By Michele L. Boutaugh, Susan M. Jenkins, Kristie P. Kulinski, Kate … · 2019. 2. 4. · activities. Priority is given to serving older adults (ages 60 and older) who live in medically

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GENERATIONS – Journal of the American Society on Aging

Copyright © 2015 American Society on Aging; all rights reserved. This article may not be duplicated, reprinted or distributed in any form without written permission from the publisher: American Society on Aging, 575 Market St., Suite 2100, San Francisco, CA 94105-2869; e-mail: [email protected]. For information about ASA’s publications visit www.asaging.org/publications. For information about ASA membership visit www.asaging.org/join.

M embers of racial and ethnic minority groups in the United States continue to

face disproportionate chronic illness burden and disparities related to healthcare access (U.S. Department of Health and Human Services [HHS], 2013). These disparities must be ad-dressed because older adults with multiple chronic conditions are at greater risk for prema-ture death, poor functional status, unnecessary hospitalizations, adverse drug events, and high healthcare costs (Parekh et al., 2011).

To help mitigate the growing impact of chronic diseases, since 2003, the Administration on Aging (AOA), a program division within the Administration for Community Living (ACL), has supported Stanford University’s Chronic Disease Self-Management Program (CDSMP) and other evidence-based prevention programs (HHS, 2010). Repeated studies have demonstrat-ed that CDSMP participants experience many positive benefits, including significant improve-ments in self-reported health and in specific symptoms such as pain, fatigue, and depression; increased frequency of exercise; and greater self-efficacy (Brady et al., 2013). Some studies also have shown decreases in outpatient visits,

emergency room visits, and hospital days (Lorig et al., 2001; Ory et al., 2013a). These positive health outcomes have been replicated among participants from diverse age groups, racial and ethnic backgrounds, geographic settings, and health status (Lorig, Ritter, and Jacquez, 2005; Swerissen et al., 2006; Tomioka et al., 2012; Smith et al., 2013).

This article describes recent AOA initiatives to increase access for diverse populations to evidence-based programs, and synthesizes key lessons learned from initiative evaluations in the context of the “RE-AIM” (Reach, program Effectiveness, Adoption, Implementation, and Maintenance) framework (Glasgow, Vogt, and Boles, 1999; Glasgow et al., 2004; Belza, Toobert, and Glasgow, 2008).

Relevant AOA and ACL InitiativesThe AOA administers the Older Americans Act (OAA), which authorizes state-based formula grants to fund health and human services, including prevention and health promotion activities. Priority is given to serving older adults (ages 60 and older) who live in medically underserved areas, or who are in greatest

By Michele L. Boutaugh, Susan M. Jenkins, Kristie P. Kulinski, Kate R. Lorig, Marcia G. Ory, and Matthew Lee Smith

Lessons learned from the Administration on Aging’s efforts to increase access for racial and ethnic minorities to evidence-based prevention programs that are known to work.

Closing the Disparity Gap: The Work of the Administration on Aging


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economic need. Since 2012, congressional appropriations require this funding be used only for evidence-based programs. Recently, ACL refined its definition of evidence-based pro-grams. Effective October 1, 2016, funding will be restricted to programs that meet the criteria listed in Table 1 (above). AOA also provides formula grants to tribal organizations that support health promotion programs and home- and community-based supportive services (HCBS) for Native American, Alaskan Native, and Native Hawaiian elders.

Since 2006, AOA also has provided three major competitive grant programs to support dissemination of evidence-based programs (Table 2, below). The Evidence-Based Disease and Disability Prevention Program (EBDDP) grants supported CDSMP and evidence-based physical activity, falls prevention, nutrition, and behavioral health programs. Both the American Recovery and Reinvestment Act (ARRA) and the

Prevention and Public Health Fund (PPHF) grant programs have supported the generic CDSMP and also self-management programs developed for specific chronic conditions (arthritis, diabetes, HIV/AIDS, and chronic pain), Spanish-speaking populations, and in an online format.

The three grant programs were aimed at increasing the number of older adults who participate in evidence-based programs, and building delivery infrastructures and systems to sustain program delivery. Reaching underserved populations was an explicit expectation. The ARRA and PPHF funding announcements included the requirement that grantees demon-strate capacity and ability to achieve health equity among disparately affected populations, as follows:

Applicants must identify and select a specific targeted population(s) including at least one low-income, minority, rural, limited

Table 1. AOA Evidence-Based Criteria

• Demonstrated through evaluation to be effective for improving the health and well-being or reducing disease, disability, or injury among older adults;

• Proven effective with older adult population, using Experimental or Quasi-Experimental Design;

• Research results published in a peer-review journal; • Fully translated in one or more community site(s); and,• Includes developed dissemination products that are available to the public.

Source: Administration on Aging, 2014

Table 2. Major AOA Discretionary Grant Programs Supporting Evidence-Based Health ProgramsGrant Program Years of Funding Number of Awards

Evidence-Based Disease and Disability Prevention Program (EBDDP)

2006–2012 27 states*

American Recovery and Reinvestment Act Communities Putting Prevention to Work: Chronic Disease Self-Management Program (ARRA)

2010–2013 45 states, the District of Columbia, and Puerto Rico

PPHF—2012—Empowering Older Adults and Adults with Disabili-ties through Chronic Disease Self-Management Education Programs, financed by the Affordable Care Act Prevention and Public Health Fund (PPHF)

2012–2015 22 states

*Includes three states funded by The Atlantic PhilanthropiesSource: Kulinski et al., in press.

Social and Health Disparities in America’s Aging Population

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English speaking or other underserved older and/or disabled population with chronic conditions and provide a rationale for this selection. Grantees are expected to coordinate with tribal entities in their jurisdiction, if applicable, and during the project period to negotiate and implement at least one written partnership agreement with a tribal entity or other agency . . . (AOA, 2012).

In addition to granting money directly to states, since 2003, AOA has been funding the National Council on Aging’s (NCOA) Center for Healthy Aging as a technical resource center, providing leadership and support to the field to promote evidence-based programming. Since 2010, NCOA has maintained an online data collection system used by state grantees and program sites to report workshop and participant data. NCOA continues to host Web seminars on engaging racial and ethnic minority populations, disseminates customized marketing materials for specific populations and other resources devel-oped by grantees on its website, and provides a listserv to allow discussion of issues such as offering CDSMP within tribal communities.

In 2012, the ACL established the National Aging Resource Consortium on Racial and Ethnic Minority Seniors. It is made up of four national minority aging organizations: the National Caucus and Center on the Black Aged, Inc.; the Asociacion Nacional Pro Personas Mayores; the National Asian Pacific Center on Aging, Inc.; and, the National Indian Council on Aging, Inc. The Consortium is a resource center, providing expertise in designing, developing, and disseminating culturally competent information and materials for racial and ethnic minority older adults (see Table 3 on page 110).

The Essential Evidence-Based Program EvaluationsThis article synthesizes key lessons learned about reaching and serving diverse populations, drawn from four AOA/ACL grant program evaluations:

the EBDDP post-grant report (Frank and Lau, 2013); the ARRA post-grant report (NCOA, 2013; Ory et al., 2013a); an ARRA CDSMP process evaluation conducted by IMPAQ International and Altarum Institute through an ACL contract (Woodcock et al., 2013; Korda et al., 2013; Erdem and Korda, 2014); and, an unpublished 2014 PPHF mid-term program analysis. This article also incorporates relevant findings from the National Study of CDSMP, partially funded by AOA (Ory et al., 2013b, 2013c).

Evaluation study objectives, data sources, and methodsThe four AOA/ACL evaluations were designed to document grantee successes, challenges, accomplishments, lessons learned, and prod-ucts produced. Research questions included populations served; how grantees implemented, disseminated, and sustained their programs; and, how programs differed in completion rates, distribution channels, and delivery

systems. The evaluations included descriptive analyses for the programs and populations served based on data available in the NCOA database and AOA grantee program files (i.e., original grant applications, grantee progress and final reports, state profiles, and the results of an annual grantee “Integrated Services Delivery System Assessment” online survey). The CDSMP process evaluation also included regression analyses examining the influence of participant and workshop characteristics on workshop completion. These data were com-plemented by additional qualitative data gathered from site visits, interviews with AOA stakeholders and state-level key informants, and input from a Technical Advisory Group of academics, state– and local−level practitioners,

The grantees and their partners have successfully reached many diverse populations.


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and leaders of relevant advocacy groups. The objective of the National Study of

CDSMP was to determine the effectiveness of CDSMP among a national sample of participants organized around healthcare reform’s “Triple Aim” goals of better health, better healthcare, and lower costs (Berwick, Nolan, and Whitting-ton, 2008). The National Study of CDSMP used a longitudinal design and obtained participant and

workshop data from twenty-two organizations holding CDSMP licenses in seventeen states across the nation (Ory et al., 2013c). Data were collected at the start of each workshop and again at six and twelve months.

Discussion and synthesis of key lessons learnedKey lessons learned from the four AOA/ACL evaluations and the National Study of CDSMP are

Table 3. Sample Resources

Name/ URL Description/Sample Activities

ACL National Aging Resource Consortium on Racial and Ethnic Minority Seniors

www.acl.gov/Get_Help/Funded_Re source_Centers/AoA.aspx#A07

Coordinates four national minority aging organization partners and serves as an interconnected resource center for the aging network. Each of the Consortium organizations has agreed to partner and share their distinct strengths and culturally competent expertise for the benefit of racial and ethnic elders, their families and caregivers. An example of Consortium projects is outreach support to facilitate implementation of the U.S. Department of Health and Human Services/Walgreen’s Adult Immunization Initiative.

National Caucus and Center on the Black Aged, Inc. (NCBA)

www.ncba-aged.org

Provides a health and wellness program for African American elders that includes public awareness, community health promotion campaigns, technical assistance, and training programs that disseminate brochures, videos, and newsletters with an emphasis on cancer (breast, cervical, and prostate); cardiovascular disease; hypertension; nutrition; physical activity; and access to care.

Asociacion Nacional Pro Personas Mayores (ANPPM)

www.anppm.org

Promotes community coalition-building and develops model health promotion program materials for low-literacy, bilingual educational materials for Hispanic older adults, family members, and providers, e.g., foto novelas, PSAs, and other materials on cardiovascular diseases in men and women, prostate cancer, diabetes, and nutrition.

National Asian Pacific Center on Aging, Inc. (NAPCA)

http://napca.org/healthy-aging/resources/

http://napca.org/chronic-disease-self-management-program/

Provides a Healthy Aging Resource Center, including a library of health information and resources in Asian and Pacific Islander languages and operates a bilingual “800” information line. Worked with community organizations to implement the CDSMP for Asian American and Pacific Islander elders. NAPCA also developed in-language resources for implementing and evaluating the program.

National Indian Council on Aging, Inc.

www.nicoa.org

http://nicoa.org/for-elders/health/diabetes-education/

Provides culturally competent and linguistically appropriate health promotion and disease prevention strategies for Native American and Alaska Native elders, e.g., a manual for American Indian caregivers of individuals with Alzheimer’s Disease, diabetes education and outreach materials, and technical assistance to help tribes prevent and control diabetes.

National Council on Aging (NCOA)

www.ncoa.org/improve-health/center-for-healthy-aging/chronic-disease/how-ncoa-helps.html

Through its Center for Healthy Aging, NCOA assists community-based organizations to develop and implement evidence-based programs that promote healthy lives for older adults. As an ACL-funded resource center, NCOA hosts Web seminars and disseminates resources related to reaching and serving racial and ethnic minority populations.


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organized below using the RE-AIM framework (Glasgow, Vogt, and Boles, 1999; Glasgow et al., 2004; Belza, Toobert, and Glasgow, 2008). This framework was developed to foster consistent reporting of research results about reach (extent to which a program attracts and retains its intend-ed audience); effectiveness (participant outcomes and program value); adoption (participation rate among potential settings); implementation (extent to which the program is delivered with fidelity, as intended by the program developers); and, maintenance (extent to which participant benefits and programming are sustained).

ReachThe grantees and their partners have successfully reached many diverse populations. As of July 2014, the cumulative data in the NCOA database showed that of the nearly 200,000 participants reporting demographic data since 2010, 69.2 percent were white, 22.3 percent were African American, 17 percent were Hispanic, 3.8 percent were Asian, 1.9 percent were American Indian/Alaska Natives, 0.9 percent were Hawaiian/Pacific Islanders, and 1.9 percent were multiracial or other. As highlighted in Table 4 (below), each

of the evaluation reports documented successful reach within various racial and ethnic groups, often in greater rates than in the older U.S. population. The most common racial minority group reached was African American, ranging from 13 percent to 22.8 percent, compared to a prevalence rate of 8.5 percent of the U.S. popula-tion ages 65 and older (West et al., 2014). The percentage of Hispanic participants ranged from 11 percent to 22.3 percent, compared to 6.9 percent of older Americans.

Participation of African Americans and Hispanics was even greater for the Diabetes Self-Management Program (DSMP) than for the generic CDSMP (27.8 percent versus 17.3 per-cent, and 18.2 percent versus 13.1 percent, respectively). This finding could reflect more focused DSMP outreach efforts to recruit African Americans and Hispanics, groups dis- proportionally affected by diabetes. However, the higher prevalence was maintained whether or not the participants had diabetes (Erdem and Korda, 2014).

The grantees also have been successful in reaching many linguistic minorities. In addition to offering Tomando Control de su Salud (the

Table 4. Percentage of Participants by Race and Ethnicity Reported in Evaluation Studies Compared to U.S. Census Data on Americans Ages 65 and Older

Evidence-Based Disease and Disability Program

ARRA CDSMP

IMPAQ/ AltarumCDSMP

Prevention and Public Health CDSME

National Study of CDSMP

2010 U.S. Census Data

Hispanic 11 17 14 13.2 22.3 6.9

American Indian 2 1.7 2 2.2 0.7 0.5

Asian 3 3.9 4 3.8 2.9 3.4

Black or African American

13 22.6 19 22.8 16 8.5

Hawaiian or Pacific Islander

0 0.9 1 1 2.9 0.1

Other/ Multiracial 2 2.1 5 1.7 2.9 1.7

White 68 68 61 68.5 55.2 84.8

Sources: Frank and Lau, 2013; National Council on Aging, 2013; Woodcock et al. 2013. Unpublished 2014 NCOA data; Ory et al. 2013a, 2013b, 2013c; and West et al., 2014.


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Spanish CDSMP) and Programa de Manejo Personal de la Diabetes (the Spanish Diabetes Self-Management Program), grantees reported delivering CDSMP workshops to populations speaking Arabic, Cantonese, Chinese, Farsi, Haitian Creole, Hindi, Korean, Mandarin, Navajo, Portuguese, Russian, Somali, Tagalog, Tongan, and Vietnamese.

Once enrolled, racial and ethnic minority participants were likely to continue in the CDSMP workshops and have high “completer” rates (i.e., attending four or more of the six workshop sessions). Table 5 (below) presents data from the ARRA CDSMP process evaluation about completer rates by race or ethnicity. A separate analysis showed that the odds of completing the workshops were 47 percent higher for participants in the Spanish CDSMP workshops and 106 percent higher for the Spanish DSMP, as compared to the English- language workshops (Erdem and Korda, 2014).

Reaching these diverse populations was challenging. Across the various evaluation studies, two main methods emerged for success-fully reaching diverse populations: partnering with relevant agencies and personnel represen-tative of the population, and using specific, targeted marketing strategies.

Partnering with agencies and personnel already involved with the intended population helped ensure the programs were offered in familiar sites and at appropriate times, and were taught by well-respected peer leaders.

Mississippi and South Carolina used church-es and other faith-based organizations to reach African Americans. New Mexico and Texas recruited community health workers and promotoras (lay Hispanic community members with specialized training to provide basic health education in the community), who reached out to Spanish-speaking participants and served as peer leaders. Arizona, Colorado, New Mexico, and Utah worked together to train tribal elders and more effectively serve Native Americans. Minnesota, Washington, and Wisconsin trained tribal elders as leaders and integrated with tribal programs to reach Native Americans. In Minnesota, Wisdom Steps (http://wisdomsteps.org/) is a partnership between eleven Minne-sota Indian tribes and the Minnesota Board on Aging to encourage tribal elders to take simple steps toward better health. Through Wisdom Steps, all tribes in the state implemented CDSMP and A Matter of Balance (an evidence-based, falls prevention program). Similarly, Washington integrated CDSMP with its “Wis-

Table 5. Stanford’s Chronic Disease Self-Management Program (CDSMP): Completion Rates by Participant Race/Ethnicity

Ethnicity/Race Total

Ethnicity: Hispanic or Latino origin 77.7%

Ethnicity: Not Hispanic or Latino origin 76.9%

Race: American Indian/Alaskan Native 73.1%

Race: Asian or Asian American 77.6%

Race: Black or African American 78.6%

Race: Hawaiian Native or Pacific Islander 90.5%

Race: Other/Multiracial 77.8%

Race: White or Caucasian 76.1%

Total 76.4%

Source: Woodcock et al., 2013.


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dom Warriors” program with great success among elders from seven tribes. Many states effectively recruited low-income racial and ethnic minorities through Federally Qualified Health Centers, tribal clinics, and other com-munity health and wellness centers.

Some states also found it useful to partner with agencies whose mission it was to address health inequities. New Jersey’s State Office of Minority and Multicultural Health provided grants to community agencies to deliver evi-dence-based programs to reach African Ameri-can, Asian Indian, Chinese, Korean, Haitian, Hispanic, and Vietnamese groups. The Nebraska Office of Health Disparities helped target tribes and provided ambassadors to recruit partici-pants. Oklahoma worked with its Health Equity Resource Opportunity Network and leveraged health literacy resources to conduct outreach to African Americans, Hispanics, and Native Americans through community health centers, interfaith groups, and area agencies on aging.

Specific, targeted marketing strategies included the use of Geographic Information System (GIS) mapping in Michigan to identify high-risk groups and geographic areas in need of additional workshop site development and leader training. Word-of-mouth marketing appears to be a highly effective marketing tool using promoto-ras, tribal elders, pastors, and other local champi-ons. Missouri and South Carolina used former class participants in an Ambassador Outreach program (Centers for Disease Control and Prevention, 2013). California and Washington translated culturally relevant marketing materials into a variety of languages. Massachusetts col- laborated with the Multicultural Coalition on Aging (www.hebrewseniorlife.org/research-mul ticultural-coalition-on-aging) on a conference that provided orientation workshops in Spanish, Portuguese, Chinese, Vietnamese, Haitian Creole, and Cape Verdean Creole.

Utah specifically targeted the Tongan population, the fastest growing and largest Pacific Islander community in the state. To help

maintain its successful recruitment and high completer rates (more than 90 percent) among Tongan participants, Utah has used a champion program coordinator, pastors, and respected community members as peer leaders. Work-shops are marketed through Tongan outlets, including a newsletter, weekly radio show, website, Facebook, churches, and clubs.

Practices that appeared to help retention in other groups included over-enrolling in work-shops and holding “session zero” orientation classes prior to the first class. These informa-tion sessions provide a program overview and explain expectations for workshop participation. Additionally, administrative paperwork often is collected at this time (Jiang et al., in press). Other strategies involve using a buddy system to follow up with participants who miss a session; holding workshops at housing sites to eliminate transportation issues; scheduling workshops at times and places when and where the group already congregates; and, encouraging workshop members to bring healthy snacks to share.

EffectivenessSome grantees were able to leverage other resources to provide state-specific information about program effectiveness. Hawaii partnered with the University of Hawaii to evaluate the impact of CDSMP on its multicultural partici-pants (Tomioka et al., 2012). At six months, all groups showed significant improvements in social and role activity limitations and physician communications. In comparison with white participants, Asians and Native Hawaiians had increased self-reported health and exercise time. Asians also reported reduced physical limita-

Findings showed significant health-related improvements among diverse participants at six- and twelve-month follow-up assessments.


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tions, health distress, fatigue, shortness of breath, pain, and physician visits, as well as increased aerobic exercise, ability to cope with symptoms, and self-efficacy.

Findings from the National Study of CDSMP showed significant health-related improvements among diverse participants at six- and twelve-month follow-up assessments (Ahn et al., 2013; Ory et al., 2013b, 2013c). At six- and twelve-month follow-up, participants showed improve-ments in better health outcomes such as reduced pain, fatigue, and depression. There was also a decrease in unhealthy mental and physical health days and in sleep problems. At twelve months, participants reported significant improvements in better healthcare outcomes, such as improved communication with physi-cians, medication compliance, and confidence completing medical forms. At six months, participants reported significant improvements in better value outcomes, including reduced emergency room visits and hospitalization. Further reductions in emergency room visits were seen at twelve months. Findings show that CDSMP participation resulted in potential net savings of $364 per participant.

AdoptionAcross studies, CDSMP and other evidence-based programs were successfully adopted by,

and implemented in, many organizational settings including senior centers, area agencies on aging, healthcare organizations, residential facilities, community centers, and faith-based organizations. Grantees frequently partnered with tribal, faith-based, and other community agencies already serving the racial minority groups of interest. These agencies appeared to be more effective in reaching and retaining participants. Faith-based organizations had the highest CDSMP completion rates of any type of implementation site (79.7 percent compared to 72.7 percent in healthcare organizations).

Lessons learned about fostering the adoption of evidence-based programs by agencies serving ethnic and racial minority populations include the following:• Obtain the support of upper-level management

to commit personnel and key resources, and expect that tribal approval and other agency review procedures can be time-consuming;

• Use easily accessible tools to assess organiza-tional readiness (such as those available on the NCOA website at www.ncoa.org/improve-health/innovation-readiness.html);

• Invest time to clarify all expectations, roles, and responsibilities, and document in a written memorandum of understanding or letter of agreement;

• Engage local champions (e.g., representatives

Table 6. Common CDSMP Accommodations• Scheduling smaller workshop sizes to better accommodate challenges of reaching rural populations and to

accommodate Somalian cultural norms;

• Changing program names to increase interest; for example, in Hawaii, the program is called “Better Choices Better Health—Ke Ola Pono”;

• Using opening or closing prayers in some faith-based agencies;

• Holding voluntary six-month participant reunion meetings to provide opportunities for participants to recon-nect, socialize, and compare progress since workshop completion;

• Using a tracking stick to designate speakers or discussants in Navajo groups;

• Postponing workshops when there is a death in a tribe;

• Allowing some participants to maintain the same partner instead of changing partners at each workshop session; and,

• Providing male- and female-specific workshops to honor Tongan cultural sensitivity.

Source: Adapted from Woodcock et al., 2013.


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of the target group) to serve as program coordi-nators; and,

• Offer additional, complementary evidence-based programs to agencies to help embed ongoing programming and increase opportuni-ties for cross-marketing.

Implementation and fidelityTo ensure program quality, grantees and their partners are expected to adhere to program fidelity standards such as those outlined in Stanford’s Program Fidelity Manual for its self-management programs (Stanford Patient Education Research Center, 2012). The evalua-tion studies showed that while grantees under-stood the need for monitoring and maintaining fidelity, they encountered many challenges and several sought permission from Stanford and other program developers to make accommoda-tions to be more culturally sensitive to the needs of their targeted populations. For instance, agencies serving Somalian populations found it difficult to meet Stanford’s class-size require-ments for a minimum of ten participants per workshop. Smaller classes were offered to accommodate cultural norms. Table 6 (see page 114) lists other reported accommodations.

MaintenanceMaintenance involves sustaining individual participant benefits as well as programming. The National Study of CDSMP demonstrated that participant benefits were maintained at six and twelve months. Findings suggest the ability of CDSMP to sustain program benefits related to better health, better healthcare, and better value for up to a year after workshop initiation. Given the diverse composition of study participants, findings indicate that CDSMP can benefit dif- ferent participant sub-groups and these health-related changes can be maintained over time.

Much has been learned about maintaining programming over time. Most (twenty-five out of forty-seven) of the ARRA-funded states and territories did not receive PPHF grants, but have

continued offering programs. The ARRA CDSMP process evaluation found that to try to sustain their program efforts, including those involving diverse populations, states focused on working with coalitions and securing partnerships with health systems, health insurance groups, and other larger partners with their own funding sources. States identified multiple challenges to recruiting such partners, including a lack of state-specific research on program impact, limited understanding of existing evaluation results, and limited availability of information about program cost-effectiveness and value needed to persuade potential partners and funders.

Another challenge was retaining leaders with special cultural and linguistic skills—individuals who often come from the community and have low incomes. Many were unable to participate without receiving stipends. The tribal, faith-based, and other local community agencies often cannot sustain the program on their own. To address these issues, some grantees have estab-lished state or regional networks or collabora-tives that encourage resource-sharing and economies of scale for purchasing supplies, training activities, and recruiting and retaining trainers and leaders.

In general, past and current grantees report-ed that to sustain the programs they also needed to develop and implement business plans to secure diversified sources of funding, and use outcomes data to secure external financial support, engage multiple program champions, and have a strong management and technical assistance structure in place to support leader and participant recruitment, training, and program logistical activities.

Conclusion The AOA has played a critical role in closing the disparity gap for diverse older populations with chronic illnesses through its support of resource centers and formula and discretionary grants that fund evidence-based programs. Within the RE-AIM framework, key lessons were learned


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from past and current grant initiatives. Grantees and their partners have been able to reach and retain substantial proportions of racial and ethnic minority group participants, exceeding national population percentages. Partnering with agencies and personnel already involved with the targeted populations remains critically important. Pro-gram participants from diverse backgrounds have shown significant improvements in better health, better healthcare, and better value outcomes, which were maintained at twelve months.

Programs were successfully adopted by and offered through a variety of organizational settings. Grantees made acceptable cultural accommodations that attracted and retained diverse participants. Further, the majority of states were able to continue at least some level of programming to diverse populations after their AOA discretionary funding ended. The fact is that after the end of federal funding, many states continue to offer programs reflects successful partnering (e.g., with other state agencies or medical care organizations) to diversify funding streams and create a multi-pronged approach to funding.

Despite the successes in serving diverse groups, many challenges remain. The evalua-tions summarized here highlight the need for additional research to address practical pro-grammatic and policy concerns. More informa-tion is needed to identify why more African Americans and Hispanics participate in the DSMP versus the CDSMP, even when they do not have diabetes, and what aspects of the Span- ish CDSMP and the Spanish DSMP contribute

to the higher completion rates in these programs compared to the English versions. There also is a need for more diverse sources of financial support beyond federal grants, which require being able to document which sub-groups benefit the most from these programs and their cost-effectiveness.

The future portends a growing diversity among the rapidly growing older population. Great strides have been made, as exemplified by AOA evidence-based initiatives over the past

decade. Looking ahead, we can make a difference in reducing disparities, but it will require making integrated efforts across public and private sectors and involving key stakeholders from

the aging, public health, minority health, clinical, and academic fields. Varied partner types yield benefits such as increased reach to diverse populations, access to new funding streams, and assistance with evaluation and outcome mea-surement—all critical factors leading to pro-grammatic successes.

Michele L. Boutaugh, B.S.N., M.P.H., is an aging services program specialist with the Administration on Aging, Administration for Community Living, Atlanta, Georgia. Susan M. Jenkins, Ph.D., is a social science analyst with the Administration for Community Living, Washington, D.C. Kristie P. Kulinski, M.S.W., is senior program manager, National Council on Aging, Washington, D.C. Kate R. Lorig, Dr.PH., is professor emerita, Stanford University School of Medicine, Stanford, California. Marcia G. Ory, Ph.D., M.P.H., is Regents and Distinguished Professor and director, Program on Healthy Aging, School of Public Health, Texas A&M Health Science Center, College Station, Texas. Matthew Lee Smith, Ph.D., M.P.H., C.H.E.S., is assistant professor, College of Public Health, The University of Georgia, Athens, Georgia.

One challenge was retaining leaders with special cultural and linguistic skills—individuals who come from the community and often have low incomes.


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