To increase community-based chronic disease self-management education (CDSME) and the sustainability of these programs in the aging and disability network in Texas, the Program on Healthy Aging at the Texas A&M School of Public Health has been awarded $895,189 by the U.S. Department of Health and Human Services Administration for Community Living.

As one of only seven funded projects nationally, the SUSTAIN for Better Health and Health Care for Older Adults Program will serve as a central hub to embed a suite of Stanford Patient Education CDSME within a 59-county region in Central and East Texas.

Led by Regents and Distinguished Professor Marcia Ory, PhD, MPH, the SUSTAIN program will leverage the combined resources of Area Agencies on Aging (AAA), integrated healthcare systems and managed care organizations to increase the number of graduates from CDSME programs and to support sustainable program delivery.

“By developing and evaluating models of best practices in creating a systematic health care referral system linking clinical and community sectors, we hope to significantly increase CDSME program participants, which help individuals to better manage their chronic diseases,” Ory said.

In addition to developing a centralized hub model for referrals and data collection, other anticipated products include tools, checklists and resources for dissemination to AAAs and community organizations. Examples include Integrated Chronic Disease Awareness and Resource Education (ICARE) screening and referral tool, a return on investment fact sheet and sample CDSME Memorandum of Understandings and business plans.

“Increasingly, health and wellness workshops delivered in community settings, such as the CDSME programs, are being redefined from traditional service provision to an integral part of health care delivery,” said Doris Howell, MPH, assistant director of the SUSTAIN program. “Following the idea that ‘health starts at home,’ this project provides an opportunity to expand and evaluate delivery through innovative partnerships between those in the aging sector, health care systems and insurers.”

“These collaborative efforts align with the triple aim of ‘better health, better health care and better value,’” Ory added, “by focusing on better management and coordination of chronic conditions common in later life such as diabetes, heart conditions, lung disease and arthritis.”

— Rae Lynn Mitchell