CHAPTER 5: IMPLEMENTATION OF CDSMP
5.2 Program Oversight and Administration
State grantees oversee CDSMP implementation and administration using a variety of organizational strategies and structures to ensure efficient and effective program delivery and
14 The analyses of organizational structure and program management and administration presented in this chapter
represent the best judgment of the evaluation team. Because of data limitations and the subjective nature of classifying state programs, category assignments could not always be made with full confidence.
fidelity to the Stanford model. These activities can be wide-ranging and may include marketing and recruitment, training and supervising workshop leaders, monitoring fidelity, and collecting and analyzing program data. Departments of aging and departments of public health were eligible to serve as lead agencies; 31 grantees selected departments of aging as the lead and 16 chose departments of public health. Infrastructure for program oversight and administration are often influenced by historical patterns of funding and service delivery. Many ARRA grantees had already been delivering CDSMP for a number of years (see Exhibit 5.2) and were able to use ARRA funds to build upon and expand legacy systems for program delivery. In other cases, grantees were using 2010 ARRA funding to build CDSMP delivery systems for the very first time, which was the case for 9 states.
Exhibit 5.2. Number of States and Year of First Federal Funding to Deliver CDSMP, 2001-2010
Source: IMPAQ International and Altarum Institute
Of the 47 grantees, 14 used centralized models for program oversight and administration, 23 used decentralized models, and 10 had delivery systems in which responsibility was shared at the state and regional/local level (Exhibit 5.3). Grantees’ approaches to program oversight and administration reflected a variety of factors, including the organization and historical roles of state health and human services departments, the prominence of the state unit on aging (e.g., whether it is a separate agency with a cabinet-level secretary or an agency within the department of health and human services), the role and strength of regional/local agencies in the state (e.g., AAAs, ADRCs, private organizations, collaboratives), and existing infrastructure for the delivery of evidence-based health promotion programs.
Exhibit 5.3. Program Oversight and Administration
Source: IMPAQ International and Altarum Institute
The evaluation team examined the various oversight models, comparing and contrasting their performance. No clear patterns were identified. Variations were considerable and reflected the unique socio-political, geographic, and historical context of each state. However, specific benefits appear to be associated with each approach. Centralized approaches offer advantages such as standardization of training and delivery, leverage for data collection, and certain economies of scale. Decentralized approaches can be more responsive to local conditions and resource availability. Shared approaches are able to offer some benefits of both centralized and decentralized models.
5.2.1 Centralized CDSMP Oversight and Administration
Among the 14 states with centralized CDSMP oversight, 5 reported program oversight and administration provided by state departments of aging, 4 used departments of public health, and 5 used shared models. Some examples of centralized models are:
New Jersey: CDSMP is overseen by the New Jersey Department of Aging, which actively oversees and manages the program across the state. Prospective partners compete in a competitive application process with selected partners receiving one of multiple categories of grants. The Department of Aging has established quality assurance protocols for fidelity monitoring and developed their own instruments/checklists based on national documents tailored to New Jersey’s program. For example, the peer leader instrument lists the major skill areas and operational guidelines (e.g., use of posters, room set up) and has a check list for each class that includes the elements the leader is to address in that session. The Department of Aging also actively trains and monitors trainers and leaders.
Nebraska: Nebraska’s Department of Health and Human Services oversees policy, fidelity monitoring, master trainer and lay leader training, and partnership development. The department has implemented memoranda of understanding (MOUs) with six of the eight AAAs in the state (two dropped out due to reported over-burden and difficulties developing partnerships). They are now seeking to embed the program within the public health network and Federally Qualified Health Centers (FQHCs).
New York: The State University of New York (SUNY) at Albany has state-wide oversight and responsibility for the CDSMP program. The New York grantee distributes funds to SUNY Albany, which allocates those resources amongst the host sites. SUNY Albany develops MOUs with leaders/trainers, oversees and coordinates training, develops program policies, and monitors quality assurance for the state. Of the 14 states using centralized oversight, seven contracted with private or non- governmental entities provided program oversight. West Virginia and New York (see above) delegated responsibility and direct oversight of CDSMP to universities (Marshall University and SUNY, Albany, respectively) and California15 designated Partners in Care as their state-wide technical assistance provider. Statewide Area Health Education Centers (AHECs) provide CDSMP oversight in New Hampshire and Colorado. The Arizona Living Well Institute, a public-private partnership established to advance evidence-based programs throughout the state, and Wisconsin’s Institute for Healthy Aging, formed to advance the spread of evidence-based programs that encourage and support healthy living among older adults, oversee CDSMP in their respective states. All funds and direct project oversight were passed from the state grantees to these non-governmental entities to oversee funding distribution, training, data collection and entry, and fidelity policy and monitoring.
5.2.2 Decentralized CDSMP Oversight and Administration
Twenty-three states adopted a decentralized model for oversight in which host or delivery sites were delegated the majority of responsibility regarding funding, training, fidelity monitoring, and data collection. In these states, program oversight and administration was either regional or local (generally county or metropolitan-area), contributing to considerable within-state variation in program delivery and oversight in some cases. Additionally, decentralized delivery systems largely utilized the AAAs as regional CDSMP oversight entities; sixteen of the 23 states with decentralized models of program oversight used AAAs in a regional oversight capacity. No grantees solely used local health departments in this role, although five states used a mix of AAAs and local health departments.
Examples of decentralized models are:
Minnesota: All six AAAs within the state offer CDSMP. The AAAs are responsible for all elements of program operations, including training, materials purchase, quality assurance, and licensing.
Kentucky: CDSMP oversight occurs within each partner site, largely AAAs. There is
little coordination between the AAAs on program operations or delivery. Fidelity monitoring is conducted by the AAAs and varies by region.
Vermont: CDSMP is offered through AAAs, which are anchored in Health Service
Areas (HSAs) within the state as part of Vermont's comprehensive Blueprint for Health. HSAs receive community health funding from the state legislature that local stakeholder coalitions direct to develop and integrate comprehensive population health plans within each HSA. The AAAs, as part of this plan, develop a local work plan describing the strategy for resource use which is reviewed and approved by the HSA community coalition. CDSMP funding is passed from the state grantee to each HSA for distribution. Regional coordinators manage the program within each HSA.
Two states—Vermont and Nevada—used non‐governmental private organizations, specifically health systems, to provide oversight of CDSMP at all host sites. In Vermont, CDSMP is a core component of the state’s Blueprint for Health, a community‐based approach to health care reform that uses a chronic care model centered around hospitals and community health coalitions. Nevada uses local hospitals as host sites, with University of Nevada‐Reno’s Sanford Center for Aging providing fidelity monitoring. Respondents from states using decentralized oversight reported intra‐state variation in fidelity standards, monitoring, training, and sustainability efforts. In these settings, partner recruitment and sustainability were generally seen as host site responsibilities. Often, host sites had a full‐time coordinator on staff with responsibility for CDSMP program oversight.
5.2.3 Shared CDSMP Oversight and Administration
In this model, oversight responsibilities are shared by the state grantee and regional host sites. The ten grantees that used this model generally operated in a collaborative fashion to develop and craft program policy on delivery, training, fidelity standards and monitoring, and data collection. Additionally, these grantees used collaborative approaches to promoting sustainability, involving multiple stakeholders at the state, regional and local, or host site levels. Shared responsibility grantees exhibited consistency in fidelity standards, monitoring, training, and sustainability efforts. A typical arrangement was for host sites to have a part‐time coordinator responsible for program oversight while the state grantee maintained a full‐time program manager. Examples of shared delivery models are:
Hawaii: In a hybrid arrangement, Hawaii’s state grantee, the Executive Office on
Aging, and Island AAAs work collaboratively to manage the CDSMP program through a Healthy Aging partnership. The state distributes funding to local public health partnerships and establishes memoranda of agreement (MOAs) with leaders who oversee and participate in quality assurance. The University of Hawaii leads evaluation, fidelity monitoring (using Stanford’s 10‐item checklist), and partnership efforts. Island AAAs have established steering committees in coordination with different partners at each location to oversee and assist with CDSMP management on each Island.
Maine: To assist with CDSMP oversight, this state grantee has established a coordinating council consisting of representatives from partners, host/delivery sites, and state agencies. Established in 2004 as the Healthy Aging Advisory Committee for all evidence-based programs, the coordinating council now includes representatives of state offices on Aging and Disability and Quality Improvement, health systems, and AAAs, and includes three subcommittees: evaluation, marketing, and quality improvement/fidelity. The state grantee assists with licenses and training while the AAAs and other partners oversee much of day-to-day program operations. Maine is moving toward decentralization.