Chronic Disease Self-Management and Mental Health Integration for Older Adults and Adults with Disabilities in Connecticut - Connecticut is the 7th-oldest state in the nation, where 62% of older adults have four or more chronic conditions, and adults with disabilities are more than five times as likely as those without disabilities to report frequent depression. Monitor My Health, Inc. (MMH), a Connecticut-based 501(c)(3) nonprofit, proposes to expand statewide capacity to deliver the Chronic Disease Self-Management Program (CDSMP/Tomando Control de su Salud) and integrate the Program to Encourage Active, Rewarding Lives (PEARLS) to improve behavioral health among older adults (60+) and adults with disabilities, with priority given to individuals newly diagnosed with a chronic condition, caregivers, and those experiencing depression, anxiety, or behavioral health stressors. Over three years, MMH will train 60 new CDSMP peer leaders, two Master Trainers, and 30 PEARLS leaders (30% bilingual); deliver CDSMP to 2,800 participants (74% completer rate, 2,072 completers) and PEARLS to 560 participants (74% completer rate, 414 completers); screen 90% of participants for social needs with 75% successful referrals; achieve 85% reduction in depressive symptoms among PEARLS completers and 75% improved self-efficacy among CDSMP completers; and establish 20 MOUs with statewide CBOs and 10 sustainable referral pathways with healthcare providers. CDSMP/DSMP, licensed by the Self-Management Resource Center, reduces emergency department visits and hospitalizations, while PEARLS reduces depressive symptoms by 50%, increases social engagement, and decreases hospitalizations. Annual targets are Year 1: CDSMP 700 (518 completers) and PEARLS 140 (104 completers); Year 2: CDSMP 1,400 (1,036 completers) and PEARLS 280 (207 completers); Year 3 cumulative: CDSMP 2,800 (2,072 completers) and PEARLS 560 (414 completers). Statewide partners specialize in promoting behavioral health within the Connecticut community, providing initiatives and workshops that support emotional well-being and connect individuals to essential health resources. Other partners include Area Agencies on Aging, Federally Qualified Health Centers, senior centers, assisted living facilities, and behavioral health providers. Implementation will be statewide, using in-person, hybrid, and telehealth delivery; a mobile health lab for on-site screenings of undiagnosed diabetes, hypertension, and obesity; tailored materials; and targeted campaigns (“Caring for the Caregiver,” “Health Without Limits,” “Strong Start”). Behavioral health priorities—depression, anxiety, caregiver stress, and social isolation—will be addressed through integrated physical and mental health supports, informed facilitation, and robust social needs screening with referrals, ensuring sustainable, high-impact programming that improves chronic disease outcomes and behavioral health for older adults and adults with disabilities across Connecticut.
