Seen as a critical part of primary care for the past 20 years (1, 2), disease self-management programs have been associated with a plethora of positive health outcomes among middle-aged and older adults in the United States (3). While the healthcare system is increasingly expected to provide chronic care (1), chronic disease self-management initiatives outside of the physician’s office are now widely recognized as an effective complement to improve health indicators and quality of life while reducing overall health-related complications and associated costs (4). One of the most extensively tested programs, the Stanford Chronic Disease Self-Management Program (CDSMP), is a 6-week program (5) that has strong evidence demonstrating its ability to improve participants’ health status, modify their health behaviors, and reduce their healthcare utilization and associated costs (6–9). The interactive workshop sessions are designed to enhance three types of skills necessary for the everyday management of chronic conditions: medical management, emotional management, and social role management (6). While CDSMP remains the flagship program, Stanford has translated it to be delivered online, in multiple languages, and for specific diseases/conditions (e.g., diabetes, arthritis, chronic pain, HIV) (5). This collection of interventions (including CDSMP) comprises the suite of Chronic Disease Self-Management Education (CDSME) programs.

Building on a nascent evidence-based prevention initiative supported by the U.S. Administration on Aging (AoA) beginning in 2003 (10), funding was provided as part of the American Recovery and Reinvestment Act of 2009 (ARRA) to disseminate CDSME programs in 45 states, Puerto Rico, and the District of Columbia between 2010 and 2012 (11). Given the solid evidence base behind CDSMP, this jointly administered initiative of the AoA, the Centers for Disease Control and Prevention (CDC), and the Centers for Medicare and Medicaid Services (CMS) sought to bring these evidence-based programs to scale for the important goal of addressing the rapidly rising number of older adults struggling to manage their chronic conditions. The national goal of this ARRA-funded initiative was to reach at least 50,000 program completers (i.e., attend four or more of the six workshops sessions). Each participating state and entity was assigned a target goal for program completers based on the size of its population of older Americans. There was an expectation that certain delivery site types would be utilized (e.g., senior centers, healthcare organizations, residential facilities, educational institutions, faith-based organizations, and tribal centers), and special emphasis was placed on recruiting and enrolling racial/minority and other underserved populations.

The goal of having over 50,000 adults complete CDSME program workshops was accomplished within the first 24 months of this initiative across more than 1,000 United States counties (12). This accomplishment demonstrates the feasibility of a coordinated effort with the aging services network, the public health, and healthcare sectors. This study examined participant accrual of the first 100,000 participants enrolled in this national CDSME program roll out in four blocks (i.e., each representing 25,000 participants). Using this frame of progressing accrual blocks, the purposes of this study were to: (1) examine the geographic distribution of participation in this initiative across the Unites States; (2) describe workshop characteristics engaged to reach program participants in various settings; and (3) describe personal characteristics of the first 100,000 participants. Each subsequent entering cohort was descriptively examined to indicate whether there was constancy or change in delivery sites and populations reached over time.

Self-management education has been recognized as a critical factor in empowering adults to improve their health and functioning (3). This study provides valuable dissemination and implementation insights into the nature and progression of the largest ever national roll out of CDSME programs (i.e., highly effective evidence-based programs designed to help middle-aged and older adults more effectively manage their chronic conditions). The aging services sector, in partnership with other healthcare, public health, community, and faith-based organizations, proved to be a coordinated, efficient, and diverse delivery system capable of rapidly reaching large numbers of older adults across the country. Exceeding programmatic goals of having 50,000 participants complete CDSME program workshops (12), over 100,000 participants were reached more quickly than in previous efforts (16). Further, with the exception of a predominant female participant population typically served with health promotion programs (16–18), participants were representative of the U.S. population and not just easy-to-reach subgroups.

The ability of this initiative to quickly reach 100,000 participants can be attributed to many factors. First, having each state set ambitious yet feasible and attainable goals (19) can help stimulate them to think differently about program planning, participant recruitment, and partnership development. Second, the stimulus money utilized in this initiative was essential for reaching this recruitment goal, but it was also leveraged by funds from other organizations with some non-traditional partners (e.g., healthcare partners), which fostered growth by adopting and promoting CDSME programs as an integral care practice. Third, capitalizing on the existing program delivery infrastructure established by previous AoA initiatives, the broad network of delivery and funding partners has resulted in widespread financing of CDSME programs by other government organizations. Fourth, workshops were available in many local communities largely because of the cooperation of the program developers to utilize and expand their training infrastructure (5). As seen in this initiative, the culmination of leveraging opportunities led to the rapid dissemination of CDSME programs by creating a highly collaborative community structure that accelerated the speed of scalability across the country to meet the needs of an increasingly diverse group of participants.

Past reports have shown CDSME programs have capacity to serve large numbers of heterogeneous adults via a growing network of delivery sites (8, 12, 20, 21). Success can be attributed, in part, to a community-driven delivery system that employed existing networks for recruiting participants of varied ages, race/ethnicity; disease status; geographic region; and socio-economic status (22). However, additional efforts are needed to help CDSME programs gain major penetration among the over 35 million older Americans estimated to have at least one chronic condition (23). As such, this study suggests several actions that can help make the dissemination of CDSME programs part of routine care.

First, we must further examine and strengthen referral systems to CDSME programs and the interconnectedness of the healthcare, public health, and aging services networks. Multi-institute funding initiatives that highly encourage/mandate multi-sectorial partnerships can set the stage for bridging such connections (11). Second, we need to embrace the paradigm shift in provider-patient communications that emphasizes the value of “informed and activated” patients working collaboratively with their prepared practice team (1). This theme, initially articulated in Wagner’s chronic care model, is being revisited with the recent movement toward patient-centered care (24). Third, we need to be aware of the constraints facing today’s healthcare providers in terms of shortened office visits and greater expectations for administrative paperwork (25). Thus, we recommend easy-to-employ methods and mechanisms (e.g., automated systems) to help health care providers know where evidence-based programs like CDSMP are offered. Also, guidelines are needed for identifying the types of patients who are best suited for specific programs (e.g., information about the pros and cons of generic self-care programs versus disease-specific programs). While clinicians and other allied health providers should be trained about these guidelines and referral processes, it is also important that program participants report back to their healthcare providers about their experiences and progress in such programs. Fourth, we must recognize that programmatic scalability needs to be paired with plans for achieving sustainability over time. Thus, we recommend that national, state, and local roll outs of evidence-based programs include sustainability planning as a core element. Successful sustainability plans are those that build upon and leverage existing resources, often employing champions for recognizing and promoting new models of care (26).

There are study limitations that must be acknowledged. While this national effort afforded large numbers of participants, specific data points were limited due to community concerns regarding burden. Additionally some data was missing due to local/regional constraints, and not necessarily individual refusal. Study data represented a “snapshot” of an ongoing evolving evaluation process at a particular time point. Underserved populations (e.g., African Americans) were overrepresented in this study because of the focus of the larger initiative to serve this subgroup of Americans. However, males were underrepresented in this study, as they traditionally are in evidence-based programs delivered through the aging services network (16–18). Despite these limitations inherent when using administrative records, we nevertheless believe this study represents a unique examination about how a national evidence-based dissemination rolls out over time, what infrastructure facilitates this type of grand-scale roll out, and what types of participants are reached.

Findings from this study capture the spread of CDSME programs during a national, government-funded roll out and show the ability of this intervention to rapidly reach a diverse set of participants using a well-coordinated delivery system. As of August 2014, over 196,700 participants reached by CDSME programs through 17,500 workshops in 1,200 counties across the United States. While this initiative capitalized and built upon previous efforts to create a delivery infrastructure for CDSME programs, this grand-scale dissemination has solidified the presence of CDSME programs with great potential for long-term sustainability. While this initiative has achieved impressive participant reach and completion, it should be noted that many other organizations throughout the United States offered the intervention despite not receiving this ARRA funding. Because data from these organizations are not represented in the databased used in the current study, these findings are even more encouraging in that they underrepresent the actual translation of CDSME programs nationwide. Continued efforts are needed to track the progression and proliferation of this suite of programs to empower patients with self-management skills to deal with their chronic conditions.

The authors declare that the research was conducted in the absence of any commercial or financial relationships that could be construed as a potential conflict of interest.

This paper is included in the Research Topic, “Evidence-Based Programming for Older Adults.” This Research Topic received partial funding from multiple government and private organizations/agencies; however, the views, findings, and conclusions in these articles are those of the authors and do not necessarily represent the official position of these organizations/agencies. All papers published in the Research Topic received peer review from members of the Frontiers in Public Health (Public Health Education and Promotion section) panel of Review Editors. Because this Research Topic represents work closely associated with a nationwide evidence-based movement in the US, many of the authors and/or Review Editors may have worked together previously in some fashion. Review Editors were purposively selected based on their expertise with evaluation and/or evidence-based programming for older adults. Review Editors were independent of named authors on any given article published in this volume.