July 2006

Grant Results

National Program

Robert Wood Johnson Foundation Local Funding Partnerships


The Corporación de Servicios de Salud y Medicina Avanzada (COSSMA), in Cidra, Puerto Rico, developed a chronic disease prevention and control project to reach into rural communities and help educate those with chronic illnesses (such as asthma, diabetes and high blood pressure) to manage their own care, rather than relying entirely on their physicians. COSSMA provided services at clinics, at homes and in communities.

The project was part of the Robert Wood Johnson Foundation (RWJF) national program Local Funding Partnerships (for more information see Grant Results).

Key Results

  • The chronic disease prevention and control project reached 991 patients (as of March 2004) through educational sessions designed to teach them how to manage their chronic conditions on their own.
  • The project served 192 diabetic, asthmatic and overweight children at five free summer camps during 2002, 2003 and 2004. Hundreds of other people with chronic conditions participated in health fairs and organized physical activity and education programs run by the project.
  • Project staff recruited and trained 59 peer mentors to go into rural communities and establish physical activity and education programs for those with chronic conditions. In many cases participants were not already clinic patients. During the grant period, 919 people attended community activity sessions organized by peer mentors.

RWJF supported COSSMA's chronic disease project with a $318,000 grant from October 2001 to September 2005.

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According to the Puerto Rico Health Department, one of every three Puerto Ricans over 65 had diabetes or hypertension in 1996. Cardiovascular disease (including hypertension) is the leading cause of death in the overall Puerto Rican population Diabetes is third.

In the 1990s, the Puerto Rico Health Department delegated third-party agencies, primarily health care centers like Corporación de Servicios de Salud y Medicina Avanzada (COSSMA), as the direct health care providers of the underserved population.

COSSMA initially started as a migrant health center, but when the grant was made, it had four primary care clinics on the east coast of Puerto Rico in the towns of Cidra, San Lorenzo, Yabucoa and Hurnaco. COSSMA charges for services based on the patient's ability to pay. It provides comprehensive primary care to more than 8,000 residents per year. Almost 90 percent of these patients are underserved or uninsured.

The most common reasons for people to visit the clinics are for hypertension, diabetes and asthma. A February 2006 report from the Centers for Disease Control and Prevention (CDC) found that Puerto Ricans have a higher death rate linked to high blood pressure than do whites, African Americans or other Hispanic Americans. The reason remains unknown.

In 2001, COSSMA started a Community HealthCorps program. The Community HealthCorps is a national AmeriCorps program that promotes health care for America's underserved populations, while developing tomorrow's health care workforce. It is run by the National Association of Community Health Centers (NACHC).

HealthCorps members reach out to individuals with no regular primary care provider. They seek to increase access to health care, provide health education and support that lead to appropriate use of health care services and better "self-care." They also recruit and develop volunteers to support community health centers.

HealthCorps workers often come from the same community as their patients. They serve one or two years and receive a scholarship upon completion of their service. Many HealthCorps members pursue careers in the health care professions. COSSMA received a matching grant from NACHC that enabled it to hire and train HealthCorps members to help staff its chronic disease project.

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This project was funded within RWJF's Local Funding Partnerships program. Communities identify a pressing local health need of vulnerable populations, design the strategy for addressing it and put together a funding package that provides at least one dollar of outside support for every dollar of RWJF grant money. This bottom-up strategy is the program's guiding philosophy.

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With the RWJF funds and matching funds from other organizations, Corporación de Servicios de Salud y Medicina Avanzada (COSSMA) was able to develop and sustain its chronic disease prevention and control project to help adults and children in its rural service area learn to manage their chronic diseases themselves, rather than relying entirely on their physicians.

The program began with education sessions conducted by HealthCorps members. COSSMA physicians referred patients with chronic illnesses to attend one or two education sessions in their communities. Project staff recruited peer mentors from the education sessions and from referrals by community leaders.

The mentors, in turn, went into the communities to educate people on self-management of chronic conditions. COSSMA referred to both HealthCorps members and peer mentors as "health promoters."

COSSMA later started another community program, called HANDS (Haciendo Actividad Fisica Nosotros Diariamenta Para Nuestra Salud or "we must do physical activity daily for our health") that drew clinic patients and new participants to exercise and education sessions led by health promoters three days a week for three months.

COSSMA also held free summer camps for children with asthma or a combination of chronic conditions.

The project reached further into the rural communities through health fairs and other gatherings where staff was available to give advice and distribute written materials.

Other Funding

Project funds from RWJF paid part of the salaries of a special projects manager, a case manager, and HealthCorps health promoters, as well as related program expenses. The project received far more than the RWJF-required match from other funders. (For a list of donors, see the Appendix.)

The project also received in-kind support from many local agencies. The Puerto Rico Lung Association, for example, provided transportation, food, a nurse and a recreation leader for the summer camps. A local diabetes association gave the camps support material, films and speakers. The Department of Education provided space for the camps; supermarkets gave snacks; and pharmaceutical companies donated T-shirts and water bottles. Other support included facilities for meetings, lunch for children at camps, and educational materials.

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  • Project staff served 991 patients with diabetes, hypertension and asthma (through March 2004) through education and self-management sessions conducted by HealthCorps members under the supervision of clinic professionals. Each session lasted for three to four hours and featured discussions by experts who included nutritionists, doctors (including pediatricians), pharmacists and nurses. The sessions on diabetes and hypertension were for adults and the sessions on asthma primarily for parents and children. A pharmaceutical company donated glucometers as an incentive for diabetes patients to measure their blood-sugar levels and peak-flow meters for asthma patients to measure lung function and airway changes.

    At first, patient attendance at the sessions was disappointing. To address this situation, project staff started holding sessions closer to patients' homes (in carports, churches and community centers), but attendance still lagged. Project staff then developed a program in summer 2003 where doctors gave their patients a personal invitation to the self-management sessions. Attendance at the sessions improved substantially following implementation of this recruitment strategy.
  • Project staff identified 59 people with chronic diseases through the education sessions and from referrals by community leaders and trained them as mentors. The mentors, in turn, reached 1,028 people through physical activity sessions. Mentors received three days of training and served for three months, although many renewed their service. They were not paid, but COSSMA gave them an honorarium of $50 at the end of their service.

    Each mentor had to develop a community-based physical activities plan for a group of patients who, for the most part, were not clinic patients. They had to organize the group, find a place to meet (such as a park or track), publicize the meeting and coordinate with the clinic. At each session, following the physical activity, a clinic professional (a nurse or health promoter or other clinic staff member) discussed self-management of chronic diseases such as hypertension and diabetes. The mentors provided testimony at each of the sessions on their own success in managing their chronic diseases.
  • Project staff recruited and trained 42 HealthCorps members to conduct education sessions for patients. HealthCorps recruits received two weeks of initial training, then periodic continuing education. The training included information on standards of care, nutrition, weight management, leadership and helping patients interpret laboratory results, among other topics.
  • A health educator and, later, a nurse conducted 49 home visits to patients who required follow-up support. At first, home visits were made by health promoters, but COSSMA later recruited a nurse case manager to conduct home visits to facilitate taking blood pressure, measuring blood sugar and other clinical tasks.
  • Through its HANDS project, COSSMA engaged 187 people in three-day-a-week exercise and educational programs that lasted three months. Participants spend the first hour of each session doing physical exercises and the second hour learning to self-manage their chronic conditions. They learn to read nutrition labels, to manage stress better and to prevent transmission of HIV, for example. The programs are conducted in the four COSSMA communities and in four nearby communities. Health promoters recruit participants from clinics during other education and self-management sessions conducted by HealthCorps members (see the first bullet under Results) and by asking community leaders, such as clergy, for referrals. At the end of three months, participants "graduate" and often demonstrate significant health improvement, according to project staff.
  • Project staff held five summer camps for children with chronic diseases. Camps in 2002, 2003 and 2004 served 192 children with asthma, diabetes and weight problems. Three of the day camps were for children with asthma and two were for children with multiple chronic conditions such as asthma, diabetes and obesity. Clinic doctors from COSSMA referred the children to the free camps. Parents attended some sessions as well. Although the camps included playtime and field trips, they also featured talks by pediatricians, nutritionists and health educators to teach children to manage their own health conditions. Project staff continued the momentum started at the camps with a newsletter for camp children.
  • Through health fairs and a variety of other community outreach efforts, the project disseminated educational materials and advice to more than 10,000 people. Project staff members held health fairs in each of the four community neighborhoods from 2004 to 2005 at which health promoters gave brochures on illness management and advice to those who stopped by. Health promoters went to health fairs from other organizations such as the Department of Health and local home health programs. Many schools invited COSSMA staff to talk to students about asthma and diabetes.
  • Project staff developed a written instructional module (in Spanish) on diabetes and hypertension to help other community health centers replicate the chronic disease project. The Puerto Rico Department of Health is using the module with other communities for their diabetes programs. (See the Bibliography for details.)

COSSMA did not undertake a formal outcome evaluation to learn if its chronic disease project helped to improve participants' health. This was too complex and costly a task at the time, according to Isolina Miranda, project director and executive director of COSSMA.

"In terms of clinical outcomes, patients' conditions have improved," she said in an interview in the March/April 2004 Community Health Forum magazine. "Through the activities of the HealthCorps members, patients are following the advice of providers so they can manage their chronic diseases."

Miranda points to one patient's experience with the project to demonstrate the rapid and positive effects that physical exercise and socialization can have on an individual:

COSSMA outreach workers called on Carmen Rivera Marquez three times before persuading her to try the HANDS program. She had recently had a hip replacement, suffered from diabetes and hypertension, and was taking medication for depression, which left her bedridden. Two weeks after joining HANDS, she began to eat better, reduced her depression medication, started to lose weight, and made new friends. After graduating from the program in April 2004, she felt "like a new person."


The chronic disease project garnered attention from the media as well as other community groups. The March/April 2004 issue of Community Health Forum, the magazine of the National Association of Community Health Centers, featured an article on COSSMA's chronic disease project. There also were a number of articles in the local press about the project.

In August 2004, COSSMA staff gave a presentation on chronic disease self-management at the Puerto Rico Association of Community Health Centers meeting.

The Puerto Rico Department of Health featured health promoters from COSSMA in its 2004 television campaign to educate the population on diabetes prevention and management.

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  1. When planning home visits to patients with chronic health needs, a nurse rather than a non-medical professional is often more appropriate. For the first two years of the project, a COSSMA health promoter made the home visits to patients. In time, however, project staff decided that a trained, registered nurse could offer more appropriate care, such as taking blood pressure, measuring blood sugar levels and other screening activities. (Project Director/Miranda)
  2. Involve providers, especially physicians, when trying to recruit patients into chronic disease self-management programs. Attendance at COSSMA education/self-management sessions was low until project staff enlisted doctors to give personal invitations to their patients during visits. (Project Director/Miranda)
  3. Draw upon groups such as the Community HealthCorps when possible for local health programs. Most of the funding to pay for HealthCorps staff came from the National Association of Community Health Centers. According to the project director, without this additional staff, the outreach would have been much more limited. (Project Director/Miranda)
  4. Community leaders and volunteers are among the best allies to mobilize community members to manage their health better. When peer mentors were recruiting for the HANDS program, they received many referrals from community leaders, including clergy. (Project Director/Miranda)

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The chronic disease prevention and control project is continuing with funding from the National Association of Community Health Centers and others while it seeks additional matching grants. Many of the 59 peer mentors are continuing their community roles. COSSMA has applied to funders to expand the chronic disease project to include obesity, and is working on an instructional module on asthma that will be distributed to other communities starting a chronic disease self-management program.

The Comprehensive Health Education Foundation (CHEF) in Seattle, Wash., selected COSSMA to participate in a two-year program for Local Funding Partnerships grantees funded by RWJF (ID# 052828) on building organizational capacity and long-term sustainability through business planning. COSSMA Executive Director Miranda and two staff members traveled to Seattle in December 2005 for their first training session.

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Peer-Based Effort to Improve Health Care for People with Chronic Conditions Through Education and Self-Management


Corporación de Servicios de Salud y Medicina Avanzada (Cidra,  PR)

  • Amount: $ 318,000
    Dates: October 2001 to September 2005
    ID#:  042798


Isolina Miranda
(787) 730-8182

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Appendix 1

Funders for Chronic Disease Prevention and Control Project

In addition to the Robert Wood Johnson Foundation, matching funders included:

  • National Association of Community Health Centers, $304,300
  • Puerto Rico Community Foundation, $75,000
  • Johnson & Johnson Community Health Care Program, $150,000
  • Johnson & Johnson facility in P.R., $20,000
  • GlaxoSmithKline, $5,000

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(Current as of date of this report; as provided by grantee organization; not verified by RWJF; items not available from RWJF.)


Diabetes e Hipertensión:Actividades Para Fomentar Automanejo. (Diabetes and Hypertension: Activities to Promote Self-Management). Cidra, Puerto Rico: COSSMA, 2005.

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Report prepared by: Nanci Healy
Reviewed by: Richard Camer
Reviewed by: Molly McKaughan
Program Officer: Jane Isaacs Lowe

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