200 peer leaders made up of both professionals and
volunteers with chronic conditions. Future expectations of activity level will remain the same at a
minimum of one workshop per year. Based upon experience, the ideal mix of peer leaders is 50%
people with chronic conditions/50% professionals. This combination works best as participants identify
with leaders like themselves and for effective completion of administrative tasks.
Moving forward, the DoAS has indicated it will further define the roles and expectations involving its
partners who will implement CDSMP. The persons involved in the identified roles may be made up of
staff, Master Trainers, and/or volunteers. Should reimbursement models from MCOs, Medicaid Waiver
Program, or other sources become available, the funds will be more likely used to support workshops
and/or reimbursement/payment of participants and not for the funding of coordinator positions.
QUALITY ASSURANCE
Currently, a series of quality assurance tools are available
from the DoAS and feedback from program coordinators
suggest that they are useful and feasible to use, although
without funded program coordinators or sufficient master
trainers their use will become difficult to sustain. The state
has an established fidelity protocol, however, reviewing
attendance records and satisfaction reports. There are also differing practices and experience in
providing feedback to peer leaders when quality concerns are identified.
The state currently has a
workforce of about 200 peer
leaders made up of both
professionals and
volunteers with chronic
conditions.
22
The dedicated staff at DoAS will continue to work closely with local coordinators and quality assurance
representatives to offer support and technical assistance on an ongoing basis.
DATA COLLECTION
Traditionally, New Jersey has collected the reach and demographic data required by funders including
the AoA and the National Council on Aging (NCOA) its technical assistance center, with data entered
centrally in the AoA/NCOA database. There have been additional local level data collections including
some outcomes tracking. On the one hand there has been a belief that as an approved evidence-based
program, there is not a need to collect outcomes data but on the other hand there has been a concern
that the outcomes have not been sufficiently demonstrated to secure reimbursement or willingness by
NJ health systems and physicians to rely on CDSMP for the needs of their patients. Under the AoA/ACL
CDSME grant there is to be engagement with four managed care organizations and in support of these
efforts there is to be an evaluation component to yield New Jersey specific cost savings, utilization, and
health outcomes data.
Work with the Office of Minority and Multicultural Health has specifically targeted health disparity
communities and there are concerns here too that relying upon national outcomes data is insufficient.
The Office of Minority and Multicultural Health plans to introduce additional data collection for the
programs OMMH supports. Work with care transitions programs and with Waiver services will have
their own outcomes concerns, for example reductions in re-hospitalizations. Ongoing implementation of
health care reforms will likely mean more clarity on valued outcomes and expectations for data to be
included in electronic health records particularly if reimbursement is to occur. Changes and/or increases
in data collection will pose challenges for local program coordinators.
The State plans to continue to collect and manage data related to these programs through its dedicated
staff lines and will adjust data collection methods i.e. collect additional data for particular efforts. But,
for the majority of partners, only the required data will be collected.
As part of their standard state-specific training, all peer leaders and master trainers are trained on the
data collection/evaluation needs and updates are provided at annual meetings, in monthly newsletters
and in individualized technical assistance. The State will continue to offer these activities on a regular
basis.
23
Next Steps for New Jersey – Building A Sustainable
Program Model Business strategies: Utilizing existing resources from the Department of Human Services and its State
partners, additional resources now available from the Administration on Community Living and in order
to realize new resources from Care Transitions, Managed Care Organizations and Waiver programs the
New Jersey program will:
1. Maintain the commitment of the Department of
Human Services and its State partners to
support the staff positions currently funded and
maintain the roles of these staff in overseeing
day-to-day project activities including technical
assistance, quality assurance and
communication to agency partners; leading data collection, entry and reporting; and
managing fidelity assurance activities.
The success to date of CDSMP in New Jersey has been directly influenced by the State’s
commitment of resources. Although Federal funds have paid for many activities, the business
case for CDSMP is strengthened by this multiyear commitment as there is a resulting statewide
infrastructure and leadership. A continuing commitment to the staffing by NJDHS and to the
funding of targeted outreach efforts by the Office of Minority and Multicultural Health means
both that CDSME delivery is sustainable and that that it will reach those who will most benefit.
The involved state agencies have committed to new activities as defined by the Administration
on Aging grant. Going forward, this assures that, in addition to the prior CDSMP-specific
activities and support of increased infrastructure in selected counties with AoA/ACL funds, the -
State will engage in:
Securing approval for Medicare reimbursement for DSMP
Encouraging AAAs to dedicate Title IIID funds to CDSME delivery
Working with managed care organizations and care transition programs to make
referrals to CDSMP
Negotiating mechanisms for CDSMP to be funded under waiver services
The success to date of
CDSMP in New Jersey has
been directly influenced by
the State’s commitment of
resources.
24
Building these ongoing funding mechanisms will
require State staff to facilitate linkages between
local delivery sites and physician groups and
insurers so that reimbursement is possible. There
will also be work to identify the regions,
populations and the CDSMP programs that may
be eligible for reimbursements and allocation of
Title IIID monies. Existing programs have lauded
the use of memoranda of understanding and
other mechanisms for the above activities to be realized.
As the State works toward these realizations, the long-term objectives will be for at least one
AAA allocating Title IIID monies, Medicare reimbursement for at least one provider (and for
multiple DSMP providers), securing of either care transitions program or managed care
organization funding (and for multiple CDSMP providers) and securing of waiver funding .
Activities will ensure that providers in all 10 targeted counties will have secured at least one
source of reimbursement by the close of the CDSME grant period and that this will also be true
for at least 50% of other counties.
2. Build local capacity throughout New Jersey using existing and new partners able to reach 3000
participants over three years.
A viable delivery system and infrastructure will
attract reimbursement and other resources. A
key concern is that there are classes available
when desired or when a potential source of
reimbursement makes a referral. The desire is
that both CDSMP and DSMP will be available in
the 10 targeted counties so that interested
persons can enroll in a workshop slated to begin,
rather than be placed on a waiting list until the
minimum number of participants needed for a class is reached, and that there will be a similar
level of delivery in targeted Spanish-speaking communities. Other counties will eventually
CDSMP offers important
supports and resources to
enable people with chronic
conditions to manage their
own health, a key outcome
for those at risk for
readmissions to hospital
and/or for admission to a
nursing home.
The dedicated staff at DoAS
will continue to work
closely with local
coordinators and quality
assurance representatives
to offer support and
technical assistance on an
ongoing basis.
25
double existing levels of class delivery and will have secured sufficient resources to continue this
level of class offerings.
3. Embed referrals to CDSMP and related programs in the array of services supported in two
funded care transitions programs.
CDSMP offers important supports and resources to enable people with chronic conditions to
manage their own health, a key outcome for those at risk for readmissions to hospital and/or for
admission to a nursing home. Critical steps are making those who are providers of care
transitions aware of the value of CDSMP, offering CDSMP at times and in places when and
where those at risk might enroll, and ensuring that support of such programs is considered in
the allocation of resources for care transitions and in self-management education efforts. State
staff will work to impress upon state agency decision-makers and care transitions providers the
value of CDSMP. Providers of CDSMP will reach out to local care transitions programs to
understand how to best develop offerings and embed decisions about CDSMP participation in
care transitions planning. State leaders will support the targeting of two care transitions
programs to pilot such collaboration and will utilize the resources they are allocating under the
CDSMP grant to leverage better collaboration between CDSMP providers and care transitions
programs.
4. Working with four managed care organizations in New Jersey, State staff will collaborate with
and assist the MCOs so that they will strive to:
a) Encourage referrals by their affiliated physicians to the programs,
b) Include CDSMP as health promotion options for which members may be reimbursed,
c) Establish CDSMP as a worksite wellness option among covered employers.
To build towards achieving these goals, State staff will determine what the outcomes and local
data that the four managed care organizations need. Both for inclusion of their members and
for the reimbursement and identification of CDSME providers willing to meet these
requirements.
26
State staff, the MCOs and the providers will jointly develop projects and pilot referral and data
collection processes. State staff and providers will then explore with the MCOs different
reimbursement mechanisms, ways to expand utilization by their members, and the level of
delivery needed for CDSMP to be a viable benefit for members. Once CDSMP is established as a
member option or benefit, the providers will work with the MCOs to explore with their large
employer clients delivery of CDSMP as an onsite wellness option, particularly for caregivers.
5. Include CDSMP among programs that may be funded under the New Jersey Medicaid Waiver
to be implemented, including work to ensure that partners meet requirements to qualify for
reimbursement.
As both the viability of and mechanisms for reimbursement of CDSMP as waiver services
become established, State staff will work with CDSME providers to meet requirements to be
reimbursed. Populations to be targeted, locations where CDSMP need to be delivered, linkages
with other waiver services will all need to be determined and both the State leaders and CDSME
partners will work to tailor, outreach, marketing materials and staffing accordingly.
6. Further embed CDSMP in Community Mobilization Initiatives.
The community mobilization initiatives led by the Office of Minority and Multicultural Health are
important opportunities to target critical chronic illness concerns and to engage a variety of
community partners as individuals and communities are assisted in managing these concerns.
The skills training offered by CDSMP are important tools and community level engagement with
local organizations means that CDSMP may reach the most vulnerable.
7. Link community partners offering the Diabetes
Self-Management Program with physicians and
health centers and assist these partnerships to
qualify for reimbursement from Medicare to
support delivery of DSMP for eligible
individuals.
Reimbursement under Medicare for DSMP
delivery is possible but not easily achieved. It
The skills training offered
by CDSMP are important
tools and community level
engagement with local
organizations means that
CDSMP may reach the most
vulnerable.
27
required a working and contractual relationship between a provider of DSMP certified by the
appropriate body and a physician and/or health provider that is approved Medicare
reimbursement and is able to offer the licensed oversight required. A key activity of the State
leaders will be to facilitate these collaborations and the pursuit of required certifications and
receipt of training in all requirements. This will include developing business models for each
partnership that ensure that there will be sufficient participation for reimbursement to actually
cover each partner’s costs.
Anticipated Outcomes Through the seven steps of this business plan, over a
three-year period a statewide delivery network for
CDSMP will be established at a level likely to:
a) Attract reimbursements,
b) Be integrated into key health related initiatives (e.g., care transitions, MCO, Waiver services and
Community Mobilization),
c) Expand needed supports for persons with Cardiovascular Disease and Stroke, Asthma, and Diabetes
d) Increase access for racial/ethnic groups, particularly Spanish-speaking and for rural as well as urban
and suburban communities.
CDSMP will continue to be
the program of choice in
New Jersey.