Business Plan Living Well - Chronic Disease Self ......Mission: To enable seniors with chronic conditions to have easy access to evidence-based programs that help will help them improve

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Business Plan Living Well - Chronic Disease Self-Management Programs

Nutrition and Health Promotion Maryland Department of Aging

March 30, 2012

Living Well - CDSMP Business Plan March 2012

2 Nutrition and Health Promotion – Maryland Department of Aging

TABLE OF CONTENTS

Executive Summary ............................................................................................................................................... 3

Introduction ........................................................................................................................................................... 7

Section 1 - Vision / Mission .................................................................................................................................... 8

1.1. HISTORY AND BACKGROUND........................................................................................................................................... 9

1.2. KEY GOALS ...................................................................................................................................................................... 10

1.3 . NEEDS ........................................................................................................................................................................... 11

1.4. HEALTH OUTCOMES AND DISPARITIES IN MARYLAND ................................................................................................... 11

Section 2 – Capabilities and Experience ............................................................................................................... 13

2.1. PROGRAM CHARACTERISTICS ......................................................................................................................................... 14

2.2. MARYLAND CDSMP PROGRAM ACCOMPLISHMENTS ................................................................................................... 14

2.3. PARTNERSHIPS ............................................................................................................................................................... 16

Section 3 – Context and Marketing ...................................................................................................................... 17

3.1. COMPETITION ................................................................................................................................................................. 17

3.2. MARKETING AND COMMUNICATION ............................................................................................................................. 17

Section 4 – Strategic Approach ............................................................................................................................ 18

Section 5 – Financial Sustainability ...................................................................................................................... 20

5.1. RESOURCES REQUIRED ................................................................................................................................................... 20

5.2. POTENTIAL SOURCES OF REVENUE ................................................................................................................................ 21

5.2. OUTCOMES/ RETURN ON INVESTMENT ......................................................................................................................... 23

Section 6 – Conclusion ......................................................................................................................................... 27

Appendices .......................................................................................................................................................... 28

The Area Agencies on Aging (AAAs) ...................................................................................................................................... 29

Table 1 – Maryland Demographic Trends ............................................................................................................................. 30

Table 2 - Maryland CDSMP Population Characteristics ......................................................................................................... 31

Table 2 – Maryland CDSMP Participants Served ................................................................................................................... 32



EXECUTIVE SUMMARY MISSION AND VISION

Mission: To enable seniors with chronic conditions to have easy access to evidence-based

programs that help will help them improve their quality of life.

Vision: Seniors with chronic conditions will be able to live healthier, more independent, and

active lives.

NEED

Maryland is seeing a significant increase in the numbers of people with chronic conditions such

as diabetes, hypertension and mental illness. Eighty percent of seniors report having one

chronic condition, and 50% have more than one condition.

Chronic diseases, including heart disease, stroke, and diabetes, are among the leading causes of

death in Maryland and currently account for 75 percent of health care costs. Fortunately, those

living with chronic conditions have enormous potential to improve their quality of life and

reduce debilitating complications associated with chronic disease through nutrition, exercise,

proper health care and self-care habits.

Disparities in health outcomes are a significant challenge in Maryland. According to indicators

published by Department of Health and Mental Hygiene, African Americans and Whites in

Maryland are far more likely than Asians and Hispanics to go to the emergency room for

complications related to diabetes, hypertension and behavioral health. Wide variations in

access to health care services between rural, suburban and urban populations are another

source of disparities.

Health care costs are rising, especially in the area of chronic diseases. While nearly all seniors

have access to health care through Medicaid, Medicare or other means, regular doctor visits

and medication are not sufficient to enable people to live as healthfully as possible with their

chronic conditions. Recent research shows that the hospital readmission rate following a

hospital stay for a chronic condition such as congestive heart failure or diabetes can be

substantially higher for patients 65 and older than for acute conditions.1 Finding ways to

1 “Hospital Readmission Rates Higher for Chronic Conditions,” March 7, 2012; AHRQ News and

Numbers; http://www.ahrq.gov/news/nn/nn030712.htm

http://www.ahrq.gov/news/nn/nn030712.htm



reduce health care costs for seniors with chronic conditions is critical to reducing overall health

care costs in Maryland.

PURPOSE

Living Well with Chronic Conditions (the Chronic Disease Self-Management Program, or CDSMP)

is a series of workshops that provides tools for living a healthy life with chronic health

conditions, including diabetes, arthritis, asthma and heart disease. The Living Well Program is

an evidence-based approach to educating people with chronic conditions on how to maximize

their health and manage their condition in a way that improves their quality of life, reduces

health complications, and reduces their need for emergency care. Through weekly sessions,

the workshop provides support for continuing normal daily activities and dealing with the

emotions that chronic conditions may bring about.

The Living Well programs have been proven to enable participants to address their health

needs in outpatient settings and reduce emergency department utilization. This is a key goal of

the Maryland State Health Improvement Process being led by the Maryland Department of

Health and Mental Hygiene. The Living Well program offers an evidence-based approach to

reducing health care costs.

Maryland Department of Aging (MDoA) has provided funding, technical assistance and

oversight of the Living Well program, including the Chronic Disease and Self Management

Program (CDSMP) and the Diabetes Self Management Program (DSMP) with federal grant

funding since 2006. A one-time ARRA stimulus grant allowed MDoA to build the capacity of the

AAAs, working to replicate the program and adhere to a consistent model.

Living Well aims to achieve long-term sustainability through:

Local, state and national grant opportunities

Integrating Living Well into Medicaid and Medicare programs

Partnerships with governmental and private organizations

The Department of Aging’s mission is to focus on the health and well-being of seniors.

However, across the United States, other governmental agencies have adopted Living Well

programs for the broader population. Through partnerships and replication of the program,

Living Well could be made available to anyone with a chronic condition in Maryland and should

be a regular health service covered by a range of insurance programs.

ORGANIZATION AND KEY STEPS



MDoA works with 19 local Area Agencies on Aging (AAAs) to provide programs and services for

seniors statewide, including the Living Well program. In some instances, an AAA is an arm of

local government, but in other cases, a nonprofit organization designated by MDoA under

federal statutory authority functions as the AAA to provide for a range of services to meet the

needs of older Marylanders.

MDoA, through its network of AAAs throughout Maryland, has already developed a large

network of program leaders who are able to recruit and operate Living Well classes in their

geographic areas, and who are able to deploy 90 master trainers and 225 lay leaders to deliver

the program in a variety of settings. Local AAA’s have developed partnerships with hospitals,

YMCA’s and other community groups to host trainings and recruit participants.

Going forward, MDoA aims to raise funds through grants and partnerships to sustain and grow

the program in the medium-term (2-3 years). In the long-term, as the cost/benefit and other

impacts of CDSMP are tracked and documented, MDoA envisages this program to be

incorporated into Medicaid, Medicare and other insurance programs to allow for sustainable

funding streams for current AAAs, as well as other agencies seeking to replicate the program.

This business plan is focused on how the MDoA can secure funding for the next 2-3 years in

order to position the program for long-term sustainability.

REQUEST

MDoA aims to sustain the Living Well programs in Maryland through grants and partnerships

over the next few years to enable it to become a permanent, sustainable feature of health care

delivery for all seniors and others with chronic conditions in Maryland. To do this, MDoA seeks

funding to:

1) Sustain program delivery 2) Measure outcomes and calculate return on investment 3) Develop strategies for reducing heath disparities 4) Establish strong program marketing and information 5) Provide ongoing coordination and information-sharing among the programs 6) Develop partnerships at the state level and local levels.

RETURN ON INVESTMENT: $3.2 MILLION IN HEALTH CARE SAVINGS OVER 6 YEARS

The evidence base of the Living Well programs shows that participants experience decreased

symptoms, improve their behaviors and self efficacy, and decrease health care utilization after

six months. The most important return on investment is the improved heath of the participants

that, if sustained, will lead to reduced morbidity and mortality.



The financial return on investment is clear: participants decrease their health care utilization,

including emergency department visits, realizing an average health care savings of $1,654 per

participant, compared to an average cost per participant of $740. Therefore, $1 invested in the

Living Well program yields $2.23 in health care cost savings over 2 years. Additional cost

savings may also accrue over a person’s lifetime due to ongoing application of the habits they

learned in the Living Well program.

In Maryland, the start-up costs of the Living Well Program have already been invested. Now,

the program has a relatively low operating budget, and can continue to expand the numbers of

participants and reduce the cost per participant year after year.



INTRODUCTION This Business Plan is crafted to support sustainability actions for the Chronic Disease Self

Management and related community wellness programs in Maryland’s Area Agencies on Aging

(AAAs) in relationship to the Maryland Office on Aging (MDoA). Area Agencies on Aging are the

point of contact through which services are delivered to Maryland senior citizens, by way of

collaboration and direct support from the Maryland Department of Aging.

Plan Overview and Objectives

The objective of this Business Plan is to present actionable strategies that MDoA and Area

Agencies on Aging (AAAs) might develop in 2012 and beyond, focusing on the need for MDoA’s

services, the management options available, the operational plan to deliver the services, the

marketing plan to the constituents, and the financial requirements, including annual revenues

and expenses required by MDoA.

There are several counties in Maryland in which the AAA is an independent nonprofit entity. In

other counties, the AAA operates as a unit of county government. In each instance the AAAs

have some discretion as to how they choose to work with the Maryland Department of Aging

(MDoA) to focus resources and services for the elderly population in that local area. Some

AAAs seek to establish relationships with other organizations, and to seek financial resources

from local or regional foundations and corporations operating in Maryland for program support

to enhance their services to Maryland’s older adults.



SECTION 1 - VISION / MISSION

The Maryland Department of Aging, partnering with the Area Agencies on Aging and other

organizations, provides leadership, advocacy and access to information and services for

Maryland seniors, their families and caregivers.

MDoA- Mission Statement The Maryland Department of Aging envisions Maryland as a State where all people are able to

age with dignity, opportunity, choice and independence.

MDoA - Vision Statement

Living Well Programs Mission and Vision

Mission: To enable seniors with chronic conditions to have easy access to evidence-based

programs that help will help them improve their quality of life.

Vision: Seniors with chronic conditions will be able to live healthier, more independent, and

active lives.

Living Well aims to achieve long-term sustainability through:

Integrating Living Well into Medicaid and Medicare programs

Partnerships with governmental and private organizations

Local, state and national grant opportunities

The Department of Aging’s mission is to focus on the health and well-being of seniors.

However, across the United States, other governmental agencies have adopted Living Well

programs for the broader population. Through partnerships and replication of the program,

Living Well could be made available to anyone with a chronic condition in Maryland and should

be a regular health service covered by a range of insurance programs.



1.1. HISTORY AND BACKGROUND The Maryland Department of Aging The Department of Aging protects the rights and quality of

life of older persons in Maryland. To meet the needs of senior citizens, the Department

administers programs throughout the State, primarily through local "area agencies" on aging

(AAA’s). Area agencies administer State and federal funds for local senior citizen programs and

are governmental and nonprofit organizations. These programs include advocacy services,

health education, housing, information and referral, in-home services, and nutrition (Maryland

Annotated Code Human Services Article, secs. 10-201 through 10-214).

The Department monitors and provides technical assistance to a network of nineteen area

agencies on aging that serve all counties and Baltimore City. Grants of federal and State funds

for local programs to serve the elderly are provided by the federal Older Americans Act (Title III)

and State general funds. Area agencies also receive local funds, private donations, and

contributions from program participants.

AAAs receive additional funds through county and municipal support and other public/private

contributions. AAAs provide services to seniors either directly or through contracts with other

public or private organizations.

MDoA remains committed to efforts to promote healthy lifestyles and to train people to

manage chronic diseases more effectively. With federal and private grants, the number of

older adults taking fitness classes, learning how to prevent falls, and taking charge of their

health has increased.

Since 2006 the MDoA Health Promotion and Disease Prevention Program has provided

technical assistance, funding, and oversight for the Living Well - the Chronic Disease and Self

Management Program (CDSMP), administering federal and foundation grant funding and other

state resources. The Living Well - CDSMPs are managed by the Nutrition and Health

Promotions Programs unit of the Health Promotion and Disease Prevention Program.

The AAAs maintain a broad variety of relationships with MDoA, and administer numerous

MDoA programs beyond the Living Well - CDSMP. The Nutrition and Health Promotion

Programs unit (NHPP), which also administers an array of programs beyond CDSMP, has a small

staff (as of April 2012 = 1.0 FTE) and must carefully manage their limited staff and financial

resources.

NHPP plays an important role in the Living Well Programs, specifically in: (1) promoting best

practices and collaboration among Maryland’s AAA, (2) securing resources for the program



through grants and partnerships, (3) gathering data, monitoring and evaluation, and (4)

providing training and orientation to new staff persons as they are hired by its member AAAs.

1.2. KEY GOALS To ensure that older citizens are treated with dignity and respect, MDoA, through leadership,

advocacy and community partnerships, has established four goals. Programs and services

administered by MDoA are the vehicles for achieving the goals, which allow for flexibility and

change in the way programs can be structured for future generations of seniors. The goals are:

Goal #1 Empower older Marylanders, their families, and other consumers to make informed decisions about, and to be able to easily access, existing health and long-term care options.

Goal #2 Enable older Marylanders to remain in their own homes with a high quality of life for as long as possible through the provision of home and community-based services, including supports for family caregivers.

Goal #3 Empower older Marylanders to stay active and healthy through Older Americans Act services and the prevention benefits under Medicare.

Goal #4 Ensure the rights of older Marylanders and prevent their abuse, neglect and exploitation.

The Living Well Programs address goals 1-3 for the Department of Aging.

The overall goals of the Living Well program are to:

1. Reduce rates of disability;

2. Improve mental and cognitive function; and,

3. Lower health care costs.

In order to sustain and expand the existing Living Well programs, the MDoA has the following

goals:

1. Encourage State agencies, employers and partners to implement the program or help publicize the program.

2. Raise grant funds to support the program. 3. Demonstrate outcomes and return on investment for the program. 4. Obtain Medicaid/Medicare and other insurance reimbursement for the program to

ensure long-term sustainability.

Ultimately, it is our aim that every older adult in Maryland with a chronic condition will have

access to a convenient Living Well program in their community.



1.3 . NEEDS Maryland is seeing a significant increase in the numbers of people with chronic conditions such

as diabetes, hypertension and mental illness. Eighty percent of seniors report having one

chronic condition, and 50% have more than one condition. While nearly all seniors have access

to health care through Medicaid, Medicare or other means, regular doctor visits and

medication are not sufficient to enable people to live as healthfully as possible with their

chronic conditions.

The number of older Marylanders is increasing. Of the 5.3 million people in Maryland in 2000,

15 % (801,036) were over the age of 60. The percentage is expected to increase to 25% of

Maryland's projected population of 6.7 million by the year 2030.

The number of individuals over the age of 85 continues to grow rapidly. This cohort will grow in

number, statewide, from 66,902 in 2000 to 164,695 by the year 2030.

In 2000, 67.4% of those 60+ resided in Anne Arundel, Baltimore, Montgomery and Prince

George's Counties and Baltimore City. By 2030 this percentage is projected to decline to 61.5%,

while the 60+ population in the "newer" suburban jurisdictions of Carroll, Harford, Howard, etc.

is projected to increase.

Marylanders aged 60 and over, with functional disabilities related to mobility or personal care,

who are living in the community, accounted for 237,004, over 19% of the total number of

elderly Marylanders, in 2000. Low income older individuals are concentrated in the Baltimore

Metropolitan area, with smaller numbers of older, poorer individuals residing in western

Maryland and on the Eastern Shore. In 2000, 63,978 older Marylanders lived in poverty as

defined by the federal poverty guidelines. Of the State's aged 60+ minority population in 2000,

32.3% lived in Baltimore City, with 15.7% in Montgomery County and 24.4% in Prince George's

County. Of the population of older minority Marylanders who are 85+, 35% lived in Baltimore

City in 2000.

(Sources: U.S. Census, 2000; MD Department of Planning, Population Projections - revised 9/2005.)

1.4. HEALTH OUTCOMES AND DISPARITIES IN MARYLAND A recent report compiled by a special working group, headed by Dean Dr. E. Albert Reece at the

University of Maryland School of Medicine, showed that despite numerous positive measures

(such as having the 2nd highest rate of primary care providers per capita and one of the ten

lowest rates of smoking), Maryland ranks 35th in infectious diseases, 34th in health outcomes,

and 33rd regarding geographic health disparities.2 The working group explored and developed

2 http://www.americashealthrankings.org/MD



health care strategies and initiatives, including financial, performance-based incentives; to

reduce and eliminate health disparities; and made recommendations regarding the

development and implementation of those strategies.

The report made reference to the growing disparities within the Maryland minority population

that reflect the overall health disparities in the state. In February 2012, the Lt. Governor

announced $1.1 million in grants available through the Community Health Resources

Commission (CHRC) to Maryland communities as a means for implementing the Affordable Care

Act (ACA). The Commission provided special emphasis this year on supporting programs that

would help reduce minority health disparities and help enhance the capacity of safety net

providers as Maryland implements the ACA. “Maryland continues to be a national leader in

health care because we understand that a healthy community is a more productive

community,” said Lt. Governor Brown. “The CHRC grants will provide resources to local

communities to improve health outcomes, support safety net providers, and provide critical

care to our most vulnerable citizens. By taking steps to reduce health disparities and implement

health care reform, we will reduce costs, expand access, and improve the quality of health care

for all Marylanders.”

Among the five priorities spelled out by the CHRC announcement, one is specified as investing

in health information technology. This might be a means by which MDoA could access grant

money for the development of the dedicated website that would assist Maryland AAAs in

timely service delivery, helping to achieve the Lt. Governor’s vision. Beyond this, how might

MDoA address the existing health disparities in the state? Steps might include:

Focus on areas where there are high concentration of "co-morbidities"

Work with Faith based institutions

Emphasize Multi-Cultural outreach efforts by hiring specialty outreach coordinators and working with the State Office of Minority Health.

HEALTH DISPARITIES

Disparities in health outcomes by race are being targeted as a significant area of need in

Maryland. African Americans and Whites in Maryland are far more likely than Asians and

Hispanics to go to the emergency room for complications related to diabetes, hypertension and

behavioral health. The number of emergency room visits for hypertension was 2.5 times higher



for Whites than for Hispanics and Asians, and the number of emergency room visits for African

Americans is 3.5 times higher than that of Whites. 3

MARYLAND SHIP INDICATORS (DHMH) Asian Black Hispanic White Source

Heart disease death rate per 100,000 NA 283.3 NA 184.3 Vital statistics 2009

Diabetes-related emergency room visits 44 668.5 98.5 229.5 HSCRC, 2010 Hypertension-related emergency room visits 53.8 474.8 50.9 135.6 HSCRC, 2010 Behavioral health emergency room visits 214.3 1517.4 861.8 1168.1 HSCRC, 2010

The Living Well programs have a proven track record to enable participants to address their

health needs in outpatient settings and reduce emergency department utilization. This is a key

goal of the Maryland State Health Improvement Process (SHIP) being led by the Maryland

Department of Health and Mental Hygiene. All of the Maryland AAAs are in a strong position to

contribute to these statewide goals, but they can do so only if they maintain good records on

the programs and services they are providing.

SECTION 2 – CAPABILITIES AND EXPERIENCE The Living Well Program is an evidence-based approach to educating people with chronic

conditions how to maximize their health and manage their condition in a way that improves

their quality of life, reduces health complications, and reduces their need for emergency care.

The program and its varied components, is based on a strategic approach developed at

Stanford University. The Division of Family and Community Medicine in the School of Medicine

at Stanford University, in 1991 received a five-year research grant from the federal Agency for

Health Care Research and Policy and the State of California Tobacco-Related Diseases office.

The purpose of the research was to develop and evaluate, through a randomized controlled

trial, a community-based health self-management program that assists people with chronic

illness. The study was completed in 1996.

Participants who followed the program, when compared to those who did not, demonstrated

significant improvements in exercise, cognitive symptom management, communication with

physicians, self-reported general health, health distress, fatigue, disability, and social/role

3 http://dhmh.maryland.gov/ship: DISPARITIES

http://www.stanford.edu/

http://www.ahcpr.gov/

http://www.ahcpr.gov/

http://www.dhs.ca.gov/tobacco/

http://dhmh.maryland.gov/ship



activities limitations. They also spent fewer days in the hospital, and there was also a trend

toward fewer outpatient visits and hospitalizations. Many of these results persist for as long as

three years.

2.1. PROGRAM CHARACTERISTICS Living Well – CDSMP has been implemented in Maryland since 2006. The Maryland AAAs who

have implemented the Stanford model have developed a cohort of trained leaders who now

have core competencies in service delivery. Moreover, the AAAs have benefited from the

experience of leaders who have been engaged in the practice and implementation of

community wellness programs for more than a decade. Department of Aging had a 0.75 FTE

Evidence-based Health Promotion Coordinator for the period of April 2010-April 2012.

The Health Promotion Programs Coordinator had first-contact responsibilities and continuing

communication with each Maryland’s AAAs during this period. Some of the responsibilities have

included:

Monitoring of CDSMP programs and budgets

Creating and delivering statewide trainings for CDSMP Coordinators

Designing licensing and fidelity monitoring requirements

Providing technical assistance and developing training materials

Holding joint meetings and performing workshops for CDSMP coordinators regarding reporting requirements, program issues with the purpose of enhancing local efforts, and meeting grant requirements

Supporting local and state-level outreach/marketing efforts to enhance and expand CDSMP throughout the State

Coordinated quarterly regional meetings and monthly teleconferences with the CDSMP staff

Coordinated with statewide partners, providing presentations and overseeing MOUs, and

Input workshop data and performed reporting for the Living Well programs. The Program Coordinator is critical to the successful functioning of the network of CDSMP programs, and funding for this position is a high priority for the business plan.

2.2. MARYLAND CDSMP PROGRAM ACCOMPLISHMENTS The CDSMP program in Maryland has met and even exceeded initial expectations, expanding to

serve more than 3,500 individuals with chronic conditions in Maryland.

Program Highlights, 2006-Present:

3,586 participants through 384 workshops.

Infrastructure includes approximately 250 lay leaders, 90 active master trainers.



Programs offered: Chronic Disease Self Management Program, Chronic Pain Self Management Program, and Diabetes Self Management Program. Some AAAs are considering offering the Arthritis SMP.

$2.5 million investment over 6 years

Participant Profile

Average age of program participants 75-79

82% female among participants

36% African American, 1% Asian, plus a few Native American

Major Diseases are hypertension, arthritis, diabetes. 76% multiple conditions

Focus and Initiatives

2006-2010:

Master Trainings

Mentoring of local programs

Program Implementation and Partnership development

In 2010-2011 reached 1,910 participants through 202 workshops

2010-present

Hiring staff at state and local level

Fidelity plans developed at all grantee sites

Addition of DSMP, Pain Self Management

Sustainability plans developed at all grantee sites

Target: low income and minority seniors (areas selected based on population)

Best Practices in Maryland

During a recent strategic planning focus group convened by MDoA Nutrition and Health

Promotion staff with various stakeholders, the following practices emerged:

Partnerships with local Health Departments

Fall prevention

Outreach

Local coalition of agencies running the program (Health dept, Hospital, Housing Authority)

People who complete Living Well workshops are connected to other important services – catalyst, Build a network, and Living Well is important piece



Working with Housing Authority for seniors in housing and centers

Connects people to other services in community in terms of track& reporting

Working on health disparities: Office of Minority Outreach. Ensure diverse lay leaders: Casa de Maryland, Asian American Health Initiative, African American Health Program

Integrate Living Well Information into discharge process from hospitals: let patients know about CDSMP.

2.3. PARTNERSHIPS Among the initial group of community partners for the Living Well programs, the local AAAs

have made some significant strides. Each AAA now operating a Living Well program has a fairly

wide network of collaborating agencies – those with whom they collaborate to offer programs

and services. Collaborations help them recruit participants through referrals and marketing,

and often provide free space to make workshops more accessible for participants.

Among those institutions that are collaborating actively with the AAAs on the Living Well

programs, we can identify the following is a sampling, each of whom has had direct experience

working with community health promotion programs in association the Maryland Department

of Aging, including the evidence-based program meeting the Stanford criteria for the CDSMP

program:

Holy Cross Hospital, Silver Spring, Maryland

Western Maryland Regional Medical Center, Allegany County

Department of Health of Cecil County, Maryland

Meritus Medical Center Endocrinology, Nutrition and Diabetes office, Hagerstown, MD

Parkinson’s and Movement Disorder Center of Maryland, Columbia

Garrett Memorial Hospital

Saint Mary’s Hospital – Healthlink Program, Leonardtown, Maryland

Prince George’s County Community College

Baltimore Health Care Access, Baltimore, Maryland.

The opportunity now before the AAAs is to develop these collaborating relationships into true

partnerships, so that these external agencies have a financial stake in sustaining the Living Well

programs in their respective areas. Other Partners with extensive experience in Community

Outreach to the aging population might then be recruited to join the effort as the impact

expands.



SECTION 3 – CONTEXT AND MARKETING The successful implementation of the Living Well Programs over the past eight years has proven

that there is a high level of need for the program, that seniors do and will choose to participate,

and demographic and health trends show the need is growing.

Federal and State health reform initiatives are placing a high emphasis on addressing chronic

conditions such as heart disease, hypertension, and diabetes, especially for populations

affected by health disparities. The State Health Improvement Process (SHIP) is spawning Local

Health Improvement Coalitions across Maryland that are focused on making improvements in

39 specific health outcomes across Maryland. Health challenges addressed by CDSMP

programs have been identified as high priorities in Maryland. There has never been a better

time to have an evidence-based programs focused on improving outcomes for people with

chronic conditions.

3.1. COMPETITION The Living Well Program is the only one of its kind in Maryland that provides evidence-based

comprehensive, peer-led, interactive workshops for seniors with chronic conditions. However,

it is not the only program in the marketplace that is designed for people with chronic

conditions. A growing number of Hospitals are offering Chronic Disease & Diabetes workshops.

These are generally operating on the medical model whereby the hospitals utilize nurses on

staff and other professionals for these classes and workshops, for which Medicare provides

them reimbursements.

Hospitals also do preventive health and “wellness” programs to fulfill their community benefit

accreditation mandate. There are other medical education programs in the hospitals. Any

hospital newsletter lists many support groups, and these provide all kinds of training for

disease-specific conditions.

Living Well programs can differentiate themselves from these programs because they are

evidence-based, peer-led and interactive and have been proven to reduce health care costs.

3.2. MARKETING AND COMMUNICATION A critical key to success of the Living Well program is ongoing communication and marketing.

There is a significant opportunity for growth in awareness of the program. In particular,

familiarity with the Living Well program needs to be greatly expanded especially among health

professionals and human services providers.

As the emphasis on addressing chronic diseases will continue to increase, the Living Well

program needs to be “in the right place at the right time” to take advantage of new



opportunities. This means that knowledgeable people throughout State government need to

be informed about Living Well. The Advisory Council, MDoA staff, AAA staff and other key

stakeholders should talk with wider groups of professionals and keep them informed about the

Living Well program. Key audiences include:

County health departments, departments of social services, etc.

State agencies (DHMH generally and its Healthiest Businesses Program and Multicultural

Health division, Department of Corrections, Veterans Affairs, etc.)

Elected officials

Employers and Employee Health Systems

Unions

Health Insurers

Other programs for seniors (Senior Health Insurance Program, Senior Service

Employment Program, Nutrition Programs, etc.)

Health educators, social workers

Information and Referral Sources (2-1-1; United Way; other nonprofits)

Marketing to support the state-wide program should include:

A dedicated and interactive website through which potential partners and the AAAs can gain timely information, and which might also serve them as a tool to support their programs of service delivery to their customer base.

Targeted outreach to State agencies and private partners.

Brochures and information on program results, costs and implementation steps for potential partners.

Outreach to hospitals, physicians and other care providers about the availability of the program.

These shared marketing efforts will help enhance the local efforts to recruit participants and

partners into the program.

SECTION 4 – STRATEGIC APPROACH MDoA aims to sustain the Living Well programs in Maryland through grants and partnerships

over the next few years to enable it to become a permanent, sustainable feature of health care

delivery for all seniors and others with chronic conditions in Maryland.

Sustain program delivery: The AAA programs have a strong program infrastructure and very

little transactional costs. The average AAA Living Well program budget is about $22,000 per



year, with an average cost per participant of about $570. Approximately $500,000 - $600,000

per year will enable all AAA’s to continue the program at current levels and utilize local

fundraising and partnership resources to expand capacity and serve more people.

Measure outcomes and calculate return on investment: While there is national evidence

showing the program has significant outcomes and cost savings, the Maryland program needs

to establish these results at the state level. Resources for an external study on the outcomes

and the return on investment will be critical to securing the long-term sustainability of the

program.

Develop strategies for reducing heath disparities: Currently, AAA programs do reach a higher

percentage of African American participants (36%) than are represented in the general

population of Maryland (29%) which is a positive thing. However, chronic disease disparities for

the African American population are triple that of Whites. More will need to be done to attract

populations affected by disparities into the program, and ensure that marketing and training

techniques are culturally appropriate.

Develop partnerships: Partnerships will help sustain and expand the program in a variety of

ways. Partnerships with governmental agencies such as the Department of Health and Mental

Hygiene and the Centers for Disease Control can help get the word out to health providers

about the Living Well programs as part of their existing missions. Agencies such as the

Department of Corrections or the Veterans Administration may want to implement the Living

Well program with their constituents. And, private employers may also be interested in

adopting the Living Well program for their employees. The MDoA can play a key role in

identifying potential partners and cultivating them successfully. This will require shared

ownership of the program that may expand beyond the mandate of MDoA.

Establish strong program marketing and information: The current website for the Living Well

program is not meeting the needs of the program. Outreach to a wide range of organizations

and agencies that focus on health and wellness of seniors and public health through meetings

and personal connections will be critical. Development and maintenance of a good website is

important for program visibility and sustainability. A website should include program dates,

times and locations, eligibility, program benefits, best practices, and partnership information.

Ongoing coordination and information-sharing among the programs: Coordination among the

AAA’s on issues such as marketing, best practices, outcomes measurement, partnership

development and joint fundraising are all areas that require continuous communication and

coordination. Coordination should include informational updates, convenings, and sharing of

best practices.



SECTION 5 – FINANCIAL SUSTAINABILITY Financial sustainability of the Living Well program will rely on a combination of revenue raised

and expended at the local AAA level and at the MDoA level.

5.1. RESOURCES REQUIRED Twelve of the nineteen AAA’s completed sustainability plans. The following is a summary of the

external funding each AAA plans to seek over the next two years. We utilized the plans of the

12 AAA’s to find an average and then applied that average to all 19 AAA’s:

AAA Sustainability Plans: External Funding Sought

Jan 1 - June 30, 2012

July 1 - December 31, 2012

Jan. 1 – June 30, 2013

Jul. 1 – Dec. 31, 2013

2-YEAR TOTAL

1 YEAR AVERAGE

TOTAL FOR 12 AAA’S $118,750 $133,000 $144,500 $138,000 $534,250 $267,125

AVERAGE PER AAA $9,896 $11,083 $12,042 $11,500 $44,521 $22,260

ESTIMATE - 19 AAA'S $188,021 $210,583 $228,792 $218,500 $845,896 $422,948

Therefore, the total annual amount to be raised is approximately $423,000 per year to sustain

the local programs.

PROGRAM BUDGET

REVENUE: The revenue sources assume a sharing of the fundraising burden between MDoA

and the AAA’s, whereby the MDoA would seek grants from all available sources and develop

partnerships with State agencies and other large employers. The revenue assumes 19 AAA’s

will get an average of $10,000 in grants each, than 10 of them will be successful in developing

partnerships worth $15,000 each, and that a range of Medicaid funding streams will result in

another $83,000 across all AAA’s.

EXPENSES: The expenses assume an average cost of $22,260 per year per AAA for running the

program. Other rough estimates for staffing, training and outcomes measurements are

provided.



REVENUE MDOA AAA's TOTAL

Grants (Federal, State, Private) $224,000 $190,000 Partnerships $75,000 $150,000 Insurance companies and Medicaid

$83,000

TOTAL $299,000 $423,000 $722,000

EXPENSES

CDSMP Implementation by AAAs

$423,000 Salaries (Director and Coordinator) $120,000

Website development* $23,000 Website maintenance $6,000 Outcomes Measurement and Return on

Investment* $80,000 $40,000 Training and Convening - Direct Costs $30,000

TOTAL ANNUAL AND ONE-TIME COSTS (a) $259,000 $463,000 $722,000

TOTAL ANNUAL COSTS (b) $156,000 $423,000 $579,000

TOTAL TWO-YEAR COST (a+b)

$1,301,000

*One-time costs. All others are annual

Wherever possible, MDoA should seek large grants that it can then sub-grant to the AAA’s to

help them raise the “external resources” required in their sustainability plans. MDoA may want

to make some of those sub-grants in the form of matching grants to help incentivize the AAA’s

to develop new revenue sources.

5.2. POTENTIAL SOURCES OF REVENUE The effectiveness and efficiency of the Living Well CDSMP model reflects some of the best

aspirations of the current national dialogue around health care. An evidence-based program

that reduces costs, improves outcomes, can be faithfully replicated, is volunteer-driven, and is

self sustaining provides a powerful example for the future of health care service delivery.

The MDoA/AAAs must document the impact of the CDSMP program and communicate how

evidence-based programs save healthcare dollars, reduce the demand for healthcare, provide

value for employees, and/or generate social capital in order to attract and secure new revenue

sources.



The 2007 NCOA paper entitled “Financial Sustainability for Evidence-Based Programs” provides

a comprehensive overview of the potential of various revenue sources. These sources include:

Philanthropic & Charitable Organizations

Medicaid

Healthcare Organizations

Senior Housing

Employers

Continuing Education

Advocacy Strategies

Bequest Marketing

Charging Participants for Services

All of these sources merit close consideration and exploration. From the standpoint of financial

sustainability, the pursuit of grants & contract funding, internal & external partnerships, and

new forms of insurance reimbursement (such as Medicare and Medicaid) are the most

promising strategies for Maryland Department of Aging over the next 2-3 years.

Grants & Contracts

The pursuit of grant funding must be a primary strategy for achieving financial sustainability

and diversifying funding sources. In order to achieve consistent and reliable results, adequate

internal resources must be devoted to researching and cultivating potential funders, grant

writing, and grant management. Some of these activities are being carried out at the local

level. Others activities can be administered more efficiently on the state-wide level.

One strategy that will enhance the ability of MDoA to increase grant support is to include

funder “stakeholders” on its advisory board. Another strategy to leverage foundation or service

dollars is to seek funding designated for various populations (i.e., rural or urban populations,

racial or ethnic groups; persons with specific diseases or disabilities).

Internal and External Partnerships

States and local agencies are partnering with various types of healthcare organizations, such as

Medicare Managed Care Organizations and Special Needs Plans, nonprofit hospitals, and

Federally Qualified Health Centers. These organizations provide financial and in-kind support,

and patient referrals.

Some local AAAs have experienced success partnering with assisted living facilities, continuing

care retirement communities, and low income senior housing. Often senior housing is being



used as a venue for programming rather than a source of recurrent funding, but occasionally

sponsorship funding, state housing funds or HUD-sponsored Resident Opportunity and Self

Sufficiency (ROSS) grants are covering some program costs.

There are increasing numbers of older workers in the workplace, and this trend is expected to

accelerate. Several AAAs in Maryland are attempting to develop liaison with private employers

to offer CDSMP in the workplace as a part of employee wellness programs. One of the

Maryland AAAs has been authorized to offer CDSMP to county department employees.

Another partnership strategy that is successful is working with community colleges to offer

CDSMP as a part of their curriculum. Community colleges typically charge for these programs,

but provide facilities, materials and a stipend for instructors.

Insurance Reimbursement

MDoA is working closely with numerous state and federal agencies to explore ways to qualify

Chronic Disease Self-Management Programs (CDSMP) for Medicaid and Medicare

reimbursement. These efforts include working with Medicaid and the Health Care Commission

to get beyond Home and Community Based Service Waivers, in order to look at other means of

reimbursing CDSMP workshops and training. There is a basic paradigm shift evolving around

insurance reimbursement for preventive care services. The Community Transformation

program and other federal grant programs are changing the way reimbursements for health

care are administered, from “fee for service” to the concept of having “funding follow the

person”. This creates tangible financial incentives for providers to invest in interventions that

improve outcomes for individuals and keep people at home, out of institutions. As these trends

continue, it is likely that Medicare and Medicaid waiver programs will increasingly allow for the

reimbursement of fees related to CSDSMP workshops.

5.2. OUTCOMES/ RETURN ON INVESTMENT Based on a review of major published studies, CDSMPs result in significant, measurable

improvements in the health and quality of life of people with chronic conditions. CDSMP also

appears to save enough through reductions in health care expenditures to pay for itself within

the first year. Studies published by Agency for Healthcare Research and Quality (Lorig, et. al.)4

have indicated that participants in the CDSMP program had 2.5 fewer doctor visits over a 2-year

period than people with chronic diseases who did not participate in the program. Participants

4 http://www.ahrq.gov/research/elderdis.htm#CDSMPReduced; Lorig KR, Ritter P,

Stewart AL, et al. Chronic Disease Self-Management Program: 2-year health

status and health care utilization outcomes. Med Care 2001;39(11):1217-23.

http://www.ahrq.gov/research/elderdis.htm#CDSMPReduced



were hospitalized 0.49 days fewer than non-participants. The study was completed in 1999 and

concluded an average cost savings of $390-$520 per person after the costs of program

administration are subtracted from health care costs. The study used a figure of $1,000 per day

for hospitalization and $40 per doctor visit and estimated $70-$200 per person to run the

program.

What would be the equivalent costs in Maryland today? We reviewed the following data:

1. Average cost of a hospital stay in Maryland, as published by the Maryland Health Care

Commission in FY2011. MHCC publishes the actual rates charged by Maryland’s

hospitals for the top 15 conditions for which people are hospitalized. The following

averages were chosen for their relationship to chronic conditions:

Average Daily Cost of Hospitalization in Maryland, FY20115

Heart failure $2,255

Obstructive pulmonary disease $2,172

CVA Pre-cerebral occlusion $2,654

TOTAL AVERAGE DAILY COST OF HOSPITALIZATION $2,360 Note: Behavioral health conditions are excluded because the study cited stated that no change in

psychological well-being was reported. Also note that far more expensive hospitalizations for hip

replacement and knee joint replacement were excluded as well (averaging $6,265 and $6,796 per day

respectively.) CDSMP programs do include fall prevention, and therefore it may be considered that the

actual cost savings could be far higher if those types of hospitalizations were included.

2. Average cost of a doctor visit is $199, according to Healthfinder.gov.6

In summary, using today’s estimates of health care costs, we find the following savings

over a 2-year period for each participant:

CDSMP Participants SAVINGS

0.49 fewer hospital days $1,157

2.5 fewer doctor visits $498

TOTAL SAVINGS PER PARTICIPANT $1,654

5

Maryland Hospital Pricing Guide, FY2011, Maryland Health Care Commission http://mhcc.maryland.gov/consumerinfo/hospitalguide/hospital_guide/docs/pricing_guide.pdf

6 http://healthfinder.gov/news/newsstory.aspx?docID=652097

Health Highlights, April 2011

http://healthfinder.gov/news/newsstory.aspx?docID=652097



Note, the Lorig study abstract groups together doctor visits and emergency room visits for a total of 2.5 fewer doctor or emergency room visits. The average cost of an emergency room visit for someone 65 and older was $1,306 in 2009 according to AHRQ.

7 However, for the purposes of this analysis, since the cost of ER visit is so much

higher than the cost of a doctor visit, the lower doctor visit cost is utilized as the most conservative estimate of cost savings.

Health Benefits

Improvement in exercise and ability to participate in one’s own care over a two-year period

Improved health status in 7 of 9 variables: fatigue, shortness of breath, pain, social activity limitation, illness intrusiveness, depression, and health distress

Improved health behaviors and self-efficacy in variables related to exercise, cognitive symptom management, communication with physicians, and self-efficacy

The evidence-base of the Living Well programs shows that participants experience decreased

symptoms, improve their behaviors and self efficacy, and decrease expensive hospital-based

health care utilization after six months. The most important return on investment is the

improved heath of the participants that, if sustained, will lead to reduced morbidity and

mortality.

The financial return on investment is clear: participants decrease their health care utilization,

including doctor visits, emergency department visits and hospitalization. For the population

receiving Medicare and Medicaid benefits, the financial savings would be realized in federal and

state allocations to those entitlement programs.

Cost Per Participant

There are a number of different ways to calculate the cost per participant in the program. The

Maryland-based CDSMP programs have already invested significant funding into getting the

program launched. To look at the total amount of funding for the program received to date

($2m) and divide that by the total number of participants to date (3,586), the cost per

participant has been $570 so far taking into consideration Federal and Foundation funding only.

We estimate that local AAA’s contribute and raise another 30% of program costs, including

items like office space, classroom space, overhead, and other contributed revenue not tracked

by MDoA. Therefore, a very conservative estimate of cost per participant would be closer to

$740.

7 http://www.consumerhealthratings.com/index.php?action=showSubCats&cat_id=274; link to AHRQ database.

http://www.consumerhealthratings.com/index.php?action=showSubCats&cat_id=274



TOTAL

2006-2009 2010 2011 2006 - 2011

U.S. Administration on Aging Sept 2006-July 2010 $950,000 $808,510 $141,489

U.S. Administration on Aging April 2010-March 2012 $600,000 $225,000 $300,000

Weinberg Foundation October 2008- October 2011 $492,596 $164,199 $164,199 $164,199

Estimated Locally Raised/Contributed Resources (30%) $612,779 $291,813 $159,206 $139,260

TOTAL $2,655,375 $1,264,522 $689,894 $603,459

PARTICIPANTS 3,586 1,880 854 852

COST PER PARTICIPANT $740 $673 $808 $708

TOTAL RETURN ON INVESTMENT

Based on the original Lorig study that showed CDSMP participants utilize 0.49 fewer hospital

stays and 2.5 fewer doctor visits and applying most recent costs for those interventions

available, we estimate $1,654 total cost savings per participant for all insurance types. Looking

at a conservative estimate that includes documented federal and private grant funds plus local

investments of 30%, the cost per participant is $740. Therefore, a conservative estimate of

total savings per participant is therefore $914 over a 2-year period for each participant.

2006-2011

TOTAL COST OF PROGRAM $2,655,375

PARTICIPANTS 3,586

COST PER PARTICIPANT $740

SAVINGS PER PARTICIPANT $1,654

TOTAL SAVINGS ACHIEVED - REDUCTION IN HEALTH COSTS $5,931,244 TOTAL NET SAVINGS (total savings minus cost of program) $3,275,869

TOTAL SAVINGS:COST RATIO 2.23

NET SAVINGS:COST RATIO 1.23

The total investment of the program over 6 years is estimated at $2.6m. The total health care

cost savings is estimated at $5.9m, for a total net savings of $3.2m in health care costs in



Maryland as a result of the program. That means that $1.00 invested in the Living Well

program yields $2.23 in total health savings and $1.23 in net savings.

SECTION 6 – CONCLUSION The Living Well Program has met and exceeded its expectations in implementation of this highly

successful, evidence-based program in 16 jurisdictions across the state. Results in improving

the health of seniors and achieving significant savings in health care costs are impressive.

Demand for the program will continue to rise as the population ages and the incidence of

chronic disease continues to be a major public health challenge.

The Living Well Program has created a strong infrastructure to deliver a critical program that

fits within the health priorities set for the State of Maryland. Initial start-up costs have already

been invested, so at this point, the program can now achieve greater and greater savings each

year as the number of trained master trainers and lay leaders multiplies. It is a low-cost model

that gets better every year, and it would be a shame to let this program and infrastructure

wither for lack of resources.

The data from the last two full years of operating the Living Well programs across the state of

Maryland show some remarkable strides being made at various sites. It will be important to

keep that data current, even as funding from the ARRA grants comes to an end. Continuity in

data is absolutely critical for continued funding.

At the local level, the most immediate need is for the local AAA to take steps to “embed” the

Living Well program within its overall agency program structure, even if operating on a

diminished basis. Just keeping the program “alive” is an important step. This will allow for

some data continuity, and will allow the agency to maintain its fidelity standards and its leaders

to maintain their credentials.

For the Maryland Department of Aging, it is critical to get the word out about the Living Well

program within state government agencies, health care and insurance providers, employers

and other potential partners. Since Maryland currently ranks 35th in the nation in health

outcomes for people with chronic diseases, it is critical that policy makers understand the

impact of the program and invest resources necessary to expand and evaluate the impact of the

program on an ongoing basis.



APPENDICES

o List of AAAs

o Table 1 – Maryland Demographic Trends

o Table 2 – Maryland CDSMP Program Population

o Table 3 – Living Well – CDSMP Participants Served



THE AREA AGENCIES ON AGING (AAAS)

Allegany County: Allegany County Human Resources Development Commission

Anne Arundel: Anne Arundel County Department of Aging and Disabilities

Baltimore City: CARE Services, Baltimore City Health Department

Baltimore County: Baltimore County Department of Aging

Calvert County: Calvert County Office on Aging

Caroline County/Kent County/Talbot County: Upper Shore Aging, Inc

Carroll County: Carroll County Bureau of Aging

Cecil County: Senior Services and Community Transit of Cecil County

Charles County: Charles County Aging and Senior Programs

Dorchester County/Somerset County/Wicomico County/Worchester County: MAC, Inc.

Frederick County: Frederick County Department of Aging

Garrett County: Garret County Area Agency on Aging

Harford County: Harford County Office on Aging

Howard County: Howard County Office on Aging

Montgomery County: Montgomery County Area Agency on Aging

Prince George’s County: Prince George's County Department of Family Services

Queen Anne’s County: Queen Anne's County Department on Aging

St Mary’s County St. Mary’s County Department of Aging

Washington County: Washington County Commission on Aging, Inc.



TABLE 1 – MARYLAND DEMOGRAPHIC TRENDS



TABLE 2 - MARYLAND CDSMP POPULATION CHARACTERISTICS



TABLE 2 – MARYLAND CDSMP PARTICIPANTS SERVED

0

0

39

35

0

0

40

79

50

50

0

10

10

42

37

80

25

33

46

100

40

50

16

22

24

100

39

86

39

30

40

75

50

50

25

31

11

63

37

48

22

39

66

40

50

29

34

Allegany County

Anne Arundel County

Baltimore City

Baltimore County

Cecil County

Garrett County

Howard County

Montgomery County

Lower Eastern Shore

Prince George's County

St. Mary's County

Washington County

Workshop Particpants Served 2010-2011

Jul. 1 – Dec. 31, 2011 Jan. 1 – June 30, 2011 Jul. 1 – Dec. 31, 2010 Jan. 1 – June 30, 2010

Documents

Business Plan Living Well - Chronic Disease Self ......Mission: To enable seniors with chronic conditions to have easy access to evidence-based programs that help will help them improve