Comparison of Outcomes between Traditional and Smaller Chronic Disease Self-Management Education Workshops: Rapid Change CycleAssessment within the Valley Program for Aging Services (VPAS) Chronic Disease Self-Management Education(CDSME) Program

Joyce Nussbaum, VPASCDSME Coordinator; Sharon Andreucci, CDSME Coordinator, Virginia Department for Aging and Rehabilitative Services (DARS); and April Holmes, Coordinator of Prevention Programs, DARS

Abstract

This assessment explored the effect on participant outcomes of starting Chronic Disease Self-Management (CDSMP) workshops with six to nine participants. This project was undertaken after VPAS’ experience trying to meet the requirement of having at least ten people present at Session One. Such a requirement is often unrealistic in underserved areas, rural areas, and locations where the program is not well known. When workshops of less than ten people have to be cancelled, those who were present at the first session are left without any workshop to attend. Over a period ofthree months, twelve workshops were held, including six beginning with at least ten participants and six beginning with six to nine participants. There was no statistically significant difference in participant reported outcomes between these groups, participant completer rate was similar, and leader satisfaction with smaller workshop process and outcomes were positive. Offering Chronic Disease Self-Management Education (CDSME) programs to groups of no less than sixcan increase the reach and availability of CDSME without compromising the integrity of the program.

Introduction

Stanford University evidence-based chronic disease self-management programs are proven to be valuable and effective for participants with chronic conditions, their family members, and caregivers. The workshops equip participants with tools to help them manage health conditions and accompanying challenges in an active, positive, and confident manner.One challenge in delivering this program, however, is thatcertain workshop sites are sometimes avoidedbecause it’s difficult to recruit enough participants to start the first session; thus people who would benefit from the workshop are denied the opportunity to learn these skills. This assessment tested the hypothesis that in these situations the consumer and the local program would benefit ifworkshops could be offered to groups with no less thansix participants.

This adjustmentin participant requirements would increase the reach and benefit of CDSME in underserved areas and populations, in areas where the program is not well known, and in cultures wary of health education programs. Additionally, specific workshop sites would no longer be avoided due to recruitment difficulties, and peoplecurrently excluded because of lower Session One attendancecould benefit from the workshop.

In the article “A National Dissemination of an Evidence-Based Self-Management Program: AProcess Evaluation Study;” (Lorig, Hurwicz, Sobel, Hobbs, and Ritter), the authors state that“peer leaders, site coordinators, and regional directors identified that participant recruitment was by far the largest barrier to successful implementation.” Clearly this problem is not limited to one geographic area or program. Given the widespread challenge of recruiting a minimum of ten people, itwas possible that adjusting the number of participants required to startthe first session of the workshop series would benefit both consumers and local programs.

Background

Valley Program for Aging Services (VPAS) has successfully implemented the “You Can! Live Well” Chronic Disease Self-Management Education(CDSME) program for more than three years and currently offers Stanford University’s evidence based Chronic Disease Self-Management Program (CDSMP), Diabetes Self-Management Program (DSMP) and Tomando Control de su Salud. CDSMP and DSMP are offered in five counties and the cities therein, and Tomando Control de su Salud is offered in one city. While the program has been implemented effectively, the requirement that a minimum of ten participants be present at the first session has at times been a hindrance to implementation.

More than 80 leaders have been trained over the past three years; however, trained leaders who are excited about facilitating workshops often become discouraged when workshops are cancelled when less than ten participants are registered. In some areas, a “Session Zero” informational meeting is helpful and the workshop begins the following week. This is not always the case, however. In rural areas and in locations where the program is not well known or isviewed with suspicion, it is often difficult to recruit ten participants who are truly interested in completing the program. Even when a Session Zero leads to a full workshop,often the additional members are not fully interested and do not complete the workshop, leaving the core group of original participants and resulting in a lower completer rate. When ten participants are not available, the smaller group is denied access to the program and it is difficult to gain a commitment from them to attend a workshop in the future. This limits the reach of the program, resulting in fewer workshop completers as well as dissatisfaction with the program for leaders and champions.

Members of groups that have ended with as few asfour or five completersoften express a high level of satisfaction with the CDSME workshop experience. Participants may be more likely to complete the workshop based on an increased sense of importance to the group process. A rapid change cycle project lasting from September to December 2013 was conducted by VPAS to compare workshop completer rates, participant self-reported health benefits, and participant and leader satisfaction between traditional and smaller workshops.

Methods

Twelve workshops were held during a period of three months. The control group attended six workshops beginning with ten or more participants and the test group attended six workshops beginning with between six and nine participants. All the workshop participants were asked to complete a health survey at the first and last workshop session and were given an opportunity to comment on their satisfaction with the workshop at the final session. Leaders completed an evaluation and commented on workshop satisfaction as well.

Results

Participant and Leader satisfaction was comparable in both control and Rapid Change Cycle (RCC) groups. There was no significant difference between the two groups in participants’ satisfaction with leaders or the likelihood that they would use what they learned. Several leaders stated that they preferred the smaller workshop size, and one leader mentioned that there was difficulty with one session during a small workshop when several people were absent. Specific comments from participants and leaders are available on request.

Each participant was asked to complete a self-rated health assessment at the first and last workshop session. See attached Addendum, Virginia RCC Data Analysis, for demographic data and detailed report of pre and post survey results.

Cost Analysis

There are several variables involved in a cost analysis of each workshop. Workshop supplies for each participant can range from as little as $10 to $70 depending on whether books and CDs are given to each participant, if snacks are provided, and the cost of copying and folders or binders. The general cost for consumable suppliesfor this programis about $50 per person.

Fixed costs associated with a workshop regardless of the number of participants include:supplies such as markers, easels, and easel pads for charts; leader training; salarieswith a full-time coordinator offering about 30 workshops per year; stipends if given; and overhead:

Supplies per workshop (easel pads, markers, easel) / $100
Leader Training (300 per Leader/2 workshops each x 2 leaders) / $300
Salaries / $1530
Stipends if given / $200
Other (office expense, copier, phone, training, postage, marketing, travel etc. / $500
Total workshop cost without participant supplies / $2,630
Cost per participant if 10 attend ($2630/10=263+50)
Cost per participant if 6 attend ($2630/6=438+50) / $313
$488

There are additional costs of implementing CDSME that are difficult to measure, but should be considered in a complete cost analysis. These include:

  • cost of marketing for cancelled workshops
  • cost of leaders losing certification due to not having workshops to lead
  • loss of enthusiasm of leaders, champions, and potential participants due to cancelled workshops
  • loss of potential incomein programs funded through grants and paid per completer where getting reimbursement for five completers would be significantly better than receiving nothing when efforts have been invested in workshop planning

Recommendations

Although fully committed to the goal of recruiting the optimal group size of 10-16 to start a workshop, DARS (the program license holder) requests Stanford’s approval for the following, in certain limited circumstances:

Local program coordinators, using factors outlined under the direction of DARS, will determine when the local program and consumer will be best served by a chronic disease self-management workshop that begins with between six and nine participants. These factors include: rural area with sparse populations;new target population orpartner with no previous experience in the program; and cultural groups that may be reluctant to participate in such an activity. Other factors may be considered with prior approval by DARS. This determination is made in advance of the workshop so that leaders know that they are authorized to start when the group size is a minimum of six. Local Coordinators should anticipate possible pitfalls for leaders facilitating smaller workshops and monitor those workshops to ensure that the program is implemented according to the Leaders Manual. Programs will determine cost effectiveness at the regional level as there are significant variables from area to area.Local Coordinators and Master Trainers will monitor program effectiveness of small workshops through fidelity visits and participant and leader satisfaction reports.

While workshop size should be one factor in determining the optimal workshop experience, it should not eliminate consumers who desire an opportunity to attend a workshop where there are fewer than ten interested participants. If this Rapid Change Cycle assessment does not represent a broad enough sample to merit the proposed changes, Valley Program for Aging Services’ Chronic Disease Self-Management Education Program Coordinator requests the opportunity to continue this assessment for twelve months to test the effectiveness of workshops that begin with no fewer than six participants with a larger sample of workshops and participants.

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