Chronic Disease Self-Management in Supportive Housing

The Stanford University evidence-based chronic disease self-management program (CDSMP) has demonstrated results for people suffering from a range of issues including asthma, diabetes, and heart disease, each of which impacts Health Share members disproportionately. This program provides adults with education and tools they need to help them cope with their chronic diseases. For example, the program promotes benefits of good nutrition and physical activity as well as helping participants manage stress and communicate more

Implementing CDSMP in partnership with housing providers is an innovation that has yet to be tested in our region, possibly due to lack of health and housing partnerships and lack of resources to train staff and peers. When Health Share conducted assessment surveys among residents in affordable housing sites where acute health service usage is high, we noted that many residents requested more on-site services and demonstrated a willingness to attend groups like CDSMP. We also learned from housing providers who provide care to high utilizers of health care services that they want to be able to provide services onsite but lack the knowhow to do it. For example, one housing provider has observed a more than 50% prevalence rate of diabetes at one of their affordable housing sites and that their resident services staff often responds to health care needs that would have been better addressed before the issue became an emergency.

This project is a collaboration involving Clackamas County Health Housing and Humans Services’ (H3S) Housing Authority (HACC), Public Health and Social Services Divisions (CCSS). The goals of the project are built around the Triple Aim: to reduce health care costs, to improve individual health for better health outcomes, and to increase the mental and physical fitness for Health Share members with chronic illness living in public housing to improve population health. Currently, the Housing Authority of Clackamas County manages four public housing communities in addition to a number of scattered sites.

Within the four community sites, Health Share members comprise roughly 75% of total residents. Data collected from claims during the period of 9/1/2012 through 8/31/2013 shows that these members have significantly higher rates of chronic disease and are twice as likely to use the emergency department as Health Share members not living in public housing.

The project will include three targeted interventions:

  • A Clackamas County Public Health Nurse will be on site at each community public housing site one day per week for week to work with individuals to teach them:
    • Chronic disease management skills
    • Care coordination skills for themselves and their family members
    • Community resources available to assist residents and their families
    • The value of making a strong connection to a “health home” for care management and coordination, and to use in lieu of emergency services when appropriate
  • Social Services will provide nine hours of the curriculum Living Well with Chronic Conditions (LWCC) at each of the four public housing sites

Funders: State Transformation Fund Grant

A Public Health Nurse is working closely with four housing sites to improve residents’ chronic disease self-management. The nurse has worked with 123 residents on a variety of interventions. “Living Well with Chronic Conditions” classes are also being offered to residents and residents are identifying community space improvements to encourage healthy activities.

Contact Information: Clackamas County – Cathy Perry,