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
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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
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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.
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0
1000
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5000
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7000
1980
1982
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1988
1990
1992
1994
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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)
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Source: Congressional Budget Office, June 2008
A Joint Proposal of NASUA and n4a
Spending as Percent of Gross Domestic Product
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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
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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.
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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.
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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)
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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
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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
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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.
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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
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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
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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
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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
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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
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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
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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
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The ‘Innovation’ Challenge
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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
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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
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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
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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
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Evidence-based interventions Improved organizational capacity Broad-based coalitions and networks Population-focus Strategic partnerships Effective, targeted advocacy
Multi-Component Strategy to Achieve Impact
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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 …
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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
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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
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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
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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
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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
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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
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A Joint Proposal of NASUA and n4a
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
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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
A Joint Proposal of NASUA and n4a
Components of the Project 2020 Proposal
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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
A Joint Proposal of NASUA and n4a
35
Proposed Number of Participants
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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
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www.healthyagingprograms.org