Key Evaluation Findings FY24-25
FY24 key evaluation findings
- Diabetes Self-Management Education and Support
- Participants completed an average of 3.5 hours of programming, achieving improvements in medication adherence, weight loss, and psychosocial confidence.
- Significant clinical improvements included reductions in blood sugar (HbA1c) levels and improved disease management.
- One grantee provided wraparound services to 75 participants, such as food pantry access and cooking classes. All reported improved dietary choices and cultural inclusivity.
- National Diabetes Prevention Program
- 1,203 participants enrolled across 17 counties, including seven rural counties.
- 65% of participants met risk-reduction goals such as increased physical activity and weight loss, surpassing national averages.
- Participants reduced body weight by 5.9% and increased weekly physical activity by 439% (37.07 minutes pre- to 199.87 minutes post-intervention).
- Self-Monitored Blood Pressure (SMBP)
- Participants in CCPD-funded SMBP programs achieved an average reduction of 11.33 mmHg in systolic blood pressure (an 8.5% improvement) and 5.27 mmHg in diastolic blood pressure (a 6.4% improvement).
- Blood pressure control rates increased to 93.8%, with 36% achieving American Heart Association-recommended levels (<120/80 mmHg).
- Home-Based Asthma Management
- 162 home visits were provided to 101 participants enrolled across six counties, in which healthcare navigators identified potential environmental asthma triggers in the home, provided training on medication usage, and coordinated resources to reduce the impact of environmental triggers.
- Participants reported improved inhaler use techniques and reduced symptom severity, as evidenced by a significant increase in average Inhaler Device Assessment Tool scores (3.81 to 4.52) among participants.
- Programs connected families to resources addressing asthma triggers, contributing to better symptom control, as evidenced by a significant increase in average Pediatric Asthma Control and Communication Instrument scores (3.25 to 3.75) among participants.
- This project aims to enhance participants' continuity of care by meeting them at clinic appointments and fostering a seamless connection between clinic education and home-based support.
- School-based Asthma Management
- In the 20 schools piloting the program, 101 participants enrolled, achieving a 98% retention rate in FY24.
Asthma control scores improved from 21.5 to 23.0, inhaler proficiency rose from 17% to 93%, and emergency visits decreased from 24% to 8%. - 67% of caregivers reported significant asthma improvements in students, with 91% achieving their health goals.
- In the 20 schools piloting the program, 101 participants enrolled, achieving a 98% retention rate in FY24.
- Grantees implemented four municipal-level policies and five organizational-level policies, resulting in the standardization of all Denver school zones, the creation of Slow Zones in pedestrian-generating spaces, the removal of sugary drink options from kids' menus in Denver, and the implementation of policies focused on purchasing local food and beverages, as well as the elimination of sugar-sweetened beverages.
- Initiatives included increasing active spaces and enhancing decision-maker engagement through community events and surveys.
- Colorectal Cancer Screening
- Increased screening rates from 27% in 2022 to 36% in 2024 among 65,012 eligible patients across 16 safety net clinics.
- Implemented evidence-based interventions (EBIs) in 94% of clinics, including over 4,000 client reminders and 25,000 provider reminders in January through June of 2024.
88% of clinic representatives surveyed felt their clinic's capacity had improved in implementing an EBI to increase colorectal cancer screening rates - Recognized nationally for leadership in colorectal cancer prevention, with program outcomes presented at state and national forums.
- Cardiovascular Health Innovation
- Enrolled 1,357 participants in programs addressing cardiovascular health, with a 63% completion rate.
Reported 61% of participants improved cardiovascular health scores and 50% reduced cardiovascular risk scores through targeted health strategies. - Collaborative efforts with community health workers and local organizations enhanced program reach and participant engagement, addressing disparities in cardiovascular and behavioral health outcomes.
- This project aims to build and strengthen relationships and coordination among community and clinical organizations to improve chronic disease prevention and management among people living in the metro area.
- Enrolled 1,357 participants in programs addressing cardiovascular health, with a 63% completion rate.
- Community-Clinical Linkages
- As part of a successful pilot, the program established key partnerships between two clinics and three community organizations and supported partnering sites in adopting an innovative workflow adaptation to incorporate patient-centered screening and referral systems for chronic disease prevention and management.
- Three community events enabled the grantee to identify barriers to chronic disease prevention, maximize resource utilization, foster community awareness, and help sites connect with the communities. 95% of attendees reported learning about effective strategies and resources to manage chronic diseases.
- The grantee developed a key best practices tool kit for establishing and maintaining effective community-clinical linkages, which can be shared with partners.
FY25 key evaluation findings
- Diabetes Self-Management Education and Support Programs
- Grantees served more than 620 participants, including over 450 from underserved rural, frontier, and Hispanic/Latino communities.
- Participants experienced significant decreases in both weight and blood sugar (HbA1c), and an overall increase in medication adherence rates.
- Participants in selected programs reported
- Significantly higher levels of confidence in their ability to complete their daily diabetes routine, handle the stressors of living with diabetes, and a general increase in their overall psychosocial wellbeing.
- Achieving self-selected goals, including increasing medication adherence, blood glucose monitoring activities, adhering to a diabetes-friendly diet, and engaging in at least 30 minutes of physical activity per day.
- Diabetes Self-Management Support (DSMS) Program
- DSMS participants attended peer-developed support groups and physical activities. Participants from previous cohorts, care partners, peer educators, and current participants actively engaged with the supportive services offered by Metro Caring, attending an average of four supportive services during the fiscal year.
- Project Dulce Diabetes Among Friends participants, care partners, and peer educators attended culturally relevant cooking classes where diabetes-friendly recipes were taught. Participants reported that they:
- Learned something new from the classes
- Were more confident in making choices about healthy eating
- Felt confident that they could recreate the recipes in their own kitchen
- Felt culturally included in the classes
- Intended to make a change because of the class.
- National Diabetes Prevention Program (NDPP)
- Six grantees provided National DPP services with over 1,300 participants completing the program, including expanded access in rural Northeastern Colorado.
- Overall, 69.7% of eligible program participants who completed program requirements met at least one risk-reduction goal, exceeding the national benchmark of 66%.
- Of note, CCPD-funded programs exceeded national risk-reduction benchmarks for low socioeconomic status, Medicare-eligible, and Hispanic participants.
- Individuals who completed a CCPD-funded NDPP reduced their bodyweight by an average of 6.0% and increased their activity levels by 310%.
- Self-Monitored Blood Pressure (SMBP)
- More than 200 individuals completed hypertension control programs. Among participants who reported blood pressure, SMBP-defined blood pressure control (a blood pressure reading < 140 / 90 mmHg) increased from 21.1% to 93.8%.
- Overall, participants’ average blood pressure dropped from 144.9 / 88.8 mmHg to 124.2 / 78.6 mmHg.
- This drop signifies a shift from American Heart Association (AHA) Stage 1 Hypertension (130 >= Systolic < 140 and 80 >= Diastolic < 90) to AHA Elevated (120 >= Systolic < 130 and Diastolic < 80).
- The percent of participants at greatest risk of health complications due to high blood pressure decreased from 79.0% to 6.2%.
- 15.8% of participants who were at AHA Stage 2 achieved an AHA-controlled reading after completing SMBP programming.
- This change in blood pressure reduced the overall risk of heart attack and/or stroke, as well as reduced the risk of vision loss and kidney disease/failure.
- This change in blood pressure reduced the overall risk of heart attack and/or stroke, as well as reduced the risk of vision loss and kidney disease/failure.
- 15.8% of participants who were at AHA Stage 2 achieved an AHA-controlled reading after completing SMBP programming.
- Home-Based Asthma Management
- The grantee educated over 140 families on asthma control strategies and provided environmental remediation supports.
Program participants significantly improved their inhaler use technique from an average score of 3.5 to 4.3 as assessed through the Inhaler Device Assessment Tool. - Symptom control significantly increased among participants from an average score of 3.4 to 3.8, as measured by the Pediatric Asthma Control and Communication Instrument, decreasing the frequency and severity of experienced asthma symptoms.
- For participants who met programmatic follow-up guidelines, there was a clinically meaningful decrease in hospital admissions due to an emergency department visit post-graduation.
- The grantee educated over 140 families on asthma control strategies and provided environmental remediation supports.
- School-based Asthma Management
- Colorado Asthma Friendly Schools (CAFS) Recognition
- AsthmaCOMP activated CAFS, which is a designation pathway for schools implementing asthma-friendly practices. CAFS is a formal, tiered recognition system (gold, silver, bronze) with a new focus on providing support for severe asthma. CAFS was piloted successfully, with 13 of the 20 invited schools (65%) participating, and eight earning Gold and five earning Bronze. The model reached nearly 5,000 students, with the strongest scores in nurse preparedness, asthma education, and support for physical activity. ‘Environmental health’ emerged as the area needing the most attention moving forward.
- Colorado Asthma Friendly Schools (CAFS) Recognition
- School-Based Asthma Programs
- Asthma navigators and nurse-led programs enrolled 87 students with high-risk asthma, 98% completed the program. Among participants, asthma control improved from 86% to 94%, inhaler technique mastery rose from 12% to 88%, and 92% of students achieved their asthma management goals, demonstrating a meaningful impact for children and their families.
- Training & Technical Assistance
- AsthmaCOMP trained 418 school nurses statewide and supported more than 120 unlicensed assistive personnel (UAPs). Confidence in using asthma care plan zones and inhaler technique improved across the board, with over 96% of UAPs reporting that the training directly enhanced student care.
- AsthmaCOMP trained 418 school nurses statewide and supported more than 120 unlicensed assistive personnel (UAPs). Confidence in using asthma care plan zones and inhaler technique improved across the board, with over 96% of UAPs reporting that the training directly enhanced student care.
- Grantees spent time providing technical assistance and resources to their partnering communities and organizations. Micro-grants, educational tools, policy expertise, and staff support were used to help build local capacity and increase programming reach. Community mobilization and assessing decision-maker support were also key activities this fiscal year, helping to set the stage for implementable and sustainable PSE changes.
- Eight policies were passed. Policies addressed participant incentives, hands-free navigation vehicle laws, financial policy impacting food access, solar regulations, organizational nutrition, healthy meetings, non-acceptance of industry funds, and a municipal-level sugary drink reduction policy.
- Eleven systems and environmental changes occurred. Changes included a language access plan, plans to address public meeting disturbances, community engagement resource updates, micro-grants for changes to the physical environment and beautification efforts, Community Food Access tax retailer support, small food retailer and farmer resilience grants, and the installation of a water bottle filler station.
- Colorectal Cancer (CRC) Screening
- The Colorado Cancer Screening Program (CCSP):
- Engaged 18 safety-net clinic systems to increase colorectal cancer screening rates by an average of 7.4%, supported by evidence-based interventions, action plans, and tools such as client reminders and quality improvement.
- Delivered 101 trainings and more than 100 hours of individualized technical assistance (TA) to support clinic capacity building, workflow redesign, and data use.
- Built and coordinated a statewide TA partner network to extend resources and expertise, ensuring clinics received the proper support for implementation.
- Participating clinics improved their screening rates
- CRC screening improved from 33% in FY24 to 43% in FY25, with 28,897 individuals screened.
- Among those, 329 positive tests led to 99 CRC diagnoses, demonstrating CCSP’s impact on early detection.
- The Colorado Cancer Screening Program (CCSP):
- Cardiovascular Health Innovation
- Enrolled1,634 participants, serving rural and urban communities.
- Chronic conditions
- Nearly half of the participants reported having at least one chronic condition (diabetes, heart disease, stroke, high blood pressure, or high cholesterol.
- Medical home
- 25–32% reported not having a medical home.
- Medicaid coverage
- 9–10% were covered by Medicaid.
- Insurance status
- 22–52% had no health insurance.
- Approximately 88% of Community Heart Health Actions for Latinos at Risk participants identify as Hispanic or Latinx.
- Among enrolled participants, 90-97% completed baseline assessments on cardiovascular health, stress, and mental health, creating a strong foundation for tailored coaching.
- Ten community health workers delivered more than 3,400 coaching sessions, supported by intensive training and ongoing supervision.
- Chronic conditions
- Enrolled1,634 participants, serving rural and urban communities.
- Community-Clinical Linkages
- The Colorado Health Institute (CHI) recruited and aligned eight clinical and community-based partners in FY24. In FY25, CHI implemented a one on one partnership model in which clinics and community organizations collaborated closely to design and test workflows, thereby strengthening trust and accountability. CHI shifted its strategy for building referral pathways, moving from an “all-to-all” approach to a more focused one-to-one partner match, enabling deeper collaboration and faster activation of workflows. The organizations focused on serving
- Medicaid members, the uninsured, and populations with a high burden of chronic disease.
- By the end of FY25, the network established 10 active referral pathways, with an additional 10 in development, connecting individuals to
- National Diabetes Prevention Programs, Diabetes Self-Management Education and Support programs, Self-Measured Blood Pressure programs, and nutrition support services. Across year two, partners sent 615 referrals, with about one in four resulting in confirmed enrollment. Referrals flowed reliably between clinics and community partners, with alignment on roles, responsibilities, and shared expectations, ensuring that people were connected to the programs that best fit their needs.
Questions
Email cdphe_ccpdgrants@state.co.us.