New Jersey Sustainability & Business Plan December 2012

Acknowledgements DP Consulting LLC would like to thank the following organizations for participating in the NJ Department of Human Services (NJDHS) Business and Sustainability Plan for the Chronic Disease Self-Management Program (CDMSP): Camden Area Health Education Center Community Services Inc. of Ocean County Complete Care Health Network (FQHC) Horizon NJ Health (Medicaid Managed Care Org) Jewish Federation of Greater Metro west New Jersey NJ Department of Health Division of Family Health Services NJ Department of Health-Office of Minority & Multicultural Health NJ Department of Human Services-Division of Aging Services NJ Prevention Network Ocean Health Initiatives (FQHC) Robert Wood Johnson Center for Health & Wellness Saint Peter's University Hospital Sickle Cell Association of New Jersey Sussex County Office of Senior Service University Correctional Health Care University of Medicine & Dentistry of NJ-Department of Preventative Medicine & Community Health UMDNJ School of Osteopathic Medicine Institute for Successful Aging

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Executive Summary BACKGROUND New Jersey has established goals for the Chronic Disease Self-management Program - CDSMP program (described in the state as Take Control of Your Health) in the areas of reach, adoption, capacity and securing funds for sustainability. Targeted populations are those with a chronic condition over 60 years or with a disability (reach); continuation of the program by existing aging network agencies and greater involvement by health systems, insurers and community based organizations within health disparity communities (adoption); staffing and infrastructure to deliver and ensure quality in delivery in CDSMP in every county of the state, and similar infrastructure for the Diabetes Self-Management Program (DSMP) and Tomando Control du su Salud delivery in selected counties(capacity); and statewide management structures, dedicated funding, embedding in care transitions and waiver programs and corporate and philanthropic support so that programming will continue when ACL/AoA funding ends.

CURRENT CAPACITY The NJ Department of Human Services is funding 2.40 FTE staff dedicated to CDSMP/DSMP overseeing day-to-day project activities including technical assistance, quality assurance and communication to agency partners; leading data collection, entry and reporting; and managing fidelity assurance activities. CDSMP is now available statewide with 100 master trainers (28 for DSMP and 5 for Tomando) and 200 peer leaders providing programs in all 21of the state’s counties. There are identified program coordinators in many counties and a growing number of people are being reached with rates now of 168 participants per month. Support from the Office of Disease Prevention and Control (Chronic Disease Prevention) and the Office of Minority and Multicultural Health have also facilitated effective targeting of persons with Cardiovascular Disease and Stroke, Asthma, and Diabetes, and outreach to racial/ethnic and rural communities.

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CDSMP is now available statewide with 100 master trainers (28 for DSMP and 5 for Tomando) and 200 peer leaders providing programs in all 21of the state’s counties.

CHALLENGES Local delivery is still largely supported by small grants from the Department of Human Services and its State partners, some philanthropic and corporate support and the contributions of the 65 agencies that either provide sites or support program coordinators. Further expansion of reach into communities and to individuals who will benefit from the programs and increased adoption of the programs by community agencies, physician groups, health networks and insurers is desired. This will require more evidence of the value of the program in a New Jersey context. This may include identification and securing of funding and revenue sources as well as establishing a level of delivery that will attract both referrals and resources. These actions and similar ones, will assure partners that the revenue needed for program delivery is secured and lead to the commitment, on their part, of the required level of delivery and staffing needed to coordinate efforts.

BUSINESS STRATEGIES Utilizing existing resources from the Department of Human Services and its State partners, additional resources now available from the Administration on Community Living and in order to realize new resources from Care Transitions, MCO and Waiver programs the New Jersey program will: 1. Maintain the commitment of the Department of Human Services and its State partners to support the staff positions currently funded and maintain the roles of these staff in overseeing day-to-day project activities including technical assistance, quality assurance and communication to agency partners; leading data collection, entry and reporting; and managing fidelity assurance activities. 2. Build local capacity throughout New Jersey using existing and new partners able to reach 3000 participants over three years 3. Embed referrals to CDSMP in the array of services supported in several funded care transitions programs 4. Partner with four managed care organizations in New Jersey to a) encourage referrals by their affiliated nurse case managers to the programs, b) assess impact of CDSME on members from clinical and financial perspective; and, c) evaluate CDSMP as a health promotion option for which members may be reimbursed. 5. Include CDSMPs among programs that may be funded under New Jersey Medicaid Long Term Services and Support. Operationalize the process including ensuring that partners meet requirements to qualify for reimbursement. 4

6. Continue to include CDSMP in Community Mobilization Initiatives which will further help to embed the program into the grassroots’ expectation of health care services and its active involvement in sustaining the program through a long-term commitment.

ANTICIPATED OUTCOMES A statewide delivery network for CDSMP at a level likely to a) foster reimbursements, b) be integrated into key health related initiatives (e.g., care transitions and Waiver services), c) expand needed supports for persons with specific chronic conditions, including Cardiovascular Disease and Stroke, Asthma, and Diabetes and d) increase access for racial/ethnic groups and rural as well as urban and suburban communities.

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Business Plan Background The New Jersey Department of Human Services (NJDHS) contracted with DQ Consulting to develop a business plan for the sustaining of CDSME delivery in New Jersey.

METHOD Data collected to support the development of this business plan was gleaned from several things including:

CDSMP fits within key priorities for New Jersey agencies.

a.) A review of grant proposals, contracts and existing documentation related to delivery of the CDSMP, DSMP and Tomando Control du su Salud interventions, b.) Research on chronic illness and health disparity challenges in New Jersey, c.) Interviews with key State staff to understand where CDSMP fits within agencies’ overall missions and priorities, d.) History of the State staff involvement in the programs and plans for the future, and online focus groups with key partners to understand current delivery, infrastructure, marketing, quality assurance, evaluation, and reach achievements and challenges. A series of business planning questions emerged from these reviews to which State agency staff responded, providing a basis for the development of a proposed business plan. The plan reflects a comprehensive review of the existing infrastructure beginning with a series of assumptions, which are based upon the data collected. These assumptions outline steps to be undertaken during the three-year period of the currently funded CDSMP project that will lay the groundwork for sustainability. The completion of these steps will demonstrate that: 

There is ongoing State leadership support

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CDSMP fits within key priorities for New Jersey agencies

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The existing statewide infrastructure and planned expansions in another 10 counties is sustainable

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Planned expansions will support greater collaboration with care transitions, managed care organizations and waiver programs

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State leadership will target the marketing, delivery, evaluation and quality assurance concerns to various partners that will encourage program development and expansion.

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CDSMP delivery will be a feature of waiver programs and Medicare reimbursement will be secured for the DSMP.

Comprehensive Review Of Existing Infrastructure VISION & MISSION The New Jersey Department of Human Services (NJDHS) is the largest state agency in New Jersey. Based in Trenton, NJ, it serves approximately 1.5 million New Jersey residents, or about one of every six state residents, and employs about 15,000 people.

New Jersey’s success in the delivery of these programs can be directly attributed to state-level leadership and an array of strategic partnerships.

NJDHS serves seniors, individuals and families with low incomes; people with mental illnesses, addictions, developmental disabilities, or late-onset disabilities; people who are blind, visually impaired, deaf, hard of hearing, or deaf-blind; parents needing child care services, child support and/or healthcare for their children; and families facing catastrophic medical expenses for their children. NJDHS is made up of eight divisions, including the State Unit on Aging - the Division of Aging Service (DoAS). Within the DoAS, programs like Take Control of Your Health (the Chronic Disease Self Management Program) help older adults manage their health concerns and maintain themselves in the community. These programs are offered in local sites through extensive partnerships with communitybased agencies. Since 2006, the NJ DoAS has promoted and invested in infrastructure for delivery of the selfmanagement workshop, the Chronic Disease Self-Management Program (CDSMP). Known as Take Control of Your Health in New Jersey, CDSMP was developed by Stanford University’s Patient Education Research Center and has been endorsed as an evidence-based intervention by the Centers for Disease Control and Prevention (CDC) and the U.S. Administration on Aging (AoA). CDSMP supports workshop participants in community-based settings in developing self-management techniques to manage their chronic conditions. The small groups meet for 2.5 hours per week for 6 weeks. There are also variations on the core program targeting persons with diabetes (Diabetes Self-management Program - DSMP) and persons who are Spanish speaking (Tomando Control de Su Salud and the DSMP for Spanish speakers). Working with its community partners over the past several years, The State has been building an infrastructure to initiate and expand access to the above evidence-based programs.

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Current Delivery Structure New Jersey’s success in the delivery of these programs can be directly attributed to state-level leadership and an array of strategic partnerships. The DoAS has committed significant resources to support a fully functioning Older Adult Health Promotion unit within the Department’s Community Resources, Education and Wellness (CREW) office that: 

Provides leadership for program administration, strategic partnerships and visioning.

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Holds a multi-site license with Stanford for statewide delivery of CDSMP, Tomando and DSMP.

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Promotes programs through a State CDSMP webpage and toll-free number.

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Maintains centralized data input.

There are 2.40 FTEs dedicated to CDSMP/DSMP: The DoAS Director of CREW, (50% CDSMP dedication); Coordinator (100% CDSMP dedication) who oversees day-to-day project activities including technical assistance, quality assurance and communication to agency partners; Data Collection Coordinator (90% CDSMP dedication) leads data collection, entry and reporting; and three other staff persons who participate in fidelity assurance activities (5-10% FTE CDSMP dedication). The state’s commitment to fund staff salaries as outlined above will continue for the foreseeable future. A primary goal of the effort to date has been to build capacity and infrastructure and much has already been achieved. There is now a readiness to expand the reach for CDSMP.

CURRENT CAPACITY Three CDSME programs are currently delivered and one

The DoAS has committed significant resources to support a fully functioning Older Adult Health Promotion unit within the Department’s Community Resources, Education and Wellness (CREW) office.

additional version is contemplated: The Chronic Disease Self-Management Program (CDSMP), developed at Stanford University Patient Education Research Center, teaches skills to manage common problems related to having a chronic

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condition such as arthritis, diabetes, lung disease, and heart disease. The program has proven useful for increasing a person’s self-confidence that they can manage their chronic condition(s). Classes meet 2 1/2 hours, once a week for a 6-week succession and are facilitated by two, trained peer leaders. 

CDSMP is now available statewide with 100 master trainers and/or 200 peer leaders providing programs in all 21 of the state’s counties.

Tomando Control de Su Salud (Tomando) is a workshop given two and a half hours, once a week, for six weeks, in community settings such as senior centers, churches, libraries and hospitals. Spanish-speaking people with different chronic health problems attend together. Workshops are facilitated by two trained leaders. All workshops are given in Spanish without translators. The Program is not a translation of the Chronic Disease Self-Management Program, but developed separately in Spanish to be culturally relevant. 

There are now 7 active master trainers covering 5 counties.

Diabetes Self-Management Program (DSMP), similar to the CDSMP but focused on the management of Type 2 Diabetes was also developed by the Patient Education Research Center at Stanford University. 

There are now 28 active master trainers covering 10 counties.

Better Choices, Better Health® (BCBH) is the online version of the nationally recognized Chronic Disease Self-Management Program, developed and tested at the Stanford University Patient Education Center and managed by the National Council for Aging. Frequently, BCBH is disseminated under contracts with managed care organizations and other health systems. It does not require “real time” attendance and a pair of trained peer facilitators moderates each workshop. Weekly over a 6-week period, participants are asked to log on at least three times for a total of about two hours. Weekly activities include reading and interacting via the Learning Center, making and posting a weekly action plan, participating in problem solving and guided exercises on bulletin boards, and participating in any appropriate self-tests and activities. Participants are encouraged to post chronic condition-related concerns on a bulletin board which allows group members to express and share ideas with each other in a helpful manner. 

In NJ, for the next three years, BCBH will be offered as part of a pilot project for members of four managed care organizations.

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LOCAL INFRASTRUCTURE Sixty-five community-based agencies function as “lead agencies/host agencies,” and house master trainers, oversee peer leaders and coordinate delivery at more than 300 implementation sites. Lead agencies include Area Agencies on Aging (AAAs), hospital systems, Federally Qualified Health Centers, community and faith-based organizations, Retired and Senior Volunteer Programs (RSVPs), health departments and state health associations.

LANGUAGE CDSMP has been offered in 6 languages in select geographic areas: Mandarin/Cantonese (3 master trainers), French Creole (2 master trainers), Vietnamese (2 master trainers), Hindi (3 master trainers) and Korean (3 master trainers).

ACHIEVED PROGRAM REACH There has been a steady increase in the effective reach of the programs: 

2007 – 2009 = 1,580 participants (24 months = an average of 66 new participants per month)

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2010 = 1,418 participants (12 months = an average of 118 new participants per month)

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2011- May 2012 = 2,863 participants (17 months – an average of 168 new participants per month)

KEY PARTNERSHIPS While DoAS holds lead responsibility for CDSMP, two key public health partners – the Office of Disease Prevention and Control (Chronic Disease Prevention) and the Office of Minority and Multicultural Health -have also embraced the CDSMP. Both offices committed resources to establish institutional knowledge by training staff and allocating funds ($800,000+) to introduce the programs

Sixty-five community-based agencies function as “lead agencies/host agencies,” and house master trainers, oversee peer leaders and coordinate delivery at more than 300 implementation sites.

into their service delivery systems, which include a focus on Cardiovascular Disease and Stroke, Asthma, Diabetes, Minority Health Services and Rural Health. Both offices have collaborated with DoAS to provide oversight and support for community partners.

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The Office of Minority and Multicultural Health (OMMH) has worked closely with DoAS for the last five years to provide access to CDSMP within racial / ethnic minority communities. During this time they committed both staff and monetary resources to expand availability of CDSMP and Tomando Control de su Salud across New Jersey. OMMH also supported delivery of the Diabetes Self-Management Program by committing resources to

Both offices committed resources to establish institutional knowledge by training staff and allocating funds ($800,000+) to introduce the programs into their service delivery systems.

two providers to encourage the expansion of this program. An OMMH staff person is overseeing grants targeting minority populations, (25% dedication to CDSME). DoAS also has focused on developing capacity in CDSMP in counties throughout New Jersey, targeting persons age 60+, and/or with a disability and at least one chronic condition. As can be seen in Figure 1, statewide capacity exists for CDSMP, and some regional capacity in the Diabetes Self Management Program and in Tomando Control de Su Salud.

POTENTIAL REACH As can be seen in Figure 1, New Jersey experiences rates of chronic conditions similar to levels reported nationally:

Figure 1

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Heart disease accounted for 29% of deaths in New Jersey, while stroke caused 5% of deaths.

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28% of adults in New Jersey reported having high blood pressure (hypertension) and 39% of those screened reported having high blood cholesterol; 27% reported being diagnosed with arthritis.

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The American Cancer Society estimates that 49,370 new cases of cancer were diagnosed in the state.

Although specific local prevalence rates on chronic conditions are not easily available, the estimate is that 80% of all individuals in New Jersey age 60+, and/or with a disability have at least one chronic condition. Table 1 gives estimates of the numbers of persons who may be reached by CDSMP statewide and in the 10 target counties. These estimates represent the potential target numbers of people in New Jersey likely to benefit from CDSMP.

Table 1. Potential Reach population - New Jersey Population

Persons 60+

Persons with one or more Chronic Conditions (60+)

Persons with Disabilities (60+)

New Jersey

1,666,535

1,333,228

376,112

190,092

152,074

26,000

Burlington County

88,110

70,488

20,893

Cumberland County

28,580

22,864

10,896

129,272

103,418

Not Available

Hudson County

94,166

75,333

27,918

Mercer County

65,637

52,510

16,077

Middlesex County

140,202

112,162

26,431

Ocean County

157,064

125,651

Not Available

Passaic County

85,721

68,577

Not Available

Union County

95,107

76,086

19,892

Bergen County

Essex County

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HEALTH DISPARITIES Disparities in risk, access and health outcomes are being targeted in New Jersey and are a particular focus of The Office of Minority and Multicultural Health (OMMH). Data estimates for health disparities based upon the Behavioral Risk Factor Surveillance System (BRFSS) for New Jersey include: 

African-Americans have higher mortality rates from cardiovascular disease than do whites (Ageadjusted death rates, 2001), and from colorectal cancer although the incidence rates for both groups are similar.

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In 2005, an estimated 24% of adults were diagnosed with hypertension with highest prevalence among Non-Hispanic Black males and females. The age-adjusted stroke mortality rate for blacks is 53% higher than the rate for whites.

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Non-Hispanic blacks had the highest age-adjusted prevalence rate of diabetes at 11.5%, followed by Hispanics at 7.2%, and non-Hispanic whites at 5.3%.

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In 2003, the age-adjusted breast cancer mortality rate was 28.6 for white women and 33.9 for black women per 100,000 of population.

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Incidence rates for invasive cervical cancer are higher for blacks than they are for whites (17.5 versus 9.0 per 100,000 women in 2000) and prostate cancer incidence rates are approximately 50% higher for blacks than for whites. (Center for Health Statistics).

These estimates have encouraged ongoing targeting of health disparate populations in New Jersey with future health disparity outreach efforts focusing on Diabetes through the expansion of the English and Spanish DSMP programs. Other efforts will remain non-disease specific through the delivery of the CDSMP and the Tomando Control de Su Salud. As a result, the State intends to maintain and/or build capacity in its 21 counties partly through the expansion of infrastructure partners i.e. community partners in all counties and also to see specific expansion of delivery in Spanish.

CURRENT FUNDING Over the last several years, NJDHS has shown a long-term commitment to support the CDSMP. This has been affirmed through a recently received Chronic Disease Self Management Education (CDSME) grant from the

Several local partners have had success in securing small grants from various Foundations to support delivery of CDSMP as part of larger program initiatives.

Administration on Aging (AoA). This three year grant contains a commitment of approximately $300,000 to support full and part-time state funded positions associated with the DoAS CREW. 14

In addition, the Office of Minority and Multicultural Health has dedicated a portion of their state funds to CDSMP for the past 5 years. For the period beginning December 2012 this will represent approximately $90,000; however this is not a static amount and will

Over the last several years, NJDHS has shown a longterm commitment to support the CDSMP.

vary annually. In past years, other State agencies/offices have dedicated funds (both state and federal) to CDSMP including the Office of Rural Health and Primary Care, and the Heart and Stroke Program. These funds tend to be one-time funds. Finally, NJ DoAS has paid for the current Statewide Stanford License for the period February 2010 – February 2013, at a cost of $7000.00, or $2333.00 per year. In the past partners have received mini-grants from DHS to support start-up costs. Partners are being encouraged to seek funding sources to sustain the program. Several local partners have had success in securing small grants from various Foundations to support delivery of CDSMP as part of larger program initiatives (for example, the Robert Wood Johnson Foundation NJ Health Initiatives funds for Health Literacy Projects.). Partners are continuing to seek such funds and to also look at possibilities for corporate and health system/insurer supports. Prior funding has allowed many partners to integrate CDSMP and related infrastructure into their ongoing operations with master trainer, peer leader and project coordinator roles being incorporated into larger job responsibilities. This has the advantage of removing the need for funding for these roles but does mean that CDSMP is rarely the sole responsibility for the staff involved. The value of this contributed time, of the time of volunteer peer leaders, and donated space varies among partners. To date books and materials have been largely covered by awarded grants. Some partners have secured other sponsors for these costs, while others charged a minimal participation fee. Very few partners offer stipends to their peer leaders because, although done so by a few partners in the past, it was demonstrated that it was not viable and didn’t result in increased peer leader retention. NJ DoAS plans to work with partners in a variety of ways such as: Accessing Managed Care Organizations funding under the Comprehensive Waiver for Medicaid Long-term Services and Supports; including CDSMP in the developing Care Transitions Models being implemented by local coalitions; revenue sharing with providers of wellness programs like the CDSMP; encouraging Area Agencies on Aging to support these programs with AoA-provided Title IIID funding.

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There are some examples of success: 

In one care transition program a CDSMP partner is working with providers and hospital to reduce frequency of re-admissions for Medicare patients.

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Some pharmaceutical companies have provided short term, low level funding for delivery of CDSMP.

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Work is underway with physicians groups who are using CDSMP and Care Transitions programs to meet the Centers for Medicare and Medicaid Services (CMS) Quality Measures.

DoAS has worked with partners interested in pursuing other grant funds providing a grant template to agencies where there may not be staff able to independently submit a grant.

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Work is underway with physicians groups who are using CDSMP and Care Transitions programs to meet the Centers for Medicare and Medicaid Services (CMS) Quality Measures.

As more inroads are built and successes recorded around the inclusion of the CDSMP, additional State offices/Divisions may become involved including Managed Behavioral Health, Division of Disability Services, Mental Health and Addictions.

SERVICES NJ DoAS and its partners have committed to the delivery of four programs: CDSMP, DSMP (with the addition of the Spanish DSMP), and Tomando Control de su Salud.

MEASURES OF SUCCESS Beyond effectiveness, typical metrics of success for evidence-based programs are expressed in terms of the RE-AIM Framework (www.re-aim.org), which is designed to enhance the impact of public health programs by paying special attention to the five framework elements including REACH (meaning your intended target population; people who will most benefit from improvements in self-management) and ADOPTION (by partners who will most benefit such as health systems, insurers and local agencies who are working with chronic conditions and who are seeking to improve health outcomes, quality of life and costs of care).

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NJ DoAS and its partners have committed to the delivery of four programs: CDSMP, DSMP (with the addition of the Spanish DSMP), and Tomando Control de su Salud.

The state will measure success in REACH in terms of continuing to reach groups currently being served and in reaching new populations including people with disabilities and/or diabetes, Spanish speaking populations, people recently discharged from hospitals, and people receiving Managed Long Term Services and Supports.

COMPETITION CDSMP is usually offered in environments in which there are other evidence-based programs or efforts around health education, which may be seen as programs for competing health concerns and/or competing priorities. The DoAS has made a choice to advance the CDSMP because of its proven outcomes and because it is offered extensively throughout the state. Two things that no other program currently on the market can tout. CDSMP will continue to be the program of choice in New Jersey as long as the federal agencies like the Administration on Aging/Administration for Community Living and the Centers for Disease Control and Prevention continue to focus on and fund the program. CDSMP is being delivered at a time of rapid changes in the health care system in New Jersey (and the country) and to the extent that CDSMP represents an opportunity to better bridge and engage community and health resources and support activation of individuals then it is an attractive offering in this changing health environment.

MARKETING There are already developed materials available through the State and other national partners as well as evidence for their effectiveness. Since 2007, the state has reached over 5800 participants with these programs. The marketing materials used include: 

The DoAS has made a choice to advance the CDSMP because of its proven outcomes and because it is offered extensively throughout the state.

A professional brochure template developed highlighting cultural diversity and geared to senior audiences.

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Videos for television.

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PowerPoint presentations developed for and given by graduates and staff to community and professional groups.

The PowerPoint presentations have appeared to be the most successful marketing tool offering face to face contact, linkages to diverse participant and professional (including physician) audiences and lending

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themselves to start-up publicity, ongoing recruitment and integration with other health related and partner related marketing efforts. Other strategies that have proven effective include: 

Using quotes from program graduates inserted into brochures, as teasers for upcoming workshops, in agency newsletters, and featured on websites;

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Outreach to health disparity communities featuring quotes from local participants;

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Recruiting leaders and other volunteers to do community presentations;

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Having CEO and other provider leaders “sell” the

CDSMP is being delivered at a time of rapid changes in the health care system in New Jersey (and the country) and to the extent that CDSMP represents an opportunity to better bridge and engage community and health resources and support activation of individuals then it is an attractive offering in this changing health environment.

program to physicians and other groups; 

Finding sponsors for individual local classes;

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Use of Eventbrite for registration and Facebook and Twitter for marketing.

A hallmark of these successful strategies is that they are all relatively low cost. The State will continue to play a lead role in offering templates, standards, and maintaining branding. However, the local partners will personalize the materials and target resources to media outlets most relevant for their communities. The State recognizes that there must be great flexibility in allowing its partners the freedom to decide how the programs will be marketed to consumers

The state currently has a workforce of about 200 peer leaders made up of both professionals and volunteers with chronic conditions.

and the target community. The state’s percentage of marketing efforts will vary based upon the particular point in time and the influence of environmental factors at that time, but will include increasing individual referrals, engaging existing or new referral sources, and recruiting from existing partners as well as attracting new funders.

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ADDRESSING MARKETING CHALLENGES There is evidence of success in reaching diverse communities, MCOs, health partners and physicians. However, there is an identified challenge that true engagement with physicians and health partners will likely require greater emphasis on demonstrated outcomes data. To date there has been a reliance on evaluations conducted by Stanford and other published studies but there is feedback that more local outcomes is required. The AoA/Administration for Community Living CDSME grant (commencing September 2012) supports work with four managed care organizations including an evaluation component that promises to yield New Jersey specific cost savings, utilization, and health outcomes data. The Office of Minority and Multicultural Health is also requiring outcome measures (measures to be determined) in the grants they award in the fall 2012 which will add to data available to support marketing efforts. The state will continue to emphasize national CDSMP studies and the program’s well-documented outcomes until state data is available.

Since 2007, the state has reached over 5800 participants with these programs.

OPERATIONAL Local delivery of CDSMP and other CDSMP has relied upon a workforce comprising program coordinators, master trainers, and peer leaders.

CDSMP Program Coordinators Since the initial grant funding to develop local programming, there have been successful efforts to integrate the role of Program Coordinator into the necessary components of program implementation. This has been primarily accomplished by maintaining the Program Coordinator role within an existing staff position. Currently coordinators dedicate 10-50% time to advertising, marketing, recruitment, site selection, making peer leader charts, calling participants who do not attend sessions, making quality checks and attending first or last sessions related to data collection and thanking leaders. Some coordinators are master trainers; others have access to a master trainer to support training and quality checks. Some areas have seen turnover in master trainers and do not have as many resources as they have previously depended on.

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Master Trainers Master trainers can, be but are not always, the program coordinator. Some challenges are being experienced with master trainer turnover including master trainers not being able to maintain certification because there are not sufficient peer leader training opportunities. The state believes that the current complement of master trainers is sufficient to meet all training and quality monitoring requirements if all stay involved in program activities. However, it is recognized that additional strong leaders/volunteers/administrators are needed to take on some roles like regional/area coordination and quality assurance.

Peer Leaders The state currently has a workforce of about 200 peer leaders made up of both professionals and volunteers with chronic conditions. Future expectations of activity level will remain the same at a minimum of one workshop per year. Based upon experience, the ideal mix of peer leaders is 50% people with chronic conditions/50% professionals. This combination works best as participants identify with leaders like themselves and for effective completion of administrative tasks. Moving forward, the DoAS has indicated it will further define the roles and expectations involving its partners who will implement CDSMP. The persons involved in the identified roles may be made up of staff, Master Trainers, and/or volunteers. Should reimbursement models from MCOs, Medicaid Waiver Program, or other sources become available, the funds will be more likely used to support workshops and/or reimbursement/payment of participants and not for the funding of coordinator positions.

QUALITY ASSURANCE Currently, a series of quality assurance tools are available from the DoAS and feedback from program coordinators suggest that they are useful and feasible to use, although without funded program coordinators or sufficient master trainers their use will become difficult to sustain. The state

The state currently has a workforce of about 200 peer leaders made up of both professionals and volunteers with chronic conditions.

has an established fidelity protocol, however, reviewing attendance records and satisfaction reports. There are also differing practices and experience in providing feedback to peer leaders when quality concerns are identified.

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The dedicated staff at DoAS will continue to work closely with local coordinators and quality assurance representatives to offer support and technical assistance on an ongoing basis.

DATA COLLECTION Traditionally, New Jersey has collected the reach and demographic data required by funders including the AoA and the National Council on Aging (NCOA) its technical assistance center, with data entered centrally in the AoA/NCOA database. There have been additional local level data collections including some outcomes tracking. On the one hand there has been a belief that as an approved evidence-based program, there is not a need to collect outcomes data but on the other hand there has been a concern that the outcomes have not been sufficiently demonstrated to secure reimbursement or willingness by NJ health systems and physicians to rely on CDSMP for the needs of their patients. Under the AoA/ACL CDSME grant there is to be engagement with four managed care organizations and in support of these efforts there is to be an evaluation component to yield New Jersey specific cost savings, utilization, and health outcomes data. Work with the Office of Minority and Multicultural Health has specifically targeted health disparity communities and there are concerns here too that relying upon national outcomes data is insufficient. The Office of Minority and Multicultural Health plans to introduce additional data collection for the programs OMMH supports. Work with care transitions programs and with Waiver services will have their own outcomes concerns, for example reductions in re-hospitalizations. Ongoing implementation of health care reforms will likely mean more clarity on valued outcomes and expectations for data to be included in electronic health records particularly if reimbursement is to occur. Changes and/or increases in data collection will pose challenges for local program coordinators. The State plans to continue to collect and manage data related to these programs through its dedicated staff lines and will adjust data collection methods i.e. collect additional data for particular efforts. But, for the majority of partners, only the required data will be collected. As part of their standard state-specific training, all peer leaders and master trainers are trained on the data collection/evaluation needs and updates are provided at annual meetings, in monthly newsletters and in individualized technical assistance. The State will continue to offer these activities on a regular basis.

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Next Steps for New Jersey – Building A Sustainable Program Model Business strategies: Utilizing existing resources from the Department of Human Services and its State partners, additional resources now available from the Administration on Community Living and in order to realize new resources from Care Transitions, Managed Care Organizations and Waiver programs the New Jersey program will: 1. Maintain the commitment of the Department of Human Services and its State partners to support the staff positions currently funded and maintain the roles of these staff in overseeing day-to-day project activities including technical

The success to date of CDSMP in New Jersey has been directly influenced by the State’s commitment of resources.

assistance, quality assurance and communication to agency partners; leading data collection, entry and reporting; and managing fidelity assurance activities. The success to date of CDSMP in New Jersey has been directly influenced by the State’s commitment of resources. Although Federal funds have paid for many activities, the business case for CDSMP is strengthened by this multiyear commitment as there is a resulting statewide infrastructure and leadership. A continuing commitment to the staffing by NJDHS and to the funding of targeted outreach efforts by the Office of Minority and Multicultural Health means both that CDSME delivery is sustainable and that that it will reach those who will most benefit. The involved state agencies have committed to new activities as defined by the Administration on Aging grant. Going forward, this assures that, in addition to the prior CDSMP-specific activities and support of increased infrastructure in selected counties with AoA/ACL funds, the State will engage in: 

Securing approval for Medicare reimbursement for DSMP

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Encouraging AAAs to dedicate Title IIID funds to CDSME delivery

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Working with managed care organizations and care transition programs to make referrals to CDSMP

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Negotiating mechanisms for CDSMP to be funded under waiver services

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Building these ongoing funding mechanisms will require State staff to facilitate linkages between local delivery sites and physician groups and insurers so that reimbursement is possible. There will also be work to identify the regions, populations and the CDSMP programs that may be eligible for reimbursements and allocation of Title IIID monies. Existing programs have lauded

The dedicated staff at DoAS will continue to work closely with local coordinators and quality assurance representatives to offer support and technical assistance on an ongoing basis.

the use of memoranda of understanding and other mechanisms for the above activities to be realized. As the State works toward these realizations, the long-term objectives will be for at least one AAA allocating Title IIID monies, Medicare reimbursement for at least one provider (and for multiple DSMP providers), securing of either care transitions program or managed care organization funding (and for multiple CDSMP providers) and securing of waiver funding . Activities will ensure that providers in all 10 targeted counties will have secured at least one source of reimbursement by the close of the CDSME grant period and that this will also be true for at least 50% of other counties. 2. Build local capacity throughout New Jersey using existing and new partners able to reach 3000 participants over three years. A viable delivery system and infrastructure will attract reimbursement and other resources. A key concern is that there are classes available when desired or when a potential source of reimbursement makes a referral. The desire is that both CDSMP and DSMP will be available in the 10 targeted counties so that interested persons can enroll in a workshop slated to begin,

CDSMP offers important supports and resources to enable people with chronic conditions to manage their own health, a key outcome for those at risk for readmissions to hospital and/or for admission to a nursing home.

rather than be placed on a waiting list until the minimum number of participants needed for a class is reached, and that there will be a similar level of delivery in targeted Spanish-speaking communities. Other counties will eventually

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double existing levels of class delivery and will have secured sufficient resources to continue this level of class offerings. 3. Embed referrals to CDSMP and related programs in the array of services supported in two funded care transitions programs. CDSMP offers important supports and resources to enable people with chronic conditions to manage their own health, a key outcome for those at risk for readmissions to hospital and/or for admission to a nursing home. Critical steps are making those who are providers of care transitions aware of the value of CDSMP, offering CDSMP at times and in places when and where those at risk might enroll, and ensuring that support of such programs is considered in the allocation of resources for care transitions and in self-management education efforts. State staff will work to impress upon state agency decision-makers and care transitions providers the value of CDSMP. Providers of CDSMP will reach out to local care transitions programs to understand how to best develop offerings and embed decisions about CDSMP participation in care transitions planning. State leaders will support the targeting of two care transitions programs to pilot such collaboration and will utilize the resources they are allocating under the CDSMP grant to leverage better collaboration between CDSMP providers and care transitions programs. 4. Working with four managed care organizations in New Jersey, State staff will collaborate with and assist the MCOs so that they will strive to: a) Encourage referrals by their affiliated physicians to the programs, b) Include CDSMP as health promotion options for which members may be reimbursed, c) Establish CDSMP as a worksite wellness option among covered employers. To build towards achieving these goals, State staff will determine what the outcomes and local data that the four managed care organizations need. Both for inclusion of their members and for the reimbursement and identification of CDSME providers willing to meet these requirements.

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State staff, the MCOs and the providers will jointly develop projects and pilot referral and data collection processes. State staff and providers will then explore with the MCOs different reimbursement mechanisms, ways to expand utilization by their members, and the level of delivery needed for CDSMP to be a viable benefit for members. Once CDSMP is established as a member option or benefit, the providers will work with the MCOs to explore with their large employer clients delivery of CDSMP as an onsite wellness option, particularly for caregivers. 5. Include CDSMP among programs that may be funded under the New Jersey Medicaid Waiver to be implemented, including work to ensure that partners meet requirements to qualify for reimbursement. As both the viability of and mechanisms for reimbursement of CDSMP as waiver services become established, State staff will work with CDSME providers to meet requirements to be reimbursed. Populations to be targeted, locations where CDSMP need to be delivered, linkages with other waiver services will all need to be determined and both the State leaders and CDSME partners will work to tailor, outreach, marketing materials and staffing accordingly. 6. Further embed CDSMP in Community Mobilization Initiatives. The community mobilization initiatives led by the Office of Minority and Multicultural Health are important opportunities to target critical chronic illness concerns and to engage a variety of community partners as individuals and communities are assisted in managing these concerns. The skills training offered by CDSMP are important tools and community level engagement with local organizations means that CDSMP may reach the most vulnerable. 7. Link community partners offering the Diabetes Self-Management Program with physicians and health centers and assist these partnerships to qualify for reimbursement from Medicare to support delivery of DSMP for eligible individuals. Reimbursement under Medicare for DSMP delivery is possible but not easily achieved. It

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The skills training offered by CDSMP are important tools and community level engagement with local organizations means that CDSMP may reach the most vulnerable.

required a working and contractual relationship between a provider of DSMP certified by the appropriate body and a physician and/or health provider that is approved Medicare reimbursement and is able to offer the licensed oversight required. A key activity of the State leaders will be to facilitate these collaborations and the pursuit of required certifications and receipt of training in all requirements. This will include developing business models for each partnership that ensure that there will be sufficient participation for reimbursement to actually cover each partner’s costs.

Anticipated Outcomes Through the seven steps of this business plan, over a three-year period a statewide delivery network for CDSMP will be established at a level likely to:

CDSMP will continue to be the program of choice in New Jersey.

a) Attract reimbursements, b) Be integrated into key health related initiatives (e.g., care transitions, MCO, Waiver services and Community Mobilization), c) Expand needed supports for persons with Cardiovascular Disease and Stroke, Asthma, and Diabetes d) Increase access for racial/ethnic groups, particularly Spanish-speaking and for rural as well as urban and suburban communities.

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