Healthy Living (CDSMP) & Arizona Living Well Institute AZ Living Well Institute 10/24/2013 Healthy Living (CDSMP) & Arizona Living Well Institute www.azlwi.org www.azlwi.org

AZ Living Well Institute 10/24/2013 Agenda Background, structure and purpose of Healthy Living Arizona Living Well Institute Opportunities Q & A Arizona Living Well Institute Arizona Living Well Institute www.azlwi.org

Nationwide Evidence-Based Initiative AZ Living Well Institute 10/24/2013 Nationwide Evidence-Based Initiative U.S. Administration on Aging funded Initiative 2006 To transform Aging Services Network to health impacting sites Brings evidence-based programming to community-based organizations Stanford University’s CDSMP is the core program 2010 American Recovery and Reinvestment Act (ARRA) Communities Putting Prevention to Work: Chronic Disease Self- Management Program initiative - $27 million (45 states, District of Columbia and Puerto Rico) 2011 NASMHPD Peer Support Specialist Workforce Development Grant 2012 ACL-AoA 3rd Round of Self-Management Funding 22 States to continue to increase reach of EBP to ethnic minority groups and expand programs available Arizona Living Well Institute www.azlwi.org

Evidence-Based Programs AZ Living Well Institute Evidence-Based Programs 10/24/2013 Promising Practice Best Practice Evidence-Based Model A process of planning, implementing, and evaluating programs adapted from tested models or interventions in order to address health issues at an individual level and at a community level A process of planning, implementing, and evaluating programs adapted from tested models or interventions in order to address health issues in an ecological context. Evidence about the health issue that supports the statement “Something should be done;” Evidence about a tested intervention or model that supports the statement, “This should be done;” Evidence about the design, context and attractiveness of the program that supports the statement, “How this should be done.” An evidence-based program has been demonstrated to be effective in basic research that involved the same target audience Then it has been demonstrated to be effective in dissemination in the “real world.” There are clear protocols for training and conduct of the program so that community programs can maintain fidelity and be successful Evidence for positive health outcomes: Physical activity Sound diet & weight mgt Social connectedness Engagement & productivity Enabling environments Communities for All Ages Healthy Communities for Active Aging Smart Growth Source: Altpeter, M., Schneider, E., Bryant, L. Beattie, B., & Whitelaw, N. (2004). Using the evidence base to promote healthy aging. National Council on the Aging Evidence-based Health Promotion Series, Vol. 1. Washington, DC: National Council on the Aging. Arizona Living Well Institute www.azlwi.org

AZ Living Well Institute 10/24/2013 Healthy Living Healthy Living Stanford University’s CDSMP http://med.stanford.edu/patienteducation/ Arizona Living Well Institute Arizona Living Well Institute www.azlwi.org

AZ Living Well Institute 10/24/2013 Disease Tense Muscles Fatigue Symptom Cycle Shortness of Breath Pain Stress/ Anxiety Referring back to the list of problems generated earlier or the previous slide : 1) Point out that often pain and fatigue seems to be one of the most common problems experienced by people with chronic health problems. 2) As you may already have experienced, one symptom can then lead to a series of other problems, which often creates more symptoms. It becomes a symptom cycle. 3) Let me give you an example of how the symptom cycle works. Arthritis causes you pain because of inflammation or bone rubbing against bone. In response, to protect the hurting joint, you tighten the muscles in that affected area. As these are tightened for a long time, the muscles also begin to cause pain (ask them to make a fist or outstretch their hand and hold for a few minutes: as the time passes, they'll notice that it starts to ache). As your pain mounts, you become stressed and more tense, wondering if the pain will ever get better. You might even cut back on activities. This, in turn, causes weak muscles and emotions such as worry, anger, fear, frustration, and even depression. Stress, difficult emotions and lack of exercise can cause shortness of breath and fatigue, making the pain worse and completing the vicious cycle. 5) This vicious cycle can happen with any health problem, not just arthritis, and the cycle can start anywhere – depression, for example, can start the whole cycle, or fatigue. 6) How many of you have experienced aspects of this cycle (ask for a show of hands)? How many of you believe people can influence this cycle by using certain methods or techniques (ask for a show of hands)? 7) You can break this vicious cycle! There are a variety of ways to do this using physical exercises, mental exercises and more. Depression Difficult Emotions Arizona Living Well Institute Stanford Chronic Disease Self Management, 2006 www.azlwi.org

AZ Living Well Institute 10/24/2013 Workshop Design 6 weekly sessions that meet 1 day per week for 2.5 hours each Introduces tools needed in day-by-day life with chronic conditions Practices using self- management skills Focuses on goal setting Shared experiences, emphasizes mutual support Workshops Available English & Spanish Diabetes & Chronic Pain 2. Is it a support group? - Healthy Living is not a support group, even though participants share experiences, problem solve together, and support each other a great deal. It is facilitated from a set curriculum. Again very interactive in a workshop format rather than a traditional class format. It is a workshop where you learn and try new skills, and increase your ability to manage your health. There even is a wonderful reference book (show the book), that helps reinforce and expand on what is covered in the workshop. It is not, however, a textbook but just one more tool to tap into if you so chose. 3. The question could come up: “What if I have to miss a session because I get sick or have a doctor’s appointment or a planned trip?” These things do come up in daily life especially living with chronic conditions. If you are going to miss, you might suggest letting one of us know or giving us a call. www.wittysparks.com/2007/05/26/15-tips-to-manage-yourself-better/ Arizona Living Well Institute www.azlwi.org

AZ Living Well Institute 10/24/2013 Topics Covered Action Plans Feedback/Problem Solving  Getting a Good Night’s Sleep Managing difficult emotions Falls Prevention Physical Activity/Exercise Nutrition & Food Labels Weight Management Mind-Body Connection Informed Treatment Decisions Working with Health Care Arizona Living Well Institute Arizona Living Well Institute www.azlwi.org

AZ Living Well Institute 10/24/2013 Healthy Living Facilitators T-Trainer - Mentored by Stanford - Train Master Trainers Master Trainers - 4 ½ day training led by 2 T-Trainers - Certified through Stanford after facilitating 2 workshops - Train Leaders – 1 training per year - May facilitate workshops - May assist in fidelity monitoring Lay Leaders - 4 day training led by 2 Master Trainers - Facilitate workshops - Preferably peers with chronic conditions - May be volunteers or staff, usually not health professionals Three level of Facilitators Workshop facilitators are the foundation of Healthy Living CDSMP, and the heart and sould of the program www.azlwi.org

Ideal Abilities of a Leader Possesses good listening skills, is non-judgmental Understands the importance and purpose of fidelity (following the curriculum) Possesses good communication and interpersonal skills Exhibits enthusiasm Is dependable and consistent Comfortable in front of a small group Possesses life experience resulting in empathy to the needs and abilities of older adults. Arizona Living Well Institute

AZ Living Well Institute 10/24/2013 What are the Outcomes? Self-Management NOT Health Education Purpose of self-management is to help people gain self confidence in their ability to: - control their symptoms - control how their health problems affect their lives Health education- inform/increase knowledge, change behaviors Self-management- Helps participant to: manage life with Disease, increase skills/self confidence, problem solve and make decisions Outcomes- Increased physical activity Enhanced partnerships with physicians Improved self-reported general health Improved social/role activities Better psychological well-being Increased energy/reduced fatigue Improved health-status Health status - • Less fatigue • Less disability • Improved role function • 0.8 fewer days in the hospital Self-management - • Increased minutes of exercise • Increased use of cognitive pain and stress management techniques • Improved communication with their physicians • More confidence in their ability to manage their conditions 5 year randomized study, 1000 people Outcomes? For more information on CDSMP outcomes, Review of Findings on Chronic Disease Self-Management Program (CDSMP) Outcomes: Physical, Emotional & Health-Related Quality of Life, Healthcare Utilization and Costs, http://patienteducation.stanford.edu/research/Review_Findings_CDSMP_Outcomes1%208%2008.pdf Arizona Living Well Institute Arizona Living Well Institute www.azlwi.org 11

AZ Living Well Institute 10/24/2013 Outcomes Increased physical activity Improved health-status Improved social/role activities Better psychological well-being Decreased days in hospital Improved self-reported general health Enhanced partnerships with physicians Increased energy/reduced fatigue Reduced health care expenditures For more information on CDSMP outcomes, Review of Findings on Chronic Disease Self-Management Program (CDSMP) Outcomes: Physical, Emotional & Health-Related Quality of Life, Healthcare Utilization and Costs, http://patienteducation.stanford.edu/research/Review_Findings_CDSMP_Outcomes1%208%2008.pdf CDSMP has been extensively evaluated through repeated, randomized controlled trials. A review of major published studies found that CDSMP results in significant, measurable improvements in the health and quality of life of people living with chronic conditions. The program also appears to save enough through reductions in health care expenditures to pay for itself within the first year. Studies have indicated fewer emergency room visits, inpatient stays, and outpatient visits, fewer hospitalizations and a health care cost savings of approximately $590 per participant. Arizona Living Well Institute www.azlwi.org

National Study of CDSMP (2010-2012) AZ Living Well Institute 10/24/2013 National Study of CDSMP (2010-2012) How does CDSMP affect the lives of participants and society as a whole? What are the impacts on: Symptom management and lifestyle behaviors? Better care? Improved health? Reduced health care costs? Study Participants Baseline (n=1,170) 12 month (n=825) Measures Symptom management and lifestyle behaviors Better Care Experience of care Better Health Population health Lower Health Care Cost Symptom management and lifestyle behaviors: Pain, fatigue, shortness of breath, stress, pain, physical activity •Better Care: Communication with MD, medication compliance, health literacy •Better Health: Self-assessed health, depression, quality of life, unhealthy physical/mental days •Lower Health Care Cost: ER visits, Hospitalization 83% Female 65.4 years 55% non-Hispanic White 3.0 Comorbidities 79% Completion Rate Statistically Improved Symptom Management -Fatigue, Pain, SOB, Stress, Sleep Problems Increase in Moderate Activity minutes per week Statistical analyses •Examining change at baseline and 12-month follow-up controlling for key socio-demographics and chronic conditions •Analytical models appropriate to type variables •Findings in terms of percent improvement or adjusted ratios Whitelaw, N., Lorig, K., Smith, M. L., & Ory, M. G. (March 19, 2013). National Study of Chronic Disease Self-Management Programs (CDSMP). Retrieved April 2, 2013, from www.ncoa.org/cha Berwick et al. (2008). The Triple Aim: Care, Health, And Cost. Health Affairs. Arizona Living Well Institute www.azlwi.org

Estimated Cost Savings Related to Reduced ER Visits & Hospitalization AZ Living Well Institute 10/24/2013 Estimated Cost Savings Related to Reduced ER Visits & Hospitalization Preliminary Results: ~$740 per person savings in ER and hospital utilization ~$390 per person net savings after considering program costs at $350 per participant Reaching even 10% of Americans with one or more chronic conditions would save ~$4.2 billion! Calculating Potential Cost Savings Examine the pattern of health care utilization use Identify mean costs from national data (age-adjusted) Estimate costs saved from reduced utilization Estimate program costs in CDSMP Study Deduct program costs for net savings Extrapolate to national savings Consider study limitations Cost Calculation Limitations Using self-reported data There are prior studies indicating good concordance between self-reported and actual documented health care utilization but we acknowledge possible misreporting. Generalizing from aggregate national data instead of exact expenses We employed age-specific estimates but not link specific conditions to reported outcomes. All of our participants were selected based on having a chronic disease We extrapolate to the US population with chronic conditions although participants’ self-reports of chronic conditions are not an exact match to those in national data bases. Arizona Living Well Institute www.azlwi.org

Workshop Types in Arizona English Spanish Healthy Living CDSMP Healthy Living with Diabetes DSMP Healthy Living with Chronic Pain CPSMP Tomando Control de su Salud Spanish CDSMP Programa de Manejo Personal de la Diabetes Spanish DSMP Arizona Living Well Institute

What Else Do I Need to Know? Healthy Living will NOT interfere with other programs - it will complement other programs! Healthy Living is not a support group. Even though participants share experiences and support each other, it is a workshop where you learn and try new skills, and increase your ability to manage your health. To be most effective, it is important for participants to be present and contribute in all sessions. 2. Is it a support group? - Healthy Living is not a support group, even though participants share experiences, problem solve together, and support each other a great deal. It is facilitated from a set curriculum. Again very interactive in a workshop format rather than a traditional class format. It is a workshop where you learn and try new skills, and increase your ability to manage your health. There even is a wonderful reference book (show the book), that helps reinforce and expand on what is covered in the workshop. It is not, however, a textbook but just one more tool to tap into if you so chose. 3. The question could come up: “What if I have to miss a session because I get sick or have a doctor’s appointment or a planned trip?” These things do come up in daily life especially living with chronic conditions. If you are going to miss, you might suggest letting one of us know or giving us a call. Arizona Living Well Institute

Arizona Living Well Institute AZ Living Well Institute 10/24/2013 Arizona Living Well Institute The mission: to advance evidence-based programs for Arizona communities through structured communication, multi-level coordination and systematic coaching. Arizona Living Well Institute www.azlwi.org

AZ Living Well Institute 10/24/2013 Arizona Living Well Institute Empowerment Systems, Inc. AZ Living Well Institute Greater Valley AHEC Community Outreach Health Informatics AZ Coalition for Military Families The AZ Living Well Institute, the Greater Valley AHEC, and the AZ Coalition for Military Families are part of Empowerment Systems, Inc., a nonprofit family of health education and wellness programs.   Funds to launch the Arizona Living Well Institute were made available by grant funds from St. Luke’s Health Initiatives and the Arizona Department of Health Services through a grant from the Administration on Aging. www.azlwi.org Arizona Living Well Institute www.azlwi.org

How AZLWI Provides Support Coordination and leveraging of resources to create greater impact A systematic approach to data collection and management Coordination of training opportunities throughout the state, including coordination of self-management workshops Educate employers, health care providers and community services organizations about the benefits of self-management programs and evidence-based health promotion programs Arizona Living Well Institute Arizona Living Well Institute

Community-Based Referral Network AZ Living Well Institute 10/24/2013 Community-Based Referral Network A comprehensive membership system of evidence-based wellness programs Promoted and integrated with primary and behavioral health outpatient providers of service for those living with or at risk of developing chronic conditions. In order to sustain and expand the impact of self-management programs, AZLWI is further developing, supporting and promoting a structured provider membership system to ensure quality evidence-based wellness services are provided at affordable prices. In order to sustain and expand the impact of self-management programs, AZLWI is further developing, supporting and promoting a structured provider membership system to ensure quality evidence-based wellness services are provided at affordable prices. Arizona Living Well Institute www.azlwi.org

AZ Living Well Institute 10/24/2013 Community-Based Referral Network Community Outreach Navigators Health & Human Service Providers Insurance Providers AHEC Interns Self-Referral Referrals Evidence-based Self-Management Workshops Referral to other needed services (e.g. ASHLine, WIC, etc.) Assistance completing health & human service applications (e.g. AHCCCS) Referral to potential Medical Home Database Management Invoicing & Billing Services Services Response to referral source of services provided to include: Participation in Self-Management Workshop Other completed referrals/services Outcomes Web-Based, Integrated Participant Referral & Tracking System www.azlwi.org

Benefits of Connecting Through AZLWI Strategic Growth Technical Assistance Regional Collaboratives County Coalitions Improved Retention Facilitators Participants Stay up to Date CDSMP Updates Meet & Retreats Refresher Trainings Improved Problem Solving Local Mentors Statewide Webinars Leverage Funding Opportunities Partners supporting Partners System Infrastructure Rather than person centered Creation of infrastructure that was not person centered. Our Mission Coordination Communication Engage Empower Educate Coaching 3 E’s of Communication -Engage with conversation -Empower with knowledge -Education with reliable content Arizona Living Well Institute

AZ Living Well Institute 10/24/2013 Opportunities Arizona Living Well Institute www.azlwi.org

Partnership Opportunities AZ Living Well Institute 10/24/2013 Partnership Opportunities Partnering with CBOs to broaden the array of non-clinical services New models of care delivery provide flexibility for service design and payment to include self-management programs Greater focus on patient motivation and engagement Growing awareness of effectiveness of self-management programs and value of partnering with community resources Lachenmayr, S. National Council on Aging “Patient Self-Management As a Strategy to Reduce Hospital Readmissions”, September 2012. Slides 19-22. Arizona Living Well Institute www.azlwi.org

ACL CDSME Completer Payments AZ Living Well Institute 10/24/2013 ACL CDSME Completer Payments Limited funding associated with the ADHS’ Administration for Community Living CDSME grant Primary goal to increase CDSMP/DSMP workshops to populations disproportionately impacted by chronic disease, specifically Spanish speaking, rural and minority populations. $125 per completer payment. September 1, 2013 and August 31, 2014 A “completer” is defined as a participant that has attended 4 or more of the 6 sessions per workshop. One have one opportunity now for completer payments. The Arizona Department of Health Services/Office of Chronic Disease (ADHS) has limited statewide funding available for Local County Health Departments and community organizations to implement Chronic Disease Self-Management Education (CDSME) programs. These funds are associated with the ADHS’ Administration for Community Living grant with the primary goal to increase CDSMP/DSMP workshops to populations disproportionately impacted by chronic disease, specifically Spanish speaking, rural and minority populations. Arizona Living Well Institute www.azlwi.org

AZ Living Well Institute 10/24/2013 Participant Comments I feel that this class has been of great benefit to me which will stay with me in times of difficulty or when I feel myself slipping back toward depression or isolation from people. I will put forth an extra positive effort to continue the breathing techniques and especially the exercises learned or reinforced in a continued plan to control my painful condition in the best possible way without being dependent upon prescription drugs. Rebecca – Arizona City We had experienced, or learned different parts of this program before, but no part alone was life changing. But with this program structure, I am a different person than I was just six- weeks ago and hope to stay motivated! MDC - Goodyear Arizona Living Well Institute www.azlwi.org

AZ Living Well Institute 10/24/2013 Questions? AZ Living Well Institute info@azlwi.org (480) 982-3118 www.azlwi.org Arizona Living Well Institute www.azlwi.org