Clear Impact logo

NCCHW Chronic Disease Self Management Support Scorecard 2022-2025

This Scorecard reflects the work of the North Carolina Center for Health and Wellness’ (NCCHW) “Empowering Communities to Deliver and Sustain Evidence-Based CDSME” initiative which is funded by the Administration for Community Living for May 1, 2022 - April 30, 2025 and builds on the work of previous CDSME (Chronic Disease Self-Management Education) grants in North Carolina from 2019 to 2023. 

Scorecards are a web-based platform for tracking and communicating the following:

RESULTS—the conditions of health and wellbeing we envision and are collectively working to achieve;

INDICATORS—the measures of population health and wellness we use to track our collective progress towards achieving our results; (*These often focus on differences in conditions and outcomes among groups [disparities], so that improvements show achievement of greater equity.)

STRATEGIES—the overarching sets of activities we undertake to create changes to help achieve our results; and

PERFORMANCE MEASURES—the measures of the quality and impact of our efforts, which we track by asking "how much" we did, "how well" we did it, and whether "anyone is better off?"

Time Period
Current Actual Value
Current Target Value
Next Period Forecast Value
Current Trend
Baseline % Change
Why Is This Important?

America’s Health Rankings’ 2022 Senior Report ranks North Carolina 34th nationwide in a combined assessment of many strengths, challenges and trends. Several of the measures that are used to determine North Carolina’s overall ranking are related to the prevalence of eight chronic conditions across the state and the number of NC older adults with more than one of these conditions. 

According to the North Carolina State Center for Health Statistics, 83.7% of North Carolina adults aged 65+ have at least one chronic condition, and 21.8% have three or more. Among participants who were enrolled in NC CDSME programs from 2019 to 2022, the top three health conditions reported were hypertension, arthritis and high cholesterol, with 46% of participants reporting two or more chronic conditions. 

Chronic conditions are medical conditions that last more than a year, require ongoing medical attention and/or limit daily life activities. Adults with multiple chronic conditions represent one of the highest-need segments of the population, since each chronic condition is likely to require extra medication and monitoring. As the number of chronic conditions an individual has increases, their risk of other poor health outcomes also increases: 

In addition to the increased risk of unnecessary hospitalizations and early death associated with chronic conditions and the impact chronic conditions can have on older adults’ physical and mental health, the economic burden of chronic conditions is also substantial. The Centers for Disease Control and Prevention report that chronic diseases are the leading causes of death and disability and are the leading drivers of the nation’s $4.1 trillion in annual health care costs. America’s Health Rankings also reports that adults who have five or more chronic conditions spend 14 times more on health services compared with adults who have no chronic conditions. It is estimated that 71 cents of every dollar of health care spending goes toward treating people with multiple chronic conditions.

Time Period
Current Actual Value
Current Target Value
Next Period Forecast Value
Current Trend
Baseline % Change
Who We Are

NCCHW is located at the University of North Carolina at Asheville and its statewide resource center for evidence-based health programs, Healthy Aging NC (HANC), supports the state’s older adult health programming network by providing data management, technical assistance, communication, and funding resources. HANC’s dedicated staff improves responsiveness to address ongoing needs that are impacting communities across the state.

What We Do

In 2022, NCCHW was awarded funding from the Administration for Community Living (ACL) that was disbursed to help communities develop or expand their capacity for, deliver, and sustain evidence-based programs (EBPs) for older adults and adults with disabilities, particularly those in underserved geographic areas and populations. Our project has two specific goals:


Evidence-Based Chronic Disease Self-Management Education (CDSME) Programs

The National Council on Aging defines CDSME programs as interactive workshops for people living with one or more chronic physical or mental health conditions. Participants learn skills such as exercise, healthy eating, symptom management, weight loss and communication skills to help them manage their conditions. Each program consists of an in-person or virtual 6-week workshop, held weekly in 2.5 hour sessions taught by two trained facilitators.  Our project focuses on three CDSME programs:

  1. CDSMP – the Chronic Disease Self-Management Program is a workshop for adults with at least one chronic health condition, such as arthritis. It focuses on disease management skills including symptom control, decision making, problem-solving, and action planning.
  2. CPSMP – the Chronic Pain Self-Management Program is a workshop for those living with chronic pain such as arthritis, back pain, neck pain or headaches. Participants learn the skills to manage their pain on a day to day basis and to deal with concerns such as fatigue, sleep problems, difficult emotions, weight loss and communicating with family, friends, and coworkers.
  3. DSMP – the Diabetes Self-Management Program is a workshop to help people with diabetes manage their symptoms, tiredness, pain, and challenging emotions.  

PEARLS - the PEARLS program was developed by the University of Washington and is described as a program that “educates older adults about what depression is (and is not) and helps them develop the skills they need for self-sufficiency and more active lives.” The Centers for Disease Control and Prevention further describe it as a treatment program designed to reduce symptoms of depression and improve quality of life among older adults and among all-age adults with epilepsy. The program consists of six to eight in-home counseling sessions that focus on solving problems, becoming socially and physically active and scheduling enjoyable activities.

Our project also has the following objectives:

  1. Bolster the CDSME & PEARLS provider network
  2. Ensure well-trained program leaders and administration processes
  3. Support the AAA network through the implementation of robust sustainability strategies
  4. Connect agencies invested in EBPs through centralized and regional meetings
  5. Expand partnerships between NCCHW and AAA partners to enhance collaboration and sharing of best practices.

The table below provides more detailed information about our project’s goals for each year of the three-year award period. For each of the four programs (Chronic Disease Self-Management Program [CDSMP], Chronic Pain Self-Management Program [CPSMP], Diabetes Self-Management Program [DSMP] and the Program to Encourage Active, Rewarding Lives [PEARLS]), the first number represents the number of participants we hope to enroll each year and the second number represents the number of participants we hope will complete the program in which they enrolled. (Our goals are based on a 75% completion rate which aligns with the national average. Our PEARLS enrollment and completion goals are based on 2021 data published by the University of Washington Health Promotion Research Center related to the implementation of PEARLS nationally by similar CBOs.) 


Year 1 (25%) Participants/Completers 

Year 2 (50%) Participants/Completers 

Year 3 (100%) Participants/Completers 


















To achieve the project’s goals of (1) expanding access to and utilization of two evidence-based programs (Chronic Disease Self-Management Education [CDSME] and the Program to Encourage Active Rewarding Lives [PEARLS]) and (2) improving mental health outcomes among PEARLS participants, NCCHW is proud to partner with seven Area Agencies on Aging (AAAs) - six of which are sub-recipients of the grant funding - and with the North Carolina Division of Aging and Adult Services and the Health Promotion Research Center (HPRC) at the University of Washington. (PEARLS was developed by the HPRC in partnership with Seattle’s local AAA.)

Centralina and its CDSME Training Academy are an essential partner in this endeavor. Centralina has been offering CDSME programs since 2007 and is among the most successful AAAs in the nation.Their CDSME Training Academy is offering lay leader training during the first year of the project. 

CDSME 2022 Grant Sustainability Partners with Letter of Commitment:

  • HPRC at UW (PEARLS program administrator)
  • Centralina AAA (Region F)
  • Southwestern Commission AAA (Region A)
  • Land of Sky AAA (Region B)
  • High Country AAA (Region D)
  • Western Piedmont AAA (Region E)
  • Upper Coastal Plain AAA (Region L)
  • Triangle J AAA (Region J)

CDSME 2022 Grant Sub-recipients - NC Area Agencies on Aging

  • Southwestern Commission (Region A)
  • Land of Sky (Region B)
  • High Country (Region D)
  • Western Piedmont (Region E)
  • Upper Coastal Plain (Region L)
  • Centralina Training Academy (Region F)

In addition to the specific objectives and activities involving our AAA partners described above, other AAAs in the state’s network will receive support from NCCHW to assist with training, technical assistance, and program evaluation as requested. 

Story Behind the Curve

North Carolina ranks 9th nationwide in the number of adults aged 65 and older. In 2021, there were 1.8 million older adults (65+) living in North Carolina, comprising 17% of the state’s population. That number is expected to increase 50% to 2.7 million by 2041. North Carolina’s oldest adult population (aged 85+) is expected to grow 114% during the same period. Because chronic condition rates (and multiple chronic condition rates) are higher in the older adult population, the state will likely experience significant increases in ED visits, hospitalizations and deaths as a result of these morbidities and its growing older adult population. 

Adding to the challenge of these likely increases in chronic disease prevalence, hospitalizations and deaths, is the urgent challenge of changing public perception about chronic diseases through an increased understanding that these conditions are manageable. This concept is critical to public health efforts to improve feelings of self-efficacy and confidence in the ability to adapt to and self-manage chronic illnesses.

Staff turnover and other organizational priorities in the AAA network cause additional challenges in maintaining the capacity needed to deliver CDSME programs facilitated by trained lay leaders. The expansion of partnerships with other community-based organizations is a strategy to increase the infrastructure needed to reach more older adults and adults with disabilities especially in rural areas of NC.

How We Impact

The North Carolina Center for Health and Wellness (NCCHW) builds capacity, impacts policy and ignites community initiatives statewide. 

Capacity Building: NCCHW maintains an integrated network of CDSME program providers through our Healthy Aging NC (HANC) Resource Center. We build capacity among the AAAs as the regional organizations delivering CDSME programs in NC by removing administrative barriers, and we ignite CDSME initiatives by expanding relationships between agencies across the state. Additionally, we guide AAAs in accreditation by the Association of Diabetes Certified Educators and Specialists (ADCES) and facilitate reimbursement of DSMES programs through Medicare and quality billing as a means to impact policy and ensure sustainability of programming. 

Impacting policy: NCCHW assists AAAs in becoming accredited to offer DSMES as a billable Medicare service, creating non-traditional delivery and sustainability mechanisms for local government agencies. This also opens opportunities for older adults receiving Medicare to have more access to DSMES in an effort to increase uptake of the billable service. NCCHW also creates opportunities for CDSME programs to be reimbursed through value-based care investments, ultimately improving North Carolinians’ self-management skills. 

Igniting community initiatives: NCCHW supports the scaling of CDSME programs in communities that need them by connecting referral systems, offering marketing and registration online via our website, conducting research on program best practices and developing requested toolkits. Through our partner agencies, NCCHW increases self efficacy for individuals which leads to better patient-provider interactions and helps providers understand the value of CDSME programs. NCCHW also contributes to building clinical and community connections across the state. This is done by providing community-based organizations with tools to connect with healthcare partners who could find value in CDSME programs, and providing healthcare partners with information on connecting to community-based organizations delivering valuable CDSME programs.

North Carolina also benefits from a strong network of partners across the state dedicated to improving the lives of North Carolina’s older adults. 

The state’s unit on aging, NC Division of Aging and Adult Services (DAAS), works to promote the independence and enhance the dignity of North Carolina's older adults, persons with disabilities and their families through a community-based system of opportunities, services, benefits and protections. Division staff are an integral part of the efforts to create more access and visibility of chronic disease self-management strategies and evidence-based programs in North Carolina. NCCHW strives to build capacity, impact policy, and ignite community initiatives among the state’s 16 AAAs and local service delivery sites (such as senior centers). In collaboration with DAAS and the state’s AAAs, we make strategic choices and create guidance for the state on how to disseminate and operate evidence-based programs.

The Chronic Disease and Injury Section (CDIS) of North Carolina’s Division of Public Health (DPH), along with local health departments and other partners, works to reduce death and disabilities related to chronic disease and injury. NCCHW collaborates with the Community and Clinical Connections for Prevention and Health (CCCPH) branch (within the Chronic Disease and Injury Section), to find linkages to each other’s work in chronic disease prevention, shared risk and protective factors, promotion of physical activity and healthy eating, and support for brain health and caregiving. 

NC’s State Center for Health Statistics (SCHS) is responsible for data collection, health-related research, production of reports and maintenance of a comprehensive collection of health statistics. NCCHW collaborates with DPH and SCHS to better understand chronic disease burden in the state and uses data to focus and mobilize efforts. 

The NC Association of Area Agencies on Aging’s (NC4A) primary mission is to build capacity and coordinate the activities of the 16 Area Agencies on Aging (AAAs) in North Carolina. AAAs are offices established through the Older Americans Act that facilitate and support programs addressing the needs of older adults in a defined geographic region. In NC, the 16 AAAs are located within regional Councils of Government and all of them directly or indirectly offer health promotion and disease prevention programs. Most AAAs offer Chronic Disease Self-Management Education (CDSME) programs. NCCHW provides technical assistance and expansion support to facilitate program implementation, evaluation, and sustainability. All of these partners are further potential for increasing the visibility of our services and resources.

Who We Serve

This project supports North Carolina’s older adult population through the expansion of chronic disease self management programming, and it also aims to increase the availability of CDSME programming for older adults living in rural areas across the state. Six of the seven regions represented by our AAA partners (Southwestern Commission Region A, Land of Sky Region B, High Country Region D, Western Piedmont Region E, Upper Coastal Plains Region L, and Triangle J Region J) serve a total of 34 counties in North Carolina, 30 of which are designated as rural (defined as <250 people per square mile) by the North Carolina Rural Center

Older adults living in rural areas experience much greater health challenges than their counterparts in urban and suburban areas. America’s Health Rankings provides the following summary of the rural health challenges faced by North Carolina’s older adults:

In nearly all measures, seniors in rural areas experienced greater health challenges than those living in urban and suburban areas. Of the measures examined, excessive drinking is the only measure in which rural seniors fare better than suburban and urban seniors. The disparities in rural health are evident across a wide range of behaviors, clinical care and outcomes measures. Rural health challenges include a higher prevalence of falls, obesity, physical inactivity, and smoking and a lower prevalence of dedicated health care providers, pain management, health screenings, high health status (defined as those who report their health as “excellent” or “very good”) and dental visits. 

A 2017 study titled Dissemination of Chronic Disease Self-Management Education (CDSME) Programs in the United States: Intervention Delivery by Rurality found that, although over half of United States counties were reached by CDSME Program workshops (56.4%), the majority of the workshops (80.4%) were delivered in metro areas and the majority of participants who enrolled (82.1%) lived in metro areas. Specific data on CDSME enrollment across North Carolina is difficult to obtain but 78% of the state’s counties (78 of 100) are considered rural and 40% of its residents (4 million) live in those 78 counties. 

Below are additional graphs that reflect the distribution of CDSME program participants by race and ethnicity and by age and gender. (Data is for all participants from May 1, 2022 through March 7, 2023.)



Additional Measures

The map, bar graph and pie chart below provide additional information about the North Carolina counties where Chronic Disease Self Management Education (CDSME) programs have been implemented and about the number and type of chronic conditions CDSME program participants in North Carolina have.

From May 1, 2022 to present, CDSME programming has been implemented in 14 counties, as shown on the map below:

The pie chart below depicts the percent of CDSME program participants (from May 1, 2022 to March 7, 2023) who have two or more chronic conditions and five or more chronic conditions. 

The bar graph below provides a breakdown of the types of chronic conditions that CDSME program participants (from May 1, 2022 to March 7, 2023) had and the percent of participants who had each.


The EBP Program Participants image below provides an at-a-glance depiction of how many CDSME and PEARLS program participants have enrolled in all four of the programs supported by this grant (blue) versus the number we hope will enroll by the end of the first year of the three-year award (orange).


The EBP Program Completer image below provides an at-a-glance depiction of how many of the program participants who were enrolled in any of the four programs supported by this grant completed the series of classes (blue) versus the number of participants we hope will complete the series by the end of the first year of the three-year award (orange). Our goals are based on a 75% completion rate which aligns with the national average.

EBP workshops are being provided in the statewide network, but data reporting is incomplete at this time due to our transition to the Mon Ami database system.

Clear Impact Suite is an easy-to-use, web-based software platform that helps your staff collaborate with external stakeholders and community partners by utilizing the combination of data collection, performance reporting, and program planning.

Scorecard Container Measure Action Actual Value Target Value Tag S A m/d/yy m/d/yyyy