Living Well Chronic Disease Self-Management Program

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Executive Summary

Living Well Chronic Disease Self-Management Program is a nonprofit in North Carolina that teaches adults living with diabetes, high blood pressure, arthritis, asthma and other long-term conditions the skills to manage their health day by day. Trained lay leaders, many living with a condition themselves, teach free six-week workshops, and participants receive home tools, cooking demonstrations and a coach who helps them prepare for doctor visits.

Chronic conditions are the main cause of illness and cost in our communities, and managing them is hard when visits are short and costs add up. Skills, a plan and a community can help people live better.

With this grant we will serve about 150 adults in Year 1 at 3 sites. Our workshops teach skills and do not replace medical care, and our leaders do not give medical advice. We call 911 in any emergency. We promise honest information, safe workshops and respect for every participant.

Our Year 1 budget is about $176,500, growing to about $250,000 by Year 5 as we add sites, coaches and participants. Each year's budget is planned to balance, with a small surplus each year. We have 4 staff in Year 1 (an Executive Director, a Program Coordinator and two part-time health coaches) and 8 by Year 5.

We are asking the Carolina Community Health Foundation for $50,000 for the Program Coordinator and home monitoring supplies. Our other income and startup support cover the rest. These numbers are estimates based on the assumptions listed at the end of this proposal, and we do not promise any result beyond what we describe.

Company Description

Living Well Chronic Disease Self-Management Program is a nonprofit organization in North Carolina. We are a registered charity with a volunteer board of directors, a written conflict-of-interest policy and a yearly budget the board reviews.

Our mission. People living with a long-term health condition should have the skills, tools and support to live well every day.

What we do.
- Teach six-week self-management workshops for adults living with diabetes, high blood pressure, arthritis, asthma and other long-term conditions.
- Train lay leaders, many of whom live with a condition themselves, to teach the workshops.
- Provide home blood pressure cuffs and simple tools to participants through partner pharmacies and clinics.
- Teach cooking and healthy eating on a budget in cooking demonstrations.
- Help participants prepare for doctor visits and keep appointments.
- Connect participants with clinics, pharmacies and community resources.

Our values. Respect for every participant, honesty with families and partners, safety first and a place for everyone who wants to belong.

What we do not do. Our workshops teach skills and do not replace medical care. Leaders are not clinicians and do not diagnose, change medicines or give medical advice. A nurse advisor reviews all materials, and participants are told to talk with their own doctor. We call 911 in any emergency. We do not promise any health result. We follow the rules of our partner sites and our insurer.

How we got here. A group of nurses, community health workers and neighbors who live with diabetes began holding workshops in a church. People kept coming back and asked for more. We kept simple records of attendance and what participants said. This proposal asks for support to move from church workshops to a steady program with paid, trained staff and the materials to match.

Problem & Opportunity

Chronic conditions such as diabetes and high blood pressure are the main cause of illness and cost in our communities, and managing them day by day is hard.

Cost. Medicines, supplies, healthy food and missed work add up, and many people skip appointments or doses because of cost.

Access. Clinic visits are short, and many patients leave without understanding what to do at home. Some live far from clinics.

Safety and trust. Participants and clinics want reliable information that fits with a doctor's advice and is delivered safely.

Missed benefits. People who cannot manage a condition at home are more likely to end up in the emergency room, and families bear the burden.

What we hear.
- A man says he takes his pills when he remembers and does not know what his numbers mean.
- A nurse says patients leave with a handout and no plan.
- A woman says she learned to cook with less salt and her pressure dropped.
- A leader says people open up to someone who lives with the same condition.

We do not claim that a program can solve every challenge. We believe that skills, a plan and a community of people who understand can help people live better with a long-term condition.

Products & Services

Living Well Chronic Disease Self-Management Program gives adults living with long-term health conditions a safe, welcoming place to manage their health and live well.

How the program works.
1. Sites. We partner with churches, clinics and community centers that provide rooms.
2. Workshops. Six weekly two-and-a-half-hour sessions for groups of about twelve, led by trained lay leaders.
3. Skills. Participants learn to set goals, make action plans, manage symptoms and stress, eat well and talk with their doctors.
4. Tools. Participants receive a home blood pressure cuff or other simple tools through partner clinics and pharmacies.
5. Cooking. A cooking demonstration shows healthy meals on a budget.
6. Connections. A coach helps participants prepare for visits, keep appointments and find community resources.
7. Follow-up. We call participants at three and six months.

What a typical session looks like. Participants arrive and check in with a staff member, settle in together, work on the day's activity in small groups and finish with a short talk about what went well. Staff praise effort, correct mistakes kindly and make sure no one is left out.

Staff. Our lay leaders complete a certified training, pass a background check, are supported by a nurse advisor and are paid a stipend.

Access and fairness. Programs are free. Workshops are free. We welcome every adult with a long-term condition and offer workshops in English and Spanish.

Market Analysis

Who we serve. Adults ages 18 and older who live with a long-term health condition in our service area. Eligibility is a self-reported long-term health condition and where a person lives, and no one is turned away for lack of insurance.

How we estimate need. We cannot count every young person who could benefit, so we plan from what we can see. In our church workshops we served full rooms and kept a waiting list. Clinics told us that many more patients need support at home than they can offer. For Year 1 we plan to serve about 150 participants at 3 sites. By Year 5, with more staff and sites, we plan to serve about 430.

Where participants come from.
- Clinics, pharmacies and hospitals.
- Churches and community centers.
- Health departments and senior centers.
- Participants who tell a friend.

Who else benefits. Families gain healthier members. Clinics gain patients who keep appointments. Communities gain fewer avoidable emergency visits.

What the numbers mean. Every number here is a person who learned to read their own numbers. We keep our early counts modest and honest so we can do the work well.

Competitive Landscape

What young people can find today, and how we are different.

1. Clinic visits. Essential and short. We add skills and support between visits.

2. Hospital education classes. Valuable and not always offered near home. We bring workshops into the community.

3. Diabetes prevention programs. Strong for people at risk. We serve those who already have a condition.

4. Apps and websites. Convenient for some and impersonal.

5. Home health nurses. Skilled and limited to certain patients. We offer a peer approach.

What makes us different.
- Free workshops close to home.
- Leaders who live with a condition.
- Home tools provided.
- Healthy cooking on a budget.
- Follow-up at three and six months.

Why this gap matters. Existing programs do good work, and most serve people who can already pay or who live close to them. The people we serve are the ones left over: they live in the wrong neighborhood, have the wrong schedule or have no one to ask. We are built to reach them.

We have spoken with clinics, pharmacies, health departments and other chronic disease programs to make sure we are filling a gap and not duplicating services. Their letters of support are in the attachments.

Marketing & Sales Strategy

How young people and partners will find us.

Reaching young people.
- Clinics and pharmacies. We will give staff a short referral form and a named contact.
- Churches and community centers. We will post flyers and hold open sessions.
- Senior centers and health departments. We will share information and schedules.
- Social media and local radio. We will share simple messages.
- Word of mouth. Participants tell friends.
- A simple website and a phone line with a text option.

Reaching staff and sponsors.
- Recruit lay leaders through clinics, support groups and community health workers.
- Offer an orientation, a background check and training in safety, privacy and respectful practice.
- Give partners a short report each quarter with counts of participants and what they said.

How we decide who joins. We use a simple sign-up form and enroll participants in the order received, with priority for those with the greatest need and for people new to the program. We keep a waiting list when the program is full.

What we watch. Sign-ups, attendance, workshops finished, goals met and how many participants return for a second season.

Operations Plan

How the program will be carried out.

Timeline for Year 1:
- Months 1 and 2 (July and August): Hire the staff, buy equipment and materials, finalize the waiver, consent form and privacy policy with our attorney and sign site agreements.
- Month 3 (September): Train lay leaders and begin the first workshops at three sites.
- Months 4 to 10: Hold workshops, cooking demonstrations and follow-up calls.
- Months 11 and 12: Survey participants and clinics, report to funders and plan Year 2.

Space. Workshops are held in churches, clinics and community centers, provided at low or no cost.

Safety and privacy.
- Leaders do not give medical advice, and every participant is told to talk with their own doctor about changes to medicines or care.
- Cooking demonstrations follow food safety and allergy rules.
- Every staff member and volunteer passes a background check and completes safety training.
- Staff work in pairs or in view of others whenever participants are minors or in a vulnerable situation.
- We keep an emergency plan at every site, and participants complete an emergency contact form.
- We keep records private, share them only with a participant's permission or as the law requires and follow a written policy.

Equipment. We buy about $7,000 of equipment once at the start: laptops and projector for workshops ($3,000), portable cooking demonstration kits ($2,000), blood pressure cuffs, scales and demonstration tools for loan ($2,000). Later years replace or add a few items.

Staffing. In Year 1 I serve as Executive Director. The Program Coordinator, paid $42,000 a year, manages workshops and partners. Two part-time health coaches, each paid $20,000 a year, lead workshops and follow-up. We add coaches as we add sites.

Management & Organization

Dr. Angela Whitfield, Executive Director. I lead the organization, report to the board and am responsible for budgets, partnerships and reporting. I came to this work as a nurse who saw patients return again and again with the same preventable problems. I will complete the training we require of our lay leaders so I understand the program from the inside. (Replace this paragraph with your own background.)

Staff. The Program Coordinator manages workshops and partners, and part-time health coaches and lay leaders lead sessions. Each passes a background check. These positions are part of our grant request.

Board of directors. Our volunteer board includes a nurse, a pharmacist, a person living with diabetes, a banker who serves as treasurer, an attorney and a pastor. The board meets every other month, approves our budget and reviews our safety plan. No board member is paid, and members with a conflict of interest step out of related decisions.

Advisory partners. A physician, a dietitian and a county health department staff member give guidance twice a year.

Staffing and pay in this plan: Executive Director, paid $50,000 a year; program Coordinator, paid $42,000 a year; health Coach (part-time), paid $20,000 a year.

Milestones Narrative

Our goals, how we will measure them and when we plan to reach them.

Year 1 outcomes (July 2027 through June 2028):
- Serve about 150 participants at 3 sites.
- Run at least two full seasons and a summer session.
- Have at least 85 percent of participants attend most sessions.
- Have at least 80 percent of participants return for a second season.
- Receive positive feedback from at least 90 percent of families who answer our short survey.

What we count and how.
- Participants enrolled, sessions and games attended, from our records.
- Skills learned and goals met, from the coach's checklist.
- Equipment issued and returned, from our log.
- Participant and family feedback, from a short, confidential form.
We report what we find, including what did not work, and use it to improve.

Growth over five years.
- Year 2: About 220 participants at 4 sites.
- Year 3: About 290 participants at 5 sites.
- Year 4: About 360 participants at 6 sites.
- Year 5: About 430 participants at 7 sites.

Learning along the way. At the end of each quarter, the director and the board review the numbers and decide whether we are on track. If we are behind, we will adjust our outreach, our sites or our schedule before asking for more money.

After the grant. By Year 5, grants make up about 48 percent of our budget, down from about 63 percent in Year 1, as partners and donors give more. We will keep building those relationships every year.

Funding Request

What we are asking for, and how the money will be used. Our request: $50,000 from the Carolina Community Health Foundation for the Program Coordinator and home monitoring supplies, for July 2027 through June 2028.

The request is spread across these budget lines:
- Personnel: Program Coordinator salary, $42,000.
- Supplies: Home monitoring supplies and workshop materials, $8,000.

Other money in the program. This request is about 45% of our Year 1 grant income. Other grants and the income lines below pay for everything it does not cover.

Year 1 budget: about $176,500, planned to balance with a small surplus (about $7,100 after the yearly wear on equipment). Year 1 money coming in: Grant Revenue $110,500; state Chronic Disease Funding $36,000; health System Partners $22,000; individual Donors $8,000. Year 1 costs: executive Director $50,000; program Coordinator $42,000; health Coach (part-time) $20,000; workshop Materials and Supplies about $6,000; healthy Food and Cooking Demonstrations about $6,000; home Monitoring Supplies about $8,000; transportation about $4,000; leader Training about $4,000; administration and Insurance about $8,000; about $3,000 a year for the wear on equipment.

One-time startup costs. Startup costs of $14,000 are paid once from startup money, not from the yearly budget: $3,000 for laptops and projector for workshops; $2,000 for portable cooking demonstration kits; $2,000 for blood pressure cuffs, scales and demonstration tools for loan; $2,000 for attorney review of the consent form, privacy policy and workshop agreement; $1,500 for banners, flyers and a simple website; $1,500 for lay leader training and background checks; $2,000 for first insurance payment.

How we got our startup number. The Funding Need Calculator in this plan adds the startup costs ($14,000), the cash the program uses before it balances (about $0) and a cash cushion of about $42,000, which is about three months of Year 1 costs. In all, that comes to $56,000. We start with $6,000 from our founding board and $52,000 in startup support from a community foundation and a health system, $58,000 in all, which covers that amount with room to spare.

The next five years. Our budget grows from about $176,500 in Year 1 to about $250,000 in Year 5. Grants are planned at $110,500, $118,000, $104,500, $112,000 and $120,000 in Years 1 to 5. Other income grows: state Chronic Disease Funding from $36,000 to $60,000; health System Partners from $22,000 to $46,000; individual Donors from $8,000 to $24,000. Our surplus is planned at about $7,100 in Year 1, about $8,700 in Year 2, about $9,100 in Year 3, about $10,400 in Year 4 and about $12,100 in Year 5. We grow from 3 sites to 7 by Year 5, adding a part-time coach for each new site.

Savings. We plan to keep several months of costs in savings. The lowest year-end balance in the plan is about $52,400, at the end of Year 1. Some grant payments and partner payments arrive after we bill, so we plan for about $7,060 owed to us at the end of Year 1.

Cost per participant. In Year 1, our total costs are about $1,129 per participant served, which includes setting up the program. By Year 5, with more participant served and a trained team in place, that falls to about $553 per participant.

After the grant. State chronic disease funding, corporate sponsors and individual donors grow every year, so grants become a smaller share of our budget. Participants and families share their stories, and businesses can sponsor a team or a season by name. We will look for partnerships with schools and the city that want a safe, free chronic disease self-management option for every child.

Risks and how we will handle them:
- An injury. Certified coaches, proper equipment, groups matched by age and skill, a written emergency plan and insurance.
- A site is no longer available. We keep agreements with more than one site and a plan for bad weather.
- A coach leaves. We keep a list of trained backup coaches and share lesson plans.
- Low attendance. We adjust sites, times and rides based on family feedback.
- A privacy problem. We follow a written policy, use secure systems and train every staff member and volunteer.
- A grant ends. We keep savings and grow partner and donor support each year.

If you are just starting. A new organization can begin before it has its own 501(c)(3) status through a fiscal sponsor: an established nonprofit that receives grants for you and passes them to your program, usually for a fee (commonly around 5% to 10% of the grant, sometimes more; ask before you agree). Another way is to start smaller: one neighborhood, a handful of participants and a small team, tracked carefully. Strong results from a small start make larger grants easier to win.

Appendix Notes

Documents to attach with this proposal:

- Your IRS 501(c)(3) determination letter, or your fiscal sponsor agreement.
- Your most recent financial statements and your current year budget.
- A list of your board members and what each one does.
- Signed letters of support from partner schools, agencies and sites.
- Your site agreements and your insurance certificate.
- Your consent, waiver and privacy policy.
- Your safety plan and background check policy.
- Your program outline and schedule.
- Quotes for equipment and materials.
- Resumes for your Executive Director and key staff.
If you don't have any of this yet, no worries - let's continue.

The assumptions behind our numbers (change them in the Financials section to match your own):
- Grant Revenue: $110,500 in Year 1, growing to $120,000 in Year 5.
- State Chronic Disease Funding: $36,000 in Year 1, growing to $60,000 in Year 5.
- Health System Partners: $22,000 in Year 1, growing to $46,000 in Year 5.
- Individual Donors: $8,000 in Year 1, growing to $24,000 in Year 5.
- Pay (a full year, per person, including payroll taxes and workers' compensation): executive Director $50,000; program Coordinator $42,000; health Coach (part-time) $20,000.
- Other yearly costs in Year 1: workshop Materials and Supplies $6,000; healthy Food and Cooking Demonstrations $6,000; home Monitoring Supplies $8,000; transportation $4,000; leader Training $4,000; administration and Insurance $8,000. These grow between 4% and 5% a year.
- Equipment: $7,000 at the start, then $1,500 to $2,500 a year.
- Startup costs: $14,000, paid once from $58,000 in startup money.
- Participants served: about 150 in Year 1, growing to about 430 in Year 5. Sites: 3 in Year 1, growing to 7 by Year 5. Workshops run in six-week cycles throughout the year.
- About 4% of each year's income is still owed to us at year end.
- Tax: none, as a nonprofit.
- Every dollar amount is an estimate. Replace them with your own quotes and real budget.

Startup Costs