Evidence-Based Program Application Form
STAGE 1: Research and Outcomes
2-STAGE APPLICATION PROCESS
Stage 1: Research and Outcomes
Stage 2: Program Implementation – *BY INVITATION ONLY*
APPLICATION SCHEDULE
Letter of Intent Due | August 18, 2017
Stage 1 Application Due | September 15, 2017
Invitations to Submit Stage 2 (Program Implementation) Applications | By November 15, 2017
Stage 2 Application Due | December 15, 2017
Notifications to Applicants | Mid-February, 2018
The purpose of the Evidence-Based Program Application is to identify new community programs that meet the criteria established by the Administration for Community Living/Administration on Aging (ACL/AoA) for evidence-based programs funded through the Older Americans Act (OAA) Title III-D (see Appendix A). It is important to note that Title III-D criteria specifically addresses older adults, but programs submitted through this process may address older adults and/or adults with disabilities.
The ACL-funded National Chronic Disease Self-Management Education Resource Center, based at the National Council on Aging (NCOA), is overseeing this process in partnership with the Evidence-Based Leadership Council (EBLC). Together, NCOA and EBLC have established a Review Council to conduct the assessments of programs submitted through this application process. The Review Council consists of national leaders with expertise in program research, evaluation, and implementation.
The evidence-based program review process provides several benefits:
· Programs will be reviewed for potential inclusion on the ACL Title III-D approved list in a timely, unbiased manner;
· More programs targeting varied risk factors and populations will be available for dissemination; and
· Community, state, and tribal organizations/agencies can use the recommendations of Review Council to reference programs that have been deemed to be appropriate for inclusion for ACL Title III-D or other ACL future evidence-based program discretionary funding.
NCOA and EBLC would like to draw your attention to the two-stage process, as noted in the Application Schedule at the top of this notice.
1. The first stage is an application that addresses the evidence and evaluation details related to the program. Once evaluated by Review Council members with expertise in research and program evaluation, applicants will be notified whether or not they will be invited to complete the second stage of the application. The application that follows is the Stage 1 application.
2. The second stage will require information about the program implementation, training, dissemination materials, supports available, and other elements essential for successful program dissemination. If your program is not selected to move onto the second stage, you will be eligible to receive technical assistance provided by NCOA and EBLC, and will be able to re-apply during a subsequent review cycle.
Please use this form to record your responses; an online form will be available soon here so that you can copy and paste your responses from this document into the online form. The completed online forms must be submitted by September 15th, 2017.
SECTION I: PROGRAM NAME AND CONTACT INFORMATION
Name of Program:
Name of Primary Contact:
Position/Title:
Organization/Institution:
Phone Number:
Email:
Street Address:
City, State, Zip:
** If the Primary Contact is not the prevention program developer, please attach a letter of support from the program developer. **
Co-Authors/Co-Investigators:
Please provide, as applicable, the name, organization, contact information, and role(s) of up to five people, other than yourself, who were instrumental in developing the program, creating implementation/dissemination components, or researching or evaluating the program. (Note: This list should include any co-principal investigators for single-site or multisite trials.)
1. Name:
Position/Title:
Organization/Institution:
Email:
Phone Number:
Role:
2. Name:
Position/Title:
Organization/Institution:
Email:
Phone Number:
Role:
3. Name:
Position/Title:
Organization/Institution:
Email:
Phone Number:
Role:
4. Name:
Position/Title:
Organization/Institution:
Email:
Phone Number:
Role:
5. Name:
Position/Title:
Organization/Institution:
Email:
Phone Number:
Role:
SECTION II: PROGRAM OVERVIEW AND RESEARCH
Please answer all questions below. Your submission will be considered incomplete if all questions are not answered. Please be clear, concise and complete in responding. The Evidence-based Program Review Council is not able to contact you for additional information. Your submission will be reviewed solely on the information you provide in this application.
Primary health condition addressed by program:
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ÿ *Diabetes
ÿ *Nutrition
ÿ *Oral Health
ÿ *Hypertension
ÿ *Behavioral Health
ÿ Self-Management
ÿ Physical Activity
ÿ Medication Management
ÿ Other – Write in______
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*Priority topic areas—programs addressing these topic areas will be reviewed first
Brief Description of Program Goals/Objectives (Maximum of 250 words)
List up to three primary goals of the program.
Target Audience (Maximum of 250 words)
Describe the target audience(s) for whom this program has been evaluated as effective.
Program Setting(s) (Maximum of 250 words)
Describe the community settings in which this program has been evaluated as effective.
Research design
What type of research design did you use for evaluating the program?
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ÿ Randomized Controlled Trial (RCT)
ÿ Quasi-experimental
ÿ Single Posttests
ÿ Multiple posttests
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ÿ Other (write-in) ______
Summary of research (Maximum of 800 words)
Provide a summary of the research design used for evaluating this program. Please reference the peer-reviewed article(s) that demonstrate(s) the research design. Please also include any adverse outcomes or events that occurred as part of your research.
(Your response should address Review Criterion #2: Proven effective with older adults and/or adults with disabilities, using Experimental or Quasi-Experimental Design.)
Summary of program outcomes (Maximum of 800 words)
Describe the outcomes that are achieved with this program. Please describe the instruments/tools/metrics used to measure outcomes, and any evidence of their validity, where applicable in the study population. Please reference the peer-reviewed article(s) that demonstrate(s) evidence for each outcome listed as well as which table(s) in the research articles provide evidence for each key outcome. Please also include any adverse outcomes or events that occurred as part of your program.
(Your response should address Review Criterion #1: Demonstrated through evaluation to be effective for improving the health and wellbeing or reducing disease, disability and/or injury among older adults and/or adults with disabilities.)
Published articles (Maximum of 250 words)
Attach up to three articles that have been published about this program in a peer-review journal. Please include studies referenced above (i.e. under “Summary of research”).
(Your response should address Review Criterion #3: Program research results published in a peer-review journal or journals.)
Attach up to three published articles here (PDFs only).
How many subjects were in the original efficacy trial?
Treatment N: ______
Control N: ______
For up to 6 key outcomes, please specify the outcome name and measure, provide the author, year, and table # (if applicable) for the trial, time points data were collected (e.g. baseline/pre, post/6-months, follow-up/12-months), the significance AND effect size.
Author, Year Table # (if applicable) / Time 1 / Time 2 / Time 3 / Significance / Effect SizeOutcome 1
Outcome 2
Outcome 3
Outcome 4
Outcome 5
Outcome 6
Comments (Maximum of 250 words):
Current Activities
Please list the organizations that have adopted your program in the past year. If more than 10, please provide in a separate attachment.
Appendix A
U.S. Administration on Aging Title III-D Highest-Level Criteria for Disease Prevention and Health Promotion Evidence-Based Programs
The review process for evidence-based programs will use the U.S. Administration for Community
Living’s highest level benc hmarks for evidenc e -based programs that were place as of October 1, 2016, for Older Americans Act Title III-D funding, which require that programs meet the following criteria:
· Demonstrated through evaluation to be effective for improving the health and wellbeing or reducing disease, disability and/or injury among older adults; and
· Proven effective with older adult population, using Experimental or Quasi-Experimental Design;* and
· Research results published in a peer-review journal; and
· Fully translated** in one or more community site(s); and
· Includes developed dissemination products that are available to the public.
* Experimental designs use random assignment and a control group. Quasi-experimental designs do not use random assignment.
** For purposes of the Title III-D definitions, being “fully translated in one or more community sites” means that the evidence-based program in question has been carried out at the community level (with fidelity to the published research) at least once before. Sites should only consider programs that have been shown to be effective within a real world community setting.
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