Chronic Disease Self-Management Education (CDSME) programs help people living with ongoing health conditions build skills to manage symptoms, communicate with providers, make informed decisions, and improve quality of life. For organizations delivering CDSME, the challenge is often not proving that the programs are valuable, but identifying where they are needed most and using that information to strengthen outreach, partnerships, and funding efforts.

Feedback from grantees has shown a need for more concrete examples of how state chronic condition data can support outreach planning. State maps, public dashboards, and local health indicators can help grantees move from broad statements about chronic disease in their communities to clearer, data-informed explanations of why CDSME is needed in a specific region, county or ZIP code.

Where to find state-level health data

One helpful starting point is the Behavioral Risk Factor Surveillance System, or BRFSS, which collects state-level data on health-related risk behaviors, chronic health conditions, and use of preventive services among adults across all 50 states, the District of Columbia, and U.S. territories.¹ For more local planning, CDC PLACES provides data at the county, place, census tract, and ZIP Code tabulation area levels, helping organizations look beyond statewide averages and better understand community-level need.²

State chronic condition maps can help grantees identify where outreach may be most needed. For example, a map showing higher rates of diabetes, arthritis, heart disease, physical inactivity, or frequent physical distress can help organizations decide where to host workshops, where to recruit leaders, and which partners to engage. These maps can also support funding narratives by showing that outreach decisions are tied to documented community need.

Grantees can also use NCOA’s Evidence-Based Programs Public Tableau to complement state chronic condition maps. This public Tableau profile can help organizations visualize program and participant information, identify patterns, and communicate data in a more accessible format. Used alongside state health data, these dashboards can help grantees tell a stronger story: the community has a documented need, CDSME is an evidence-based response, and program data can help track reach, satisfaction, and outcomes over time.

How to use data to strengthen funding language

This kind of data-informed outreach can strengthen funding language. Instead of writing, “We will recruit participants through community partners,” a stronger justification might be:

“State chronic condition maps show elevated rates of diabetes and frequent physical distress in the counties targeted for this project. The grantee will prioritize outreach in these areas through health care, aging services, and community-based partners to connect adults with evidence-based self-management support. Public data dashboards will be used to monitor reach and support continuous quality improvement.”

Data can also help organizations tailor CDSME messaging to local needs. If data show high rates of arthritis or chronic pain, outreach can emphasize pain management, movement, fatigue, and daily activity. If data show high rates of diabetes or hypertension, messaging can focus on managing symptoms, communicating with providers, medication use, and building confidence.

State data can also make partnership conversations more concrete when coupled with program-level data captured in the Healthy Aging Programs Integrated Database (HAPID). Instead of simply asking a clinic, housing site, senior center, or community organization for referrals, grantees can show how CDSME aligns with the needs of the people that partner already serves. For example:

“The state dashboard shows high rates of diabetes and physical inactivity in this area. CDSME can help your participants build skills to manage symptoms, communicate with providers, and stay active in daily life.”

How data can improve program reach

Finally, data can support continuous quality improvement. If a county has high chronic disease burden but low CDSME enrollment, that may signal a need to adjust outreach, workshop locations, language access, transportation supports, referral workflows, or partner engagement. Grantees can compare chronic condition maps, Tableau dashboards, and their own program data to see whether workshops are reaching the communities identified as high priority.

State chronic condition maps cannot replace relationships, trust, or community knowledge. But they can help grantees make stronger decisions and tell a clearer story. When CDSME providers use data to explain where they are focusing, why those communities were selected, and how outreach will respond to local needs, they are better positioned to build partnerships, justify funding, and reach the people who can benefit most.

This project was supported by the Administration for Community Living (ACL), U.S. Department of Health and Human Services (HHS) as part of a financial assistance award totaling $10,000,000 with 100 percent funding by ACL/HHS.  The contents are those of the author(s) and do not necessarily represent the official views of, nor an endorsement, by ACL/HHS or the U.S. Government.

Sources

1. Centers for Disease Control and Prevention. Behavioral Risk Factor Surveillance System. U.S. Department of Health and Human Services. Found on the internet at https://www.cdc.gov/brfss/

2.Centers for Disease Control and Prevention. Interactive PLACES map. U.S. Department of Health and Human Services. Found on the internet at https://www.cdc.gov/places/tools/interactive-map-tool.html

3. National Council on Aging. Get the facts on chronic disease self-management. Found on the internet at https://www.ncoa.org/article/get-the-facts-on-chronic-disease-self-management/

4. National Council on Aging. Evidence-Based Programs Tableau Public profile. Tableau Public. Found on the internet at https://public.tableau.com/app/profile/angelica.herrera.venson/vizzes

5. National Council on Aging. NCOA’s National CDSME Resource Center for professionals. https://www.ncoa.org/professionals/health/center-for-healthy-aging/national-cdsme-resource-center/