managing-chronic-disease-programs

# Managing Chronic Disease Programs

## Why This Skill Exists

Chronic diseases — heart disease, cancer, diabetes, chronic lower respiratory disease, stroke, and Alzheimer's disease — account for 6 of the top 7 causes of death in the United States and drive 90% of the nation's $4.1 trillion in annual healthcare expenditure. CDC's National Center for Chronic Disease Prevention and Health Promotion (NCCDPHP) funds state and local chronic disease programs through cooperative agreements (1305, 1815, 1817) that require evidence-based intervention implementation, BRFSS data collection, and progress toward Healthy People 2030 objectives. The Community Preventive Services Task Force (Community Guide) provides the evidence base for intervention selection. The Chronic Care Model (Wagner) and the CDC 6|18 Initiative provide implementation frameworks. This skill structures the management of comprehensive chronic disease prevention and control programs at the jurisdictional level.

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## Checkpoint A — Intake and Scoping

### Intake Questions

1. Which chronic diseases or risk factors are in scope — cardiovascular disease, diabetes, cancer (which sites?), COPD, obesity, tobacco, physical inactivity, nutrition?
2. What CDC cooperative agreements fund the program (1305 State and Local Public Health Actions, 1815 Tobacco Control, 1817 Cancer Prevention)?
3. What are the program's required activities and performance measures per the cooperative agreement?
4. What population-level data sources are available — BRFSS, YRBSS, vital records, state cancer registry, hospital discharge/ED data, Medicaid claims?
5. What evidence-based interventions are currently implemented?
6. What clinical-community linkage partnerships exist (health systems, FQHCs, pharmacies, community organizations)?
7. What is the program's relationship with the state/local tobacco quitline?
8. What health equity focus areas have been defined for chronic disease programming?

### Required Documents

- CDC cooperative agreement notice of funding opportunity (NOFO) and program requirements
- Current work plan and annual performance report
- BRFSS prevalence estimates for key chronic disease indicators
- State cancer registry incidence and mortality data
- Vital records data: leading causes of death, premature mortality
- Community Guide recommendations for selected interventions
- Chronic Disease State and Local Public Health Actions logic model
- Healthy People 2030 chronic disease objectives and current progress

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## Step 1 — Assess Chronic Disease Burden

Compile the chronic disease epidemiologic profile for the jurisdiction:

- **Mortality**: Age-adjusted death rates for heart disease, cancer (all sites and site-specific), stroke, COPD, diabetes, and Alzheimer's. Calculate YPLL (years of potential life lost before age 75). Source: NCHS/state vital records.
- **Morbidity/Prevalence**: Self-reported prevalence of diagnosed diabetes, hypertension, high cholesterol, asthma, COPD, obesity (BMI ≥ 30), and cancer survivorship. Source: BRFSS.
- **Risk factor prevalence**: Current smoking, e-cigarette use, binge drinking, physical inactivity (no leisure-time activity), fruit/vegetable consumption (< 5 servings/day), obesity. Source: BRFSS, YRBSS for youth.
- **Healthcare utilization**: Preventable hospitalization rates (AHRQ PQI composites for diabetes, COPD, heart failure, hypertension), ED visit rates for chronic disease exacerbations. Source: state hospital discharge data.
- **Screening rates**: Colorectal cancer screening (adults 45-75), breast cancer screening (women 50-74), cervical cancer screening (women 21-65), blood pressure screening, diabetes screening (adults with BMI ≥ 25). Source: BRFSS.
- **Disparities**: Stratify all indicators by race/ethnicity, income, education, geography (urban/rural), and insurance status. Identify populations with the highest burden and lowest service access.

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## Step 2 — Select Evidence-Based Interventions

Match interventions to the jurisdiction's burden profile using the Community Guide and CDC program frameworks:

**Tobacco cessation and prevention**:
- State tobacco quitline with evidence-based counseling and NRT (Community Guide: recommended)
- Smoke-free policies (workplaces, restaurants, bars, multi-unit housing) (Community Guide: recommended)
- Tobacco tax increases (Community Guide: recommended)
- Youth prevention: counter-marketing (Truth campaign model), retail licensure, tobacco 21 laws
- Health systems interventions: Ask-Advise-Refer clinical protocols, EHR-embedded tobacco screening

**Nutrition and physical activity**:
- Community-wide campaigns for physical activity (Community Guide: recommended)
- Built environment strategies: complete streets, bike/pedestrian infrastructure, park improvements
- Food environment strategies: healthy food procurement policies, food prescription programs, healthy corner store initiatives
- Diabetes Prevention Program (DPP) — CDC-recognized lifestyle change program for prediabetes
- Workplace wellness programs with evidence-based components

**Chronic disease management and clinical-community linkages**:
- Self-measured blood pressure monitoring with clinical support (Community Guide: recommended)
- Team-based care for hypertension control (Community Guide: recommended)
- Community health worker programs for diabetes management and CVD risk reduction
- Chronic Disease Self-Management Program (CDSMP) — Stanford model
- Pharmacist-led medication therapy management for uncontrolled hypertension or diabetes

**Cancer screening**:
- Patient navigation to increase colorectal, breast, and cervical cancer screening (Community Guide: recommended)
- Client reminders for cancer screening (Community Guide: recommended)
- Reducing out-of-pocket costs for screening (Community Guide: recommended)
- HPV vaccination promotion for cancer prevention (see skill: managing-vaccination-campaigns)

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## Step 3 — Implement Through Clinical-Community Linkages

Chronic disease programs achieve population impact through partnerships:

- **Health systems**: Establish data-sharing agreements with health systems and FQHCs to identify uncontrolled patients and link to community resources. Use EHR registries for population health management.
- **Community-based organizations**: Contract with CBOs for delivery of evidence-based programs (DPP, CDSMP, tobacco cessation classes, physical activity programs) in accessible community settings.
- **Pharmacies**: Partner with pharmacies for blood pressure screening, medication therapy management, and vaccination.
- **Employers**: Implement worksite wellness policies (healthy food options, physical activity breaks, tobacco-free campus, lactation support).
- **Schools**: Implement comprehensive school physical activity programs (CSPAP), school nutrition standards, and youth tobacco prevention curricula.
- **Built environment**: Advocate for and support built environment changes through cross-sector partnerships (transportation, planning, parks) that increase physical activity and food access.

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## Step 4 — Monitor Program Performance and Outcomes

Track a tiered metrics framework:

- **Process metrics** (quarterly): Number of participants enrolled in evidence-based programs, number of health systems implementing team-based care, quitline call volume and enrollment, DPP enrollment and session attendance.
- **Short-term outcomes** (annually): Quit attempts among tobacco users, DPP participants achieving 5% weight loss, hypertension patients with BP < 140/90 in partner health systems, cancer screening rate in target populations.
- **Population outcomes** (3-5 year trends): BRFSS smoking prevalence, obesity prevalence, diagnosed diabetes prevalence, age-adjusted mortality rates for target conditions, screening rates at population level.
- **Equity metrics**: Stratify all metrics by race/ethnicity, geography, and income. Calculate disparity ratios and track narrowing/widening over time.

Report to CDC per cooperative agreement requirements (annual progress reports, BRFSS data submissions, performance measure updates).

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## Step 5 — Sustain and Improve Through Policy and Systems Change

The most durable chronic disease interventions are policy, systems, and environmental (PSE) changes:

- **Policy**: Smoke-free air laws, tobacco taxes, menu labeling, sugar-sweetened beverage taxes, Complete Streets ordinances, zoning for healthy food retail.
- **Systems**: EHR clinical decision support for screening and referral, bidirectional referral systems between clinical and community settings, insurance coverage for evidence-based prevention programs (DPP, tobacco cessation).
- **Environmental**: Park and trail development, safe routes to school, healthy food access in food deserts (farmers markets, mobile food markets, healthy corner stores), removal of tobacco retail near schools.

Document PSE changes achieved with implementation date, geographic coverage, and estimated population reach. PSE changes are the primary mechanism for sustaining health impact beyond grant-funded programs.

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## Checkpoint B — Program Review

- [ ] Chronic disease burden profile current with all key indicators
- [ ] Evidence-based interventions selected with Community Guide citations
- [ ] Clinical-community linkages established with documented partnerships
- [ ] Process metrics tracked quarterly and reported to program leadership
- [ ] Population outcome trends monitored using BRFSS and vital records
- [ ] Equity metrics reported with disparity ratios for all target conditions
- [ ] PSE changes documented with reach and implementation dates
- [ ] Annual CDC cooperative agreement report submitted on time

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## Quality Audit

- [ ] BRFSS data used for population prevalence is from the most recent available year with survey methodology notes
- [ ] Cancer screening rates use age-appropriate, guideline-concordant definitions (USPSTF or ACS)
- [ ] DPP delivery sites are CDC-recognized (not self-designated)
- [ ] Tobacco quitline follows NAQC standards for evidence-based counseling
- [ ] Team-based care interventions include pharmacists, nurses, or CHWs — not just physician education
- [ ] Community Guide "recommended" interventions are prioritized over "insufficient evidence" approaches
- [ ] 6|18 Initiative high-burden conditions addressed where applicable (tobacco, blood pressure, diabetes, asthma, unintended pregnancy, healthcare-associated infections)
- [ ] Health equity plan specifically addresses chronic disease disparities with targeted strategies (not just universal programs)

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## Guidelines

- Chronic disease prevention is a long game. Population-level indicators move slowly. Do not abandon evidence-based strategies because annual BRFSS data shows no change — behavior change and mortality reduction require sustained multi-year investment.
- Clinical interventions alone cannot solve the chronic disease crisis. Without addressing tobacco marketing, food environment, built environment, and health literacy, clinical gains will be overwhelmed by upstream forces.
- The Community Guide is the evidence standard for chronic disease prevention. Interventions without Community Guide support can be implemented but should be evaluated rigorously and not displace resources from recommended interventions.
- The CDC 6|18 Initiative identifies interventions where health systems and public health alignment can achieve the greatest impact. Use 6|18 as a prioritization tool when resources are constrained.
- Medicaid is the single largest insurer of low-income adults with chronic diseases. Every chronic disease program should have a Medicaid engagement strategy — whether for reimbursement of DPP, coverage of tobacco cessation, or data-sharing for population health management.
- Health equity requires targeted universalism: universal goals (reduce diabetes prevalence) with targeted strategies (DPP in highest-burden zip codes, culturally adapted programming, transportation and childcare supports for participation).
- Escalate to program director or health officer when: BRFSS data shows a reversal in a key indicator (e.g., smoking prevalence increasing), a partner health system disengages from a clinical-community linkage, or cooperative agreement funding is threatened.