EvidenceBased Healthy Aging Programs for Older Adults

1
Evidence-Based Healthy Aging Programs for Older
Adults

• SHIP Directors Conference
• June 10-13, 2007

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Evidence-Based Prevention

• A process of planning, implementing, and
  evaluating programs adapted from tested models or
  interventions in order to address health issues
  in an ecological context
• Evidence about the health issue that supports the
  statement, Something should be done.
• Evidence about a tested intervention or model
  that supports the statement, This should be
  done.
• Evidence about the design, context and
  attractiveness of the program that supports the
  statement, How this should be done.
• Bronson and others

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Empowering Older Adults to Take More Control of
Their Health

• Evidence-Based Prevention Programming for Older
  Adults
• Donald Grantt
• Center for Planning and Policy Development
• US Administration on Aging

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Older Americans Act Health Objectives

• (2) The best possible physical and mental health
  which science can make available and without
  regard to economic status.
• (9) Immediate benefit from proven research
  knowledge which can sustain and improve health
  and happiness.

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• Presidents HealthierUS goal
• HHS Secretary Leavitts prevention priority
• Assistant Secretary on Agings Strategic Plan

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AoA Strategic Plan Priorities

• Creating a More Balanced System of Long Term Care
• Promoting Health and Disease Prevention
• Supporting our Nations Family Caregivers
• Ensuring Rights of Older Persons and Preventing
  Abuse, Neglect Exploitation

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AoAs Choices for Independence Initiative

• Empowers individuals to make informed decisions
  about their long-term support options
• Aging and Disability Resource Centers
• Provides more choices and flexible funding for
  individuals at high-risk of nursing home
  placement
• Consumer direction and cash and counseling models
• Enables older people to make lifestyle
  modifications that can reduce their risk of
  disease, disability, and injury
• Evidence-based health promotion and disease
  prevention programs through local aging services
  provider organizations

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HHS Partnerships

• Translate Results of HHS Research into Community
  Service Programs for the Elderly
• Research Primarily From CDC, NIH, AHRQ, and CMS
  

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AoA Disease Prevention Demonstration Program

• Modeled after John A. Hartford Foundation Program
  (4 grants - 3 years) NCOA Resource Center
• AoA funded 12 demonstration grants for 3 years at
  6M
• Grant to NCOA for National Resource Center

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Local Grantees (2003-2007)

• Albany, NY
• Grand Rapids, MI
• Hartford, CT
• Houston, TX
• 2 Programs
• Los Angeles, CA
• 2 Programs

• Philadelphia, PA
• Portland, OR
• Portland, ME
• San Antonio, TX
• Miami, FL

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US Administration on Aging Initiative

• July, 2006 HHS Secretary Mike Leavitt Announces
  15 Million Collaboration on Prevention for Older
  Americans
• Simply put, this collaboration will put the
  results of our research investments into the
  hands of older people so they can use it to
  improve the quality of their lives.  
• HHS research has generated a growing body of
  scientific evidence on the effectiveness of
  interventions that can help older people to
  improve their health status by better managing
  their chronic diseases, improving their nutrition
  and diet, exercising more, and avoiding injuries
  such as falls.
• HHS, AP, and NCOA are supporting efforts to
  mobilize public/private collaborations that will
  support the delivery of evidence-based programs
  for seniors at the community level.

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24 State Grantees

• Arizona
• Arkansas
• California
• Colorado
• Connecticut
• Florida
• Hawaii
• Idaho

• Iowa
• Illinois
• Maryland
• Maine
• Massachusetts
• Michigan
• Minnesota
• New Jersey

• New York
• North Carolina
• Ohio
• Oklahoma
• Oregon
• South Carolina
• Texas
• Wisconsin

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• Terri Whirrett
• Deputy Director
• South Carolina Lt. Governors Office on Aging

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Need for Evidence-Based Healthy Aging Programs

• SC ranks near the top of the nation for
  prevalence of chronic disease
• Diabetes is the 6th leading cause of death in the
  nation and in SC
• Nearly one out of 12 adults in SC has diabetes,
  the 2nd highest rate in the nation.
• In SC, people 65 and older have nearly 5 times
  higher death rates from diabetes than those in
  the 45-64 year old age group.

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Cardiovascular Disease

• Cardiovascular disease is the leading cause of
  death in SC and the nation.
• People 65 and older have almost 8 times higher
  death rate from stroke and heart disease than
  those in the 45-64 year old age group.

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Arthritis

• Arthritis is the leading cause of disability in
  the nation and SC.
• SC has the 6th highest rate of arthritis in the
  nation.
• Arthritis affects 57 of adults 60 and older in
  SC.
• Arthritis causes activity limitations.
• Lack of exercise and being overweight are
  problems among people over 60 in SC.

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Poor health and disability are not inevitable
consequences of aging
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Chronic Diseases are Often Preventable

• Healthy Lifestyles
• Early Detection of Diseases
• Immunizations
• Prevention (of diseases and injuries)
• Self Management techniques

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Evidence-Based Prevention Programs

• Less than 10 of all published prevention studies
  are translated into practice
• LGOA and DHEC partnership provides an opportunity
  to reduce the gap between the production of
  evidence-based research and implementation in
  community settings

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Benefits of an Evidence-Based Approach

• Science tells us it works
• Increases the likelihood of positive
• outcomes
• Leads to efficient use of resources
• Facilitates the spread of programs
• Uses common performance measures
• Makes it easier to get funding
•  

 
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The Living Well South Carolina program

• Chronic disease self-management program is proven
  to work.
• Chronic diseases and related injuries can be
  improved through not smoking, maintaining a
  healthy weight, and staying active.
• Targeting persons with one or more chronic
  diseases, particularly the rural underserved and
  minorities in rural communities

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Second Program A Matter of Balance (MOB)

• An Evidence-based fall prevention program found
  to improve peoples confidence in ability to
  manage their fear of falling.
• Will be implemented in 6 counties in year two of
  the grant.
• Already being provided in two other counties.
• Targeting persons with fear of falling or concern
  about falling.

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Key Partners

• Partnership for Healthy Aging at State Level
• Health Department
• USC Arnold School of Public Health
• Care Improvement Plus-
• Medicare Special Needs Health Plan in SC
• SC Hospital Association
• 30 Organizations and growing

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Partners at Local Level

• Aging Service providers (5 covering 19 counties)
• Faith-based organizations
• Health care organizations
• Housing facilities/Assisted Living
• AAAs various staff

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Roles of Partners

• Promote the program through own organization.
• Refer older adults with chronic diseases to local
  programs.
• Recommend people with chronic diseases who might
  be interested in becoming volunteer group
  leaders. (They would be trained to conduct the
  classes).
• Provide funding for class materials, program
  group leader trainings, organization licensure,
  promotion materials.

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Potential Roles for SHIPs

• Medicare Prevention
• Screenings- CVD, Diabetes, Bone density
• Shots
• Tests
• Eye
• 1 time initial free exam
• Add referral to Chronic Disease Self
  Management Programs in your state when providing
  education about prevention

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Potential Roles for SHIPs

• Assure that there is a partnership between the
  state and local SHIP offices, and any Medicare
  Special Needs Health plans.
• CDSMP and Special Needs plans both have one
  similar goal Improving the health of persons
  with chronic disease.
• It is hoped that in the future Medicare will see
  the advantage reimbursement of the proven to
  work evidence-based programs that improve health
  outcomes and quality of life of seniors.

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MarylandLiving Well-Take Charge of Your Health

• Joseph V.Gennusa III PhD, RD, LDN
• Nutrition and Health Promotion Programs Manager
• Maryland Department of Aging

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Expressed Need for Evidence-Based Healthy Aging
Programs

• of 60 Marylanders to increase to 23
  (currently 15) by 2030
• Chronic disease Maryland ranks 20th in heart
  disease (236 deaths/100,000) 31st in stroke (54
  deaths/100,000), 16th in Diabetes (28
  deaths/100,000) www.statehealthfacts.org
• Cost 2002- heart and stroke alone 813 million
  in hospital charges while the direct cost of
  physical inactivity and obesity are approximately
  24 billion (2002 Hospital Discharge Survey).

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Evidence-Based Programs Being Implemented

• CDSMP- Assist in controlling chronic disease and
  cost non-disease specific and for grant.
  Current focus on aging population for grant
  purpose
• Arthritis Program- Assist in controlling symptoms
  of arthritis. For individuals with varying
  degrees of arthritis.
• Matter of Balance- Assist in balance efforts for
  individuals to prevent falls. For individuals
  who may be at risk of falls.

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Key Partners

• DHMH- Assisting in Lead role, marketing, and LHD
  contacts as major players
• Howard County Office on Aging- Mentor Agency,
  assisting with bumps and bruises
• GOSV- State partner assisting with volunteers
• GOCI- State partner assisting with Faith Based
  contacts
• Rural Maryland Council- State partner assisting
  with outreach in rural jurisdictions
• CareFirst, Kaiser Permanente, and Care
  Improvement Plus- Assisting in marketing efforts
  of program, with possible long-term coverage for
  members

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Potential Roles for SHIPs

• Future Roles for SHIPs
• 1. Assist in marketing of program to all
  contacts
• 2. Assist contacts in enrolling into Living Well
• 3. Articulate Living Well as a prevention
  benefit for Medicare recipients

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Healthy Choices for MEEvidence-Based Health
Promotion and Prevention Programs for Older
AdultsSHIP Directors ConferenceJune 6,
2007Mary Walsh, Director of Community
ProgramsOffice of Elder ServicesMaine Dept. of
Health and Human Services

• The funding for this program was provided in part
  by grant 90AM312001 from the Administration on
  Aging to the Maine Department of Health and Human
  Services, Office of Elder Services

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The Challenge the Opportunity

• Older adults suffer from chronic diseases,
  injuries and disabling conditions.
• Preventable diseases account for nearly 70 of
  all medical care spending.
• Growing evidence base indicates that changes in
  lifestyle at any age can improve health
  function.
• People want to change unhealthy habits, but need
  support.
• The medical care sector alone can not improve the
  health of older adults with chronic conditions.
• Community agencies have connections to the
  population and untapped capacity.

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Maine Program Goals

• Develop statewide infrastructure
• Create core capacity
• Expand access to rural and underserved areas
• Develop network of volunteers
• Understand system of communication and referral
  patterns

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Healthy Choices for ME Program Dissemination

• Living Well Chronic Disease Self-Management
• A Matter of Balance/Volunteer Lay Leader Model
• EnhanceFitness
• EnhanceWellness
• Healthy IDEAS

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Aging in Maine

• 14.4 of Maines population is 65 or older
  (representing 183,589 people)¹
• Oldest state in nation median age 40.06
• Ranks third in country for highest of older
  adults in population
• 55.8 of Maines older adults live in rural
  settings compared to 21.7 nationally
• Maine ranks 2nd nationwide for of older adults
  living in rural settings²
• Most elderly residents suffer from one or more
  chronic conditions
• For persons aged 65 and older
• 42 are overweight
• 19 are obese
• 36 do not do any leisure time physical activity³
  

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Falls and the Older Adult

• Each year one of every three adults age 65 or
  older falls¹
• Falls are the leading cause of injury
  hospitalization in Maine²
• 1/3 to 1/2 of older adults acknowledge fear of
  falls
• Fear of falling is associated with
• depression
• decreased mobility and social activity
• increased frailty
• increased risk for falls as a result of
  deconditioning
• ¹Analysis of unintentional fall injuries 2004
• ²Healthy Maine 2010

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Depression and the Older Adult

• The rate of depressive symptoms among persons
  receiving long-term care in Maine is twice the
  national average¹
• 40 of the aged 60 and older population in
  residential care or home care have a diagnosis of
  depression²
• ¹ QI data from the national CMS website for the
  first quarter for 2005
• ² MDS,MDS-RCA, and MeCare data

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Strategic Partners

• Maines Department of Health and Human Services,
  Office of Elder Services
• Maine Center for Disease Control and Prevention
• Partnership for Healthy Aging/MaineHealth
• Area Agencies on Aging

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Evidence-Based Prevention

• A process of planning, implementing, and
  evaluating programs adapted from tested models or
  interventions in order to address health issues
  in an ecological context
• Bronson and others

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Philosophy A Participant-Centered Approach

• Personal choice and responsibility for change
• Active participation with peers
• Emphasis on behavior
• Self-efficacy /Self-management
• Cognitive restructuring- thinking about things in
  a different way

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Advantages of an Evidenced- Based Approach

• Increases the likelihood of positive outcomes
• Makes it easier to justify funding
• Helps to establish partnerships esp. with
  healthcare
• Leads to efficient use of resources
• Facilitates the spread of programs
• Facilitates the use of common performance
  measures
• Supports continuous quality improvement

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Benefits to Older Adults

• Longer life
• Reduced disability
• Later onset
• Fewer years of disability prior to death
• Fewer falls
• Improved mental health
• Positive effect on depressive symptoms
• Possible delays in loss of cognitive function
• Lower health care costs

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Living Well - Chronic Disease Self-Management
Program

• Evidence-based, peer led, group program
• People with different diseases participate in
  same group
• Meet 2 ½ hours per week for 6 weeks
• Built on principals of self-efficacy and
  self-management
• Participants learn about
• Symptom management, exercise, nutrition, problem
  solving, communications, advance directives
• Skills and build confidence to deal with the
  medical management, role management, and
  emotional management of their chronic conditions
• Problem solving skills, how to generate
  short-term action plan, and how to act on
  problems

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Living Well Outcomes

• Health Outcomes at 6 Months
• Improved self-rated health
• Decreased disability, pain, shortness of breath
• Improved functioning, decreased social and role
  activities limitations
• Increased energy / decreased fatigue
• Decreased distress with health state
• Fewer days in hospital
• Trend toward fewer outpatient and ER visits
• Cost savings
• Lorig KR, Sobel DS, Stewart AL, Brown Jr BW,
  Ritter PL, González VM, Laurent DD, Holman HR.
  Evidence suggesting that a chronic disease
  self-management program can improve health status
  while reducing utilization and costs A
  randomized trial. Medical Care, 37(1)5-14, 1999.
• Lorig KR, Ritter P, Stewart AL, Sobel DS, Brown
  BW, Bandura A, González VM, Laurent DD, Holman
  HR. Chronic Disease Self-Management Program
  2-Year Health Status and Health Care Utilization
  Outcomes. Medical Care, 39(11),1217-1223, 2001.

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A Matter of Balance

• Benefits anyone who
• is concerned about falls
• has sustained a fall in the past
• restricts activities because of concerns about
  falling
• is interested in improving flexibility, balance
  and strength
• is age 60 or older, ambulatory and able to
  problem-solve.
• During 8 two-hour classes, participants learn to
• View falls and fear of falling as controllable
• Set realistic goals for increasing activity
• Change their environment to reduce fall risk
  factors
• Promote exercise to increase strength and balance

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A Matter of Balance Managing Concerns about
Falls

• A Matter of Balance is a program
• based upon research conducted by the Roybal
  Center for Enhancement of Late-Life Function at
  Boston University
• designed to reduce the fear of falling and
  increase the activity levels of older adults who
  have concerns about falls
• translated into Volunteer Lay Leader Model AoA
  Grant 90AM2780

• Tennsdedt, S., Howland, J., Lachman, M.,
  Peterson, E., Kasten, L. Jette, A. (1998). A
  randomized, controlled trail of a group
  intervention to reduce fear of falling and
  associated activity restriction in older adults.
  Journal of Gerontology, Psychological Sciences,
  54B (6), P384-P392.

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A MOB/VLL Outcomes

• Participant Outcomes at 6 months
• Improvement in
• Falls Efficacy
• Falls Management
• Falls Control
• Exercise level
• Decrease in Monthly Falls
• Class Evaluation Results
• 97 - more comfortable talking about fear of
  falling
• 97 - feel comfortable increasing activity
• 99 - plan to continue exercising
• 98 - would recommend A Matter of Balance
• I am already noticing a difference in my
  physical being. I am sure I am a little more
  mobile than I had been and plan to continue these
  exercises. Hopefully Ill be jumping over the
  moon soon.
• I seem to be more aware of every situation for
  my safety. I now stop, look and listen to my
  surroundings.

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• Designed for older adults with chronic conditions
  at risk for hospitalization. Creates a team with
• Participant
• Registered Nurse
• Social Worker
• Primary Care Physician
• Health Mentor
• Seeks to improve health and functioning and
  reduce unnecessary medical care with
• A health screening and action plan
• Ongoing personal encouragement and feedback
• Problem solving, health education and regular
  monitoring
• Support and links to community services

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Randomized Control Trial Results

• Participants
• Hospital days decreased by 72
• Number of seniors hospitalized decreased by 38
• Meds used for sleep and depression decreased by
  36
• Higher levels of physical activity
• Better functioning in daily living activities
• Health mentors
• Physical function scores increased
• 28 mentors increased exercise
• 22 mentors increased social activity
• 50 increased self-management techniques
• Leveille SG, et al. (1998). Preventing disability
  and managing chronic illness in frail older
  adults A randomized trial of a community-based
  partnership with primary care. Journal of
  American Geriatrics Society, 461-9. URL
  www.americangeriatrics.org

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• EnhanceFitness (formerly Lifetime Fitness)
• a low-cost, highly adaptable exercise program
  offering levels that are challenging enough for
  active older adults and levels that are safe
  enough for the unfit or near frail.
• Exercise components (Core Elements)
• cardiovascular endurance
• strength training
• balance and posture
• Stretching
• Outcomes
• Improved physical and social functioning
• Reduced incidence of pain, fatigue, and
  depression

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Healthy IDEASIdentifying Depression, Empowering
Activities for Seniors

• Evidence-based community depression program
• Embedded in case management programs
• Designed to detect and reduce the severity of
  depressive symptoms
• Two question screening
• 15 item Geriatric Depression Scale (GDS)
• Education about depression and self-care
• Referral, linkage and follow-up for older adults
  with untreated depression partner with health
  care providers
• Behavioral activation linking mood and activity

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Healthy IDEAS Outcomes

• Reduction in depression severity and pain
• Increased knowledge of how to get help for
  depression
• Increased knowledge of how to reduce symptoms
  through increasing activities
• Self report of increased level of physical and
  social activity

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Adoption in Maine

• 31 MOB/VLL Master Trainer Sites
• Agencies on Aging
• Regional Hospitals
• Healthy Maine Partnerships
• YMCAs
• Community Centers
• Retirement Communities
• 63 Master Trainers
• 800 older adult participants
• 135 volunteer coaches

• 9 Living Well Sites
• Agencies on Aging
• Regional Hospitals
• Healthy Maine Partnerships
• 45 volunteer leaders
• 9 EnhanceFitness Sites
• 3 EnhanceWellness Sites
• 1 Healthy IDEAS site in year 2

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SHIP Connection

• Potential for new partnerships
• SHIP counselors have positive, healthy option to
  recommend to consumers
• Share SHIP brochures, information about My Health
  My Medicare, other information with participants
  at sessions

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SHIP Connection

• Performance Requirement Help Medicare
  beneficiaries in their understanding and access
  to program benefits, including Medicare
  prevention services
• Value of self-responsibility
• Consumers attending these classes may need SHIP
  assistance due to high medical costs and/or
  medication needs

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SHIP Connection

• link to 5 requirement to provide counseling to
  low-income dual eligibles with mental
  disabilities
• Chronic Disease Self Management addresses chronic
  physical and mental conditions
• Healthy IDEAS addresses depression, a mental
  disability
• EnhanceWellness and Matter of Balance may also
  help meet 5 requirement