Sustainability Case Study: Don Smith

Case study: Using a collaborative model to successfully launch and sustain evidence-based programs


Don Smith is the Director of the Area Agency on Aging and Vice President of Community Development at United Way of Tarrant County, with a primary office located in Fort Worth, Texas. While our initial target population was older adults with diabetes or dementia and their caregivers, two years ago we expanded to include adults 35+ with multiple chronic conditions. We made this change due to data that showed earlier onset of diabetes and other chronic diseases and the increased risks of hospitalization and nursing home placement for those with multiple chronic diseases.

EBPs Currently Offered

The United Way and Area Agency on Aging of Tarrant County began offering the following programs in 2009 or earlier:

  • Stanford Chronic Disease Self Management Program (both English and Spanish)
  • Stanford Diabetes Self Management Program (both English and Spanish)
  • A Matter of Balance
  • Resources for Enhancing Alzheimer’s Caregiver Health II (REACH II)
  • Diabetes Salud! (clinic based intervention developed by Baylor Healthcare System)

Since 2009, several other programs have been added or are under development:

  • HomeMeds Medication Management
  • Care Transitions Intervention (Coleman Model)
  • Stressbusting for Caregivers

  We have also developed two national award winning evidence-informed initiatives:

  • In Home Diabetes and Nutrition Counseling (administered by dieticians and diabetes educators using evidence based tools)
  • Community Heath Navigation (uses promotora model and Patient Activation Measure coaching).
  • We also provide Respite Care to Alzheimer’s caregivers whose loved ones with moderate Alzheimer’s disease are at a high risk for nursing home placement. Since 2008, over 80% have remained in the community after six months.

During 2006-2008 we also implemented Healthy IDEAS, but were unable to serve a high enough volume of consumers to justify continuation.

Steps Taken to Ensure Long-Term Sustainability

The Area Agency on Aging (AAA) provided start-up funding for the majority of these programs, but United Way of Tarrant County has invested over $5 million since 2010. The AAA continues to invest, as does Tarrant County Public Health, Texas Health Resources (largest hospital system in area) and Health South. These organizations provide staff, training materials, marketing materials and host consumer training events.

As a community we embraced the Collective Impact model, which has led to common measurement and shared data systems. This allows us to produce measurable and demonstrable outcomes to payers. We have also negotiated a contract with a managed care organization.  All partner agencies funded by United Way are required to provide match amounts that progressively increase each year. For some programs we have developed, or are in the process of developing, sliding fee cost sharing programs that also contribute to sustainability.

Funding Sources 

In 2005, we began by utilizing Older Americans Act funding (Title IIIB, D and E) from the AAA before United Way of Tarrant County started investing between $1 – $1.6 million year in 2010. In 2013, Tarrant County Public Health began receiving 1115 b Medicaid funding from the State Medicaid Agency to support expansion of both the Stanford Chronic Disease Self Management and Matter of Balance programs. Texas Health Resources, the largest hospital in the Dallas/Fort Worth area, has also added Master Trainers and Lay Leaders.

Tarrant County Public Health and Texas Health Resources also provide training and marketing materials. The primary United Way-funded provider, Senior Citizen Services of Tarrant County, provides the bulk of classes, but master trainers from all three organizations often share staff and resources to provide consumer training. In addition to the United Way funding, leveraged resources from partner organizations totaled $1.2 million in the 2013 fiscal year. Meals on Wheels of Tarrant County, which serves over 3000 homebound people per year and provides three evidence-based programs, has also begun billing Medicare for services that use registered dieticians and certified diabetes educators. A grant from the WellMed Foundation also provided funding for initial training needed for the AAA to initiate Stressbusting for Caregivers program. The local Alzheimer’s Association has received funding from the Rosalyn Carter Institute to expand the REACH II program. Additionally, the AAA recently entered into a contract with a Medicaid Managed Care Organization to provide HomeMeds and the Care Transitions Intervention.  

Preventing New Programs from Jeopardizing Existing Programs

We use AAA Older Americans Act (OAA) and Foundation funding for research, development, initial training costs and as a gap filler for operational costs. We always try to provide training to employees of multiple organizations under our licenses. This provides a strong foundation for sustainability as funding waxes and wanes. The flexibility of OAA funding also allows for revenue shifting between programs to support sustainability as needed.

As mentioned above, we encourage other organizations to provide the same programs and pursue additional funding. Due to our commitment to shared measurement systems and data, we are able to sustain the Collective Impact model. We are not attached to which organizations provide services or who receives the revenue as long as the programs are able to continue, and in most cases, expand.

We also encourage providers to develop sliding fee/cost sharing options as an additional source of revenue.

Advice for Other Organizations

When possible, assemble a cross-sector strategic design group that includes potential partners to select a target population and desired outcomes. Start collaborating with and training other organizations to provide evidence based programs at the outset. Just like any team, the skill sets and traits of the players are unique and each team member is able to make contributions to the shared vision. Stay open to, and continuously look for, possibilities that will enable existing and new team members to support the collective endeavor.

Don’t get attached to who will provide the program or who will control the revenue. If there is a shared vision, shared data and measurement, accountability for producing outcomes and continuous communication which enables the timely resolution of collective issues, you will have a strong foundation to assure sustainability.  

If you have more questions for Don, he can be reached by email.