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 Amercans 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, and even online or by telephone. Some programs are one-on-one (e.g., HomeMeds, PEARLS) or self-directed (e.g. 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 crtieria 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

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 2-3 times per week for a total of about 2 hours per week, participants do not need to log on at the same time. 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 family or friend caregivers. It is delivered via telephone, mail, and email by trained care consultants. The core components of the Program include: 1) assessment, 2) action planning, and 3) 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 family 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 such as arthritis, diabetes, heart disease, depression, etc. 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 Conditions (Mailed and/or with phone)*
• Toolkit for Active Living with Chronic Pain (Mailed and/or with phone)*
• Toolkit for Active Living with Diabetes (Mailed and/or with phone)
• Toolkit for Tomando Control de Su Salud (Mailed and/or with phone)*
• Chronic Pain (In-Person or Online)*
• Diabetes Self-Management (In-Person or Online)
• Positive Self-Management (In-Person or Online)
• Tomando Control de Su Salud (In-Person or Online)*
• Workplace CDSMP (In-Person or Online)*

HealthMatters Program

HealthMatters™ Program is an evidence-based health promotion program for people with intellectual and developmental disabilities (IDD). Through our community-academic partnerships, 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 fourteen 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 7-week program comprised of an orientation session (Week 1) followed by the 6-week diabetes self-management education lessons (Weeks 2-7). Classes are approximately two hours in length. Each lesson module is made up of 9 to 10 activities. ¡Sí, Yo Puedo! utilizes the social cognitive theory and the self-regulation model as its theoretical foundation to promote behavior change.

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 (“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*

AEA Arthritis Foundation Aquatic Program is a recreational group exercise program conducted in warm water that consists of two levels, Basic and Plus, to accommodate different ability levels. 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 *

AEA Arthritis Foundation Exercise Program (Land-based) 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 work 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 low-cost, evidence-based group falls prevention and physical activity program developed specifically for older adults. The exercises have been packaged into a formal regimen focusing on four key areas important to the health and fitness of mature participants: low impact cardiovascular; dynamic/static balance work, strength training and stretching. Classes meet three times a week, an hour each session, providing social stimulation as well as physical benefits.

Fit & Strong*

Fit & Strong! is an evidence-based physical activity/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/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 class. Ongoing classes are held twice-weekly for 45 minutes.

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, 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 is a perfect means for attracting contracts with health plans, health systems and provider groups. It is relatively easy to implement and affordable. The program includes an in-home assessment 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 pratitioner, or physician if any alerts arise for 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 in-home 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).

Walk with Ease (Self-Guided or Group)*

The Arthritis Foundation’s Walk with Ease program helps participants develop a walking plan that meets their particular needs, stay motivated, manage pain, and exercise safely. The Walk with Ease materials 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.