Evaluation Measures for Rural Chronic Disease Management Programs

Rural communities implementing chronic disease management programs are using a range of process, outcome, and impact evaluation measures. Evaluation measures can be tailored to specific chronic diseases and program designs. Additional information on evaluation strategies and measures is included in the Rural Community Health Toolkit.

Sample Evaluation Measures by Domain

Evaluation measures for rural chronic disease management programs vary depending on the program model and its goals. Rural communities should consider collecting a range of measures. Process measures can show progress toward program goals, including in the short-term. Outcomes, like changes in clinical measures, can demonstrate the success and value of the program.

Process measures focus on how chronic disease management programs are implemented. Process evaluation can be conducted periodically during program implementation and provides information on the types, quantity, and quality of activities or services provided. Examples of process measures related to chronic disease management programs include:

Proportion of eligible patients referred to chronic disease management
Proportion of eligible patients enrolled in chronic disease management
Number of patients completing chronic disease management programs
Proportion of eligible patients referred to case management or care coordination who receive needed services
Number and type of program activities or sessions convened

Outcome measures focus on health outcomes and the overall results of the program. Examples of outcome measures related to chronic disease management include:

Percentage of patients screened for chronic diseases
Change in clinical outcomes among chronic disease management program participants (for example, A1C levels, blood pressure, cholesterol levels, weight)
Number of hospitalizations and emergency department visits among chronic disease management participants compared to controls
Change in knowledge, attitudes, and beliefs regarding chronic disease
Change in lifestyle, self-management practices, and skills specific to managing certain chronic diseases (for example, glucose monitoring, dietary intake, physical activity, foot care for diabetes)
Change in self-efficacy
Change in medication usage and adherence
Change in patient satisfaction with program and overall care
Cost savings associated with reduced hospitalizations and outpatient visits

Impact evaluation measures look at the long-term results of the program. Impact evaluation provides information on the broad impact of the program, including whether it achieved its intended results — for example, whether there has been a decrease in diabetes or hypertension incidence in the population — and assessing any unintended results.

Economic (cost-benefit) evaluation measures compare the cost of a program to its benefits. Information collected is used to support continued program operations, or to compare it with other projects or programs. For example, the estimated savings associated with reduced hospitalizations for end-stage renal disease.

Resources to Learn More

Diabetes Evaluation Measures
Document
Describes evaluation metrics specifically designed for assessing type 2 diabetes prevention and control programs with a focus on worker productivity, healthcare costs, health outcomes, and organizational change.
Organization(s): Centers for Disease Control and Prevention
Date: 4/2016

Research and Evaluation Tools
Website
Provides tools and resources to use when developing an evaluation plan for chronic disease self-management programs.
Organization(s): Self-Management Resource Center

Surveillance and Evaluation Data Resource Guide: Heart Disease and Stroke Prevention Programs
Document
Provides data sources and indicators useful for program managers and evaluators when planning, monitoring, and evaluating hearth disease and stroke prevention programs.
Author(s): Andrade, N., Bhatt, A., Huang, C., et al.
Organization(s): Centers for Disease Control and Prevention
Date: 2022