Oregon’s Living Well With Chronic Conditions Program

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Submission Date: December 2013

Entry Type: Case Study

State/Territory Submitted on the Behalf of: Oregon

States/Territories Involved: Oregon

Domain Addressed:

Community-Clinical Linkages

Public Health Issue:

  • The Chronic Disease Self-Management Program (CDSMP), developed and tested by Stanford University, is an evidence-based, 6-week, peer-led workshop program that effectively improves health outcomes and reduces disability in people with many chronic conditions, including diabetes.
  • State programs and agencies that address a number of chronic conditions can partner to assure the supply of trained leaders and widespread locations to broaden program reach to those in need.

Project Objectives:

To increase the number of Oregonians participating in Living Well (the Oregon name for the Stanford Chronic Disease Self Management Program) workshops to support management of blood pressure, cholesterol and other chronic conditions.

Partners include:

-Oregon Living Well Network (program delivery partners, including local public health authorities, Area Agencies on Aging, faith- and community-based organizations, health systems, health plans, Oregon Medicaid program and state Unit on Aging)

-Oregon Primary Care Association

-Oregon community health centers

Program Action:

  • Oregon trained its first CDSMP leaders with funding from the Oregon Diabetes Program; support is now continued through the CDC Arthritis and Asthma programs and the Administration on Aging Chronic Disease Self-Management Education grant, and coordinated by the Oregon Health Authority, Public Health Division in partnership with the Oregon Department of Human Services, Aging and People with Disabilities Division.
  • Local communities provide programs through organizational support and staffing, local and federal grants, and hospital and insurer funding. The state acts as a direct partner to implementers, fostering coordination and partnership and funding technical assistance, leader training, annual meetings, and other supports.
  • House Bill 2009 guided the state’s initial health system transformation process and mandated Oregon’s Health Improvement Plan (2011-2020), which included recommendations for reimbursing chronic disease self-management for Medicare recipients, public employees, and people covered by the state’s Medicaid plan.

Data/Other Information Collected:

The 2012 Living Well with Chronic Conditions Data Report (measures are grouped by participant data, workshop data and leader data):



  • Federally Qualified Health Centers in Oregon developed systems to facilitate referral of their patients to Living Well using electronic health record technology, supported by clinical practice protocols for team-based care.
  • CDSMP workshops have been offered in 32 of Oregon’s 36 counties
  • Well over 7,000 people with chronic conditions have participated in 745 workshops over 5 years.
  • In just one year, 64% of workshops conducted were observed for fidelity or led by leaders who had been observed during the previous year. [Program fidelity increases the likelihood of achieving the desirable health outcomes.]
  • To promote sustainability, the state is making an effort to diversify funding sources to include reimbursement through public and private insurers and to embed the program into local health reform, including patient-centered medical home standards.

Challenges/Lessons Learned:

Establishing sustainable funding to support programs long-term is an ongoing high-priority activity

Next Steps:

Developing a Living Well Sustainability Business Plan to continue supporting the implementation of Living Well workshops

Program Areas:

Public Health Practice

State Contact Information:

Laura Chisholm
Oregon Health Authority, Public Health Division

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