Improving the lives of older Americans Healthy Aging: Why Does it Matter? How Do We Get There? Nancy Whitelaw, PhD Senior Vice President, Healthy Aging

Improving the lives of older Americans Healthy Aging:Why Does it Matter?

How Do We Get There?

Nancy Whitelaw, PhDSenior Vice President, Healthy Aging

National Council on AgingSeptember, 2008

© 2008. Copyright NCOA

Overview Health Promotion & Impact on Health and

Well-being of Older Adults Models and Principles

• Promotion is a systems change strategy, not just a service.

Evidence-based Prevention Movement National Attention – More is Needed


What Is Healthy Aging?

Healthy Aging Research Network Holistic Definition

The development and maintenance of optimal physical, mental and social well-being and function in older adults.

Key contributors to healthy aging:• Physical environments and communities are safe,

and support the adoption and maintenance by individuals of attitudes and behaviors known to promote health and well-being;

• Effective use of community programs and health services to prevent or minimize the impact of acute and chronic disease on function.


0

1000

2000

3000

4000

5000

6000

7000

1980

1982

1984

1986

1988

1990

1992

1994

1996

1998

2000

2002

2004

United StatesGermanyCanadaFranceAustraliaUnited Kingdom

Source: K. Davis, C. Schoen, S. Guterman, T. Shih, S. C. Schoenbaum, and I. Weinbaum, Slowing the Growth of U.S. Health Care Expenditures: What Are the Options?, The Commonwealth Fund, January 2007, updated with 2007 OECD data

Average Spending on Health (per capita)

© 2008. Copyright NCOA5

Source: Congressional Budget Office, June 2008

A Joint Proposal of NASUA and n4a

Spending as Percent of Gross Domestic Product


Our nation spends more on health care than any other country in the world.

Mensah: www.nga.org/Files/ppt/0412academyMensah.ppt#22

Life Expectancy by Health Care Spending


Genetic Predisposition

30%

Access to Medical

Care10%

Determinants of Health – Proportions of Premature Mortality

Behavior40%

SocialCircumstances

15%

Environmental Exposures

5%

Source: McGinnis JM, Russo PG, Knickman, JR. Health Affairs, April 2002. Premature mortality: Years of Potential Life Lost (YPLL) subtracts the age a person dies from their life expectancy.


Misalignment in Spending Undermines Optimal Health

Factors Influencing Health National Health Expenditures

Health Behaviors

Genetics

Access to Care

Social & Environment

Access to Care

Health BehaviorsOther

10%

20%

30%

40%

$1.2 Trillion

88%

8%

4%

Sources: Centers for Disease Control and Prevention, University of California at San Francisco, Institute of the Future, 2000.


www.cdc.gov/nccdphp/publications/burden; National Vital Statistics System, National Center for Health Statistics, CDC

190.5–230.8

231.1–250.0

255.5–284.8

285.1–354.9

United States - 172

Total Cardiovascular Disease Deaths, 1999(per 100,000 population)


Byers et al. Prev Med, 1998

Variation in Heart Disease Rates, Why? 200% difference between high and low states Nearly 2/3 of the difference in death rates is

explained by differences in modifiable risks• Tobacco• Physical inactivity• Overweight• High blood pressure• High cholesterol• Diabetes


Disability Increases with Age, But at Much Higher Rates Among the Obese*

*Data based on 1996 National Health Interview SurveySources: National Business Group on Health; Rand Corp.

Age Group

18-29 30-39 40-49 50-59 60-69

1,200

900

600

300

0

per 10,000 people

Obese

Non-Obese


Disability by Age and Health Risk

Progression of disability delayed approximately 7 years in low risk vs. high risk.

Study of University of Pennsylvania AlumniRisk based upon BMI, smoking, exerciseNote: A disability index of 0.1 = minimal disability.Vita et al. NEJM, 1998.


73% age 65-74 report no regular physical activity

81% age 75+ report no regular physical activity

61% unhealthy weight 33% fall each year 15%-20% clinically significant depression 35% no flu shot in past 12 months 45% no pneumococcal vaccine 20% prescribed “unsuitable” medications

www.cdc.gov/nchs

Threats to Health and Well-Being Among Seniors


Health Promotion Works for 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

www.healthyagingprograms.org/content.asp?sectionid=85&ElementID=304


Confronting our Challenges Ageism in health promotion and disease

prevention Great disparities based upon race, ethnicity,

income, location Science not shared – growing body of

evidence of interventions that can positively impact health, disability and quality of life

Untapped assets of 29,000 organizations currently reaching 7-10 million older adults

Fragmented systems and services across aging, medical care, mental health and public health


Changing Direction – Guiding Principles Primacy for Prevention Dependence on Science Quest for Equity and Social Justice Interdependence of Essential Partners

• Health care• Public health• Mental health• Aging and long-term care• Employers• Environmental design

*James Marks, MD, MPH when Director, National Center for Chronic Disease Prevention and Health Promotion, CDC


Evidence of a problem does NOT change behavior.

"...in spite of the multitude of evidence that physical activity improves health status, prevents a number of negative health outcomes, and improves quality of life in individuals across the age spectrum, leisure time and structured physical activity levels have changed very little over the last few decades, especially in older persons. No matter how strong the evidence that physical activity delays disability, this information by itself has not been effective in modifying individual behavior."

Luigi Ferrucci, NIA in JG:MS:2006:1154-55


Individual

Interpersonal

Organizational

Community

Public Policy

McLeroy et al., 1988, Health Educ Q; Sallis et al., 1998, Am J Prev Med

Social Ecologic Model of Healthy Aging


Health and well-being will be improved only if we work from a broad perspective.

Comprehensive planning and partnerships at all levels are required.

Harassing individuals about their bad habits has very little impact.

Changes at the individual level will come with improvements at the organizational, community and policy levels.

Make the right choice the easy choice.

What the Social-Ecological Perspectives Says


The ‘Innovation’ Challenge


National movement to address to the epidemic of chronic diseases through prevention and risk factor reduction programs in community settings

• Multiple federal, state and local agencies• Public, philanthropic and corporate partners• Reaching diverse older adults in convenient,

accessible community settings

Evidence-Based Prevention Movement: Leveraging and Strengthening the Community


US Administration on Aging & Aging Services Network

• 2003 Community Grantees: $8,400,000/$12,000,000• 2006-2007 24 State Grants:

$21,000,000/$28,000,000• Hispanic Elders Project• Evidence-based Intervention Grants - Alzheimer’s

Disease and Related Disorders: $8,000,000• “Evidence-based prevention and promotion” into the

Older Americans Act• States encourage/mandate evidence-based

programming for Area Agencies and they in turn for service delivery organizations

National Investments – Modest but Effective


More Investments Centers for Disease Control and Prevention Medicare

• QIO 9th Scope of Work Medicaid

• Proposed: Kerry–Grassley S. 3327 Empowered At Home Act

• State Waiver Program Improvements in Case Management (e.g., Meds Mgt; Healthy IDEAS)

Substance Abuse and Mental Health Services Adm.

AHRQ, HRSA and other DHHS Philanthropy


Evidence-Based Prevention

1. Evidence about the health issue that supports the statement, “Something should be done.”

2. Evidence about a tested intervention or model that supports the statement, “This should be done.”

3. Evidence about the design, context and attractiveness of the program that supports the statement, “How this should be done.”

* Bronson and others

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-based interventions Improved organizational capacity Broad-based coalitions and networks Population-focus Strategic partnerships Effective, targeted advocacy

Multi-Component Strategy to Achieve Impact


Science Not Shared –Interventions That Work

CHRONIC DISEASE SELF-MANAGEMENT PROGRAM Lorig KR et al. (1999) Medical Care.

ENHANCE FITNESS: Wallace, JI et al. (1998) Journal of Gerontology.

ENHANCE WELLNESS: Leveille et al. (1998) Journal of American Geriatrics Society

MATTER OF BALANCE: Tennsdedt, S et al. (1998) Journal of Gerontology.

PEARLS: Ciechanowski, P et al. (2004) Journal of the American Medical Association.

Healthy IDEAS: Quijano, L et al. (2007) Journal of Applied Gerontology

And others …


Community Resources - Aging Service Settings Area agencies on aging / local offices on aging Case management programs Senior centers Social service organizations Meal programs Senior congregate housing Adult day services Faith-based service organizations Churches, congregations Community centers, cultural centers Personal residence


The Value Added by Community Resources Key characteristics of community settings:

• 29,000+ organizations nationwide• Reach 10 million seniors, especially low-income, frail

and minorities• Staff and volunteers are trusted intermediaries• Agencies deliver cost-effective programs• Agencies involve older people as part of the solution

Key strengths of community settings• Outreach, screening, assessment, education• Support for self-efficacy and self-care • Peer support• Regular, positive reinforcement• Attention to social and cultural context


Evidence-Based Disease Prevention Grants

Metropolitan Area Projects of HHS Hispanic Elders Health Initiative

MA

AK

Hawaii

MT

ID

WA

CO

WY

NV

CA

NMAZ

MN

KS

TX

IA

WI

IL

KY

TN

OH

MI

ALMS

AR

LA

GA

FL

SC

WV VA

NC

MD

DE

PA NJ

OR

UT

SD

ND

MO

OK

NE

NY

ME VT

NH

CT

Guam

NorthernMarianas

IN

Funded by or Working with NCOA

RI

State Projects Funded by AoALocal Projects on Linkages between Aging Services and Health Care Providers for Evidence-based Programming


15 State Grantees – Early Reach and Adoption 7000 Participants

• 55% age 75+• 50% living alone• 25% male• 35% racial or ethnic “minority”

500 Organizations• 75 host/lead organizations• 400 program sites• Area agencies on aging / local offices on aging• Social service and case management agencies• Senior centers and senior housing • Adult day services• Faith-based service organizations, churches,

congregations• Community centers, cultural centers


Hawaii – 10:45 Monday Chronic Disease Self-Management Workshops

• 29 workshops at 21 sites on 4 islands• 314 participants

Mean age 72.5 47% Hawaiian, 28% Filipino, 18% Japanese, 17% White

Enhance Fitness• 6 sites on 2 islands• 141 participants

Mean age 77


Front Line Systems Changes NYC Department for the Aging – evidence-based

programming in developing wellness centers Texas Association of Area Agencies on Aging – cross

state collaboration for diffusion of Matter of Balance WI embeds evidence-based health promotion in $30

million state funding of aging resource centers NJ Office of Minority and Multi-Cultural Health targets

prevention and aging for grants program CA embedding prevention programming via courses in

the community colleges MASSHealth targeted for senior health promotion WA funds initial development of comprehensive fall

prevention strategy ME incorporate Healthy IDEAS into Medicaid care

management

© 2008. Copyright NCOA33


Project 2020: Building on the Promise of Home and Community-Based Services Led by n4a and NASUA (National Association of

State Units on Aging) Language in 2006 Reauthorization of Older

Americans Act Seeking appropriations to match the authorizing

language Using the past five years’ worth of tested and

proven best practices


Component Service

Person-Centered Access to Information

Provides assistance, access, counseling and awareness of long-term care services and supports

Evidence-Based Disease Prevention and Health Promotion

Targets scientifically proven interventions to reduce chronic disease and disability to affected elderly individuals

Enhanced Nursing Home Diversion Services

Provides consumer directed community care to individuals at high risk of institutionalization

34A Joint Proposal of NASUA and

n4a


Components of the Project 2020 Proposal


Component Eligibility Criteria

Estimated Number of Recipients (5 years)

Estimated Number of Recipients (10 years)

Person-Centered Access to Information

Anyone interested in Long-Term Care

40 million 105 million

Evidence-Based Disease Prevention and Health Promotion

Individuals 60 or older or who are at risk of falls, have chronic illness, etc.

1.2 million 3.9 million

Enhanced Nursing Home Diversion Services

300 percent of SSI with assets not in excess of $25,000

118,000 164,000


35

Proposed Number of Participants


Call to Act Prevention is essential to improving health and

reducing disability among older adults. The social-ecological approach is the solution. Community organizations have a significant

opportunity NOW.

Individual

Interpersonal

Organizational

Community

Public Policy


www.healthyagingprograms.org

Documents

Improving the lives of older Americans Healthy Aging: Why Does it Matter? How Do We Get There? Nancy Whitelaw, PhD Senior Vice President, Healthy Aging