Explore these proven chronic disease self-management education programs for your community. Chronic Disease Self-Management Education (CDSME) programs are supported by a variety of federal funding sources, including the Administration for Community Living discretionary grant funding, Older Americans Act Title III-D funding, and Centers for Disease Control and Prevention grant funding. Evidence-based CDSME programs focus on a variety of topics and skills for improving the management of ongoing conditions. Topics include chronic disease, falls prevention, mental health, physical activity, and more. Most curricula are small group (10-15 individuals), workshop-based programs offered in locations such as senior centers, Area Agencies on Aging, churches, libraries, hospitals, other community-based settings, online, or by telephone. Some programs are one-on-one, like HomeMeds and PEARLS or self-directed, like Tool Kit for Active Living with Chronic Conditions. 

Definitions

• Chronic Disease Self-Management Education Program (CDSME): For the purpose of Administration for Community Living (ACL) discretionary grant funding,
  "CDSME program" is an umbrella term that refers to community-based education programs specifically designed to enhance patient self-management of chronic illnesses, as well as focus on building multiple health behaviors and generalizable skills such as goal setting, decision making, problem-solving, and self-monitoring. CDSME programs are proven to maintain or improve health outcomes of older adults with chronic conditions. Always refer to the most current funding announcements for a list of programs that qualify as CDSME programs. 
• Self-Management Support Program: The ACL discretionary grant funding for CDSME allow applicants to offer a "self-management support program," defined as a community-based, behavioral change intervention that is proven to increase one or more skills or behaviors relevant to chronic disease self-management such as physical activity and medication management. Support programs can also refer to programs that fall outside the typical six-session format, such as the Toolkits for Active Living with Chronic Conditions, and those that involve a single meeting with a participant.

Notes:

• Both CDSME programs and self-management support programs can be implemented using Older Americans Act Title III-D funding. 
• Programs with an asterisk (*) meet the Osteoarthritis Action Alliance's criteria for Arthritis-Appropriate Evidence-Based Interventions (AAEBIs). AAEBIs are programs that have been shown to improve arthritis symptoms, such as pain or limitations in function. AAEBIs can be implemented with Centers for Disease Control and Prevention funding.

Chronic Disease Self-Management Education Programs

Age-Tastic!™

Age-Tastic™ is an effective and entertaining health and wellness program for older adults that incorporates gameplay, group discussions, and try-it-at-home activities to motivate lifestyle changes and build confidence. The program runs for eight weeks and consists of five modules: emotional wellbeing, physical fitness and falls prevention, fraud protection and financial mistreatment, nutrition, and how to communicate with doctors and manage medication.

Aging Well with HIV

Aging Well with HIV addresses unique topics like stigma, disclosure, isolation, self-advocacy, survivor guilt, and management of HIV-related health challenges. The program is offered for 2.5 hours per week for six weeks, either in-person or virtually.

Báa nnilah

In the Apsáalooke language Báa nnilah means, “providing love and nurturing through advice.” This program was developed by and for the Apsáalooke Nation and is adaptable for other Indigenous communities. Through shared stories, peer-led support, and hands-on activities, community members find support for managing or preventing chronic illness. The program consists of seven gatherings (sessions) held in-person and facilitated by an Aakbaabaawiilea, or “those who give advice.”

Better Choices, Better Health®*

Better Choices, Better Health® (Online CDSMP, Asynchronous) is an on-line interactive version of the Chronic Disease Self-Management Program (CDSMP). Participants log on at their convenience two to three times per week for a total of about two hours per week. The program is offered on a dedicated website utilizing discussion boards and weekly lessons, with approximately 25 people per workshop. All information is private and anonymous.

BRI Care Consultation

BRI Care Consultation™ is a care-coaching program, owned by the Benjamin Rose Institute on Aging (BRIA), for older and younger adults with chronic health conditions/disabilities and their caregivers. The training is delivered via telephone, mail, and email by trained care consultants. Core components of the program include assessment, action planning, and ongoing maintenance and support. Through nearly two decades of research, BRI Care Consultation has been proven to provide the ongoing coaching and support needed for people with chronic conditions and their caregivers. 

Chronic Disease Self-Management Education Suite of Programs*

The suite of Chronic Disease Self-Management Education (CDSME) programs, originally developed by Stanford University, have been proven to help older adults better manage their chronic conditions, improve their quality of life, and lower health care costs. CDSME is an interactive workshop for those living with one or more (physical or mental health) chronic conditions like arthritis, diabetes, heart disease, depression, and others. Participants learn skills to manage their conditions on a day-to-day basis including exercise, healthy eating, symptom management (pain, fatigue, sleep, shortness of breath, stress and depression), weight loss, and communication skills. Core self-management skills taught include action planning, problem solving and decision making. View more information about different versions of CDSME programs:

• Cancer: Thriving & Surviving (In-Person or Online)
• Chronic Disease Self-Management Program (In-Person or Online)*
• Toolkit for Active Living with Chronic Pain (Mail and/or Phone)*
• Toolkit for Active Living with Diabetes (Mail and/or Phone)
• Toolkit for Tomando Control de Su Salud (Mail and/or Phone)*
• Chronic Pain (In-Person or Online)*
• Diabetes Self-Management (Mail or Online)
• Positive Self-Management (In-Person or Online)
• Workplace CDSMP (In-Person or Online)*

Eat Smart, Move More, Prevent Diabetes

Eat Smart, Move More, Prevent Diabetes is a CDC-recognized, 12-month diabetes prevention program based on strategies proven to prevent or delay type 2 diabetes for those who are in the prediabetes range or are at high risk for developing type 2 diabetes. The program is led by Registered Dietitian Nutritionists (RDNs) who provide one-on-one support weekly to participants.

HealthMatters Program

HealthMatters™ Program is an evidence-based health promotion program for people with intellectual and developmental disabilities (IDD). Through our Community-Academic Partnerships (CAPs), we aim to provide high quality evidence-based and evidence-informed health promotion programs and training for people with IDD and their supports in health-friendly communities. 

EnhanceWellness*

Enhance®Wellness (EW) is an evidence-based program that connects participants with a personal health and wellness coach to improve physical, emotional, and social well-being. Based on the Chronic Care Model, EW’s participant-centered approach uses motivational interviewing techniques and validated assessment tools in 14 domains to guide health action plan creation and accountability. Using problem-solving strategies, participants clarify goals, responsibilities, and activities as they work toward health-related behavioral change. This program works well as a hub to refer to other health promotion interventions and community resources.

Health Coaches for Hypertension Control

The aim of Health Coaches for Hypertension Control is to improve hypertension self-management through small group educational sessions and support offered by trained health coaches. Goals include increasing knowledge about hypertension self-management, increasing stage of readiness to make lifestyle changes required for successful self-management, and promoting behavior changes in nutrition, physical activity, stress management, tobacco use, and medication management. Health Coaches for Hypertension Control consists of eight sessions delivered by health coaches using a scripted manual and visual aids. 

Mind Over Matter

Mind Over Matter: Healthy Bowels, Healthy Bladder (MOM) is a researched and proven program designed to give women the tools they need to take control of bladder and bowel leakage. Join a MOM workshop and learn strategies for preventing or lessening symptoms including information-sharing, group activities, simple exercises, and dietary changes. With practice, these new skills are proven to help you avoid or reduce leakage so you can keep doing the things that matter most to you.

¡Sí, Yo Puedo Controlar Mí Diabetes! (¡Sí, Yo Puedo!)

¡Sí, Yo Puedo! is a culturally tailored seven-week program comprised of an orientation session (week one) followed by the six-week diabetes self-management education lessons (Weeks 2–7). Classes are approximately two hours in length. Each lesson module is made up of nine to ten activities. ¡Sí, Yo Puedo! uses the social cognitive theory and the self-regulation model as its theoretical foundation to promote behavior change.

Tai Chi for Diabetes

Tai Chi for Diabetes (TCD) is a program that blends traditional tai chi principles with medical knowledge to improve blood sugar control and quality of life. The certified instructors are well versed in working with older adults living with diabetes, recognition and treatment of hypoglycemia, and are able to make modifications to exercises as needed to meet the abilities of the participants. The programming can be completed as an 8-week course (meeting twice per week) or as a 16-week course (meeting once per week). To be successful, a participant should aim to attend at least 70% of the sessions.

Wellness Recovery Action Plan (WRAP®)

Wellness Recovery Action Plan (WRAP®) is an evidence-based manualized group intervention for illness self-management delivered in a self-help group context (in-person or online). WRAP guides participants through the process of identifying and understanding their personal wellness resources, or “wellness tools”, and then helps them to develop an individualized plan to use these resources to manage daily stress and symptoms.

Self-Management Support Programs

Arthritis Foundation Aquatic Program*

The Aquatic Exercise Association’s (AEA) Arthritis Foundation Aquatic Program (AFAP) is a recreational group exercise program conducted in warm water that consists of two levels, Basic and Plus, designed to accommodate different ability levels. The programs offer multiple components to help reduce pain and stiffness, and to maintain or improve mobility, muscle strength and functional ability.

Arthritis Foundation Exercise Program *

The AEA’s Arthritis Foundation Exercise Program (AFEP) is a recreational group exercise program on land that includes a variety of exercises that can be performed sitting, standing or lying on the floor. Programs offer multiple components to help reduce pain and stiffness, and to maintain or improve mobility, muscle strength and functional ability. 

Active Living Every Day*

Active Living Every Day (ALED) uses facilitated group-based problem-solving methods to integrate physical activity for seniors into everyday living. The program utilizes the ALED book and offers optional online support resources for participants and facilitators. ALED can be offered independently or with existing community-based physical activity programs.

Eat Smart, Move More, Weigh Less

Eat Smart, Move More, Weigh Less is a 15-week online weight management program that uses evidence-based strategies proven to help participants achieve and maintain a healthy weight. Each lesson informs, empowers and motivates participants to live mindfully as they make choices about eating and physical activity.

EnhanceFitness*

EnhanceFitness is a low-cost, evidence-based group falls prevention and physical activity program developed specifically for older adults. The exercises are packaged into a formal regimen focusing on four key areas important to the health and fitness of mature participants: low impact cardiovascular; balance work, strength training and stretching. Classes meet three times a week, for an hour each session, providing social stimulation as well as physical benefits.

Feeling Fit Club

Feeling Fit Club is a functional fitness program for older adults that aims to improve strength, balance, endurance, and flexibility while fostering social connection. The program is led by certified fitness instructors and includes adaptable exercises for various abilities—to be done seated or standing. Classes are held two to three times each week in-person and are also available virtually.

Fit & Strong*

Fit & Strong! is an evidence-based physical activity and behavior change intervention that has been successfully implemented in multiple community-based settings. Participants are older adults who have lower extremity joint pain and stiffness related to osteoarthritis. Fit & Strong! blends a multiple component exercise program with group problem solving and education using a curriculum designed to facilitate arthritis symptom management, confidence in ability to exercise safely with arthritis, and commitment to lifestyle change. Before the end of the eight-week Fit & Strong! program, participants meet with the instructor to develop individualized exercise plans that foster ongoing maintenance of a balanced physical activity routine.

Geri-Fit

Geri-Fit® is a progressive resistance strength training exercise program designed to increase strength, flexibility, range of motion, mobility, gait, and balance. Exercises are performed seated in chairs (optional standing) in a group setting. Ongoing classes are held twice a week for 45 minutes each session.

Healthy IDEAS

Healthy IDEAS is a depression self-management program designed to detect and reduce the severity of depressive symptoms in older adults with chronic conditions and functional limitations. It includes screening and assessment, education, referral to appropriate health professionals, and behavioral activation. 

HealthMatters Program

HealthMatters™ Program is an evidence-based health promotion program for people with intellectual and developmental disabilities (IDD). Through our Community-Academic Partnerships (CAPs), we aim to provide high quality evidence-based and evidence-informed health promotion programs and training for people with IDD and their supports in health-friendly communities.

Healthy Moves for Aging Well

Healthy Moves for Aging Well is a simple and safe in-home physical activity intervention developed and tested by Partners in Care to enhance the activity level of frail, high-risk sedentary seniors living at home. The model was developed for community-based care management programs arranging and delivering services to seniors in the home.

HomeMeds

HomeMeds is an important medication safety intervention that helps to document and keep track of medications, their interactions, and potential adverse effects. The program includes an in-home assessment of the patient’s medication history, discussion of medication adherence and any adverse effects, and documentation of vital signs. Medications are entered into the HomeMeds software for review by a pharmacist, nurse practitioner, or physician. Recommendations are then made for any potential medication-related problems. 

On the Move

On the Move (OTM) is a group-based exercise program for older adults, designed to target key principles of the biomechanics and motor control of walking. The program contains a warm-up, stepping patterns, walking patterns, strengthening exercises, and cool-down exercises.

PREPARE for Your Care

Prepare for Your Care (PREPARE) is an online resource that helps people begin the important process of preparing for medical decision making. Using video stories and easy-to-read language, PREPARE helps people explore their personal values and preference and learn how to discuss them with family, friends, and medical providers. PREPARE also offers easy-to-read advance directives in English and Spanish for all 50 US states, a movie version that can be used for in-person or virtual group visits, and guides for facilitators.

PEARLS*

PEARLS is a highly effective method designed to reduce depressive symptoms and improve quality of life in older adults and in all-age adults with epilepsy. During six to eight sessions that take place in the client’s home and focus on brief behavioral techniques, PEARLS counselors empower individuals to take action and make lasting changes so that they can lead more active and rewarding lives. 

Respecting Choices

Respecting Choices Advance Care Planning programs support adults at any age or stage of health in understanding and sharing their personal values, life goals, and preferences regarding future medical care. The goal of advance care planning is to help ensure that people receive medical care that is consistent with their values, goals, and preferences during serious and chronic illness.

Screening, Brief Intervention, Referral to Treatment (SBIRT)

The Florida BRITE Project uses evidence-based screening tools and methods to screen older adults to identify non-dependent substance use or prescription medication issues and to provide effective service strategies prior to their need for more extensive or specialized substance abuse treatment. BRITE providers are trained in the use of the screening tools and how to administer "brief interventions" that assist the individual to look at their use of substances that put them at risk for health-related issues. BRITE is based on the national SBIRT initiative (Screening, Brief Intervention, and Referral to Treatment).

Stand Up For Your Health

Stand Up For Your Health is a four-week program aimed at older adults who sit for more than six hours per day. The program helps participants learn about the health risks of prolonged sitting, the benefits of standing more frequently, and simple strategies to adjust behaviors and sit less. After the four-week training has been completed, a two-hour refresher session is scheduled for week eight.

Walk with Ease*

The Arthritis Foundation’s Walk with Ease program helps participants develop a walking plan that meets their specific needs, while also helping them stay motivated, manage pain, and exercise safely. The Walk with Ease materials can be used individually as a self-guided plan or in a group setting and are based on programs that have been successfully implemented in research settings and have resulted in such benefits as increased physical activity, increased walking distance and speed, decreased pain, and decreased depression.