Supporting, Unifying and Streamlining in Texas through Active Integrated Networks

This project serves as a central hub to embed a suite of Stanford Patient Education Chronic Disease Self-Management Education (CDSME) within a 59 county region in Central and East Texas. SUSTAIN’s goal is to leverage the combined resources of Area Agencies on Aging (AAA), integrated healthcare systems (IHS), and managed care organizations (MCO) to better scale and sustain CDSMEs. Objectives are 1) establish partnerships among seven Texas AAAs, a minimum of two IHSs (Catholic Health Initiatives and Baylor Scott & White), and a minimum of one MCO (United HealthCare) to support sustainable program delivery; 2) increase the number of graduates from CDSME programs delivered; and 3) develop and evaluate models of best practice through memoranda of understanding and/or business plans to create a systematic healthcare referral model for linking clinical and community sectors.