1. Evidence Based Health Promotion: What's the Buzz All About?
Mary Hertel: Central MN Council on Aging
Debra Laine: Arrowhead Area Agency on Aging
Dave Fink: Metropolitan Area Agency on Aging
Tuesday June 18, :00 am to 9:15
Lake Superior Ballroom, City side

2. Information to be presented:
What are Evidence Based programs and why are they important
Research and demonstrated outcomes
How EBP can fit within the patient engagement model, compare/contrast with patient education
Overview of specific EBP’s including Stanford Self-Management, A Matter of Balance and Tai chi: Moving For Better Balance
Describe how you or your organization can get more involved

3. What is Evidence Based health promotion programming?
Simply put it is: programs based on research.
Data from intervention research studies 􀁻“Translational”projects that take proven interventions and adapt them in real world settings
An evidence-based program has been demonstrated to be effective in basic research that involved the same target audience.Then it has been demonstrated to be effective in dissemination in the “real world.” There are clear protocols for training and conduct of the program so that community programs can maintain fidelity and be successful.

4. What evidence do we need?
Evidence that a health issue exists
Evidence about design, context and attractiveness of program
Evidence that a program is effective

5. Why the interest in Evidence Based Programs?
Magnitude and serious of health and social problems in our communities
Awareness of preventability of many problems
Emergence of evidence-based practices and programs
Spend limited resources more efficiently

6. EBP’s have Demonstrated Outcomes

7. Consider:
“people with chronic conditions rarely spend more than 1% of their life at a healthcare facility. It is the other 99% of one’s life - when an individual is at home - that determines whether they return to full health or not.”
Those with ongoing health issues will make many daily health decisions:
Diet, exercise, medication, when to seek medical care
may not fully understand implications of particular health decision
may lack support to make better choices

8. Can Clients Be Engaged?
23% adopted new health behaviors (but unsure could maintain if stressed)
Remaining 77%:
Remain passive recipients (12%)
Lack basic facts to follow treatment recommendations (29%)
Have facts, but no skills, confidence (36%)
Hibbard, J. H., Mahoney, E. R., Stock, R., & Tusler, M. (2007). Do increases in patient activation
result in improved self-management behaviors? Health Services Research, 42,

9. How can Evidence Based Programs help?

10. Self-Management Differs From Patient Education (but we need both)
- Manage life with disease
Problem solve and make decisions
Improve confidence in abilities to make changes
Increase skills & self-confidence
- Change behaviour's
Information, technical skills
Disease–specific knowledge
- Use specific tools (e.g., Care Plans, Action Plans)
A chronic disease may never be cured. We are looking to improve quality of life. Patient education the goal is comliance with behavior to improve the outcomes. Self Management is increased efficacy to improve outcomes.
They must manage the disease(s)
They must maintain their life roles
They must deal with the emotional
consequences of the disease(s)
They are sometimes the only carrier
of vital information.
The patient and health professional working together.
Often involves the family.
An holistic approach to care (i.e., medical and psycho-social components of a condition).
Pro-active and adaptive strategies that aim to empower the individual.

11. Advantages of Evidence Based Programs:
First, they can significantly improve the health and well- being of older adults in the community.
Second, they can help attract new participants and funders through innovative programming.
Third, they can create powerful partnerships with other organizations, including health care providers
Evidence-based programming provides value

12. Lets talk about some of the Evidence Based Programs
Stanford University Self Management Programs:
Chronic Disease Self Management (Living Well with Chronic Conditions)
Chronic Pain Self Management
Diabetic Self Management
Additional programs:
A Matter of Balance
Tai Chi Moving for Better Balance
Example I would like to focus on is CDSMP, Tai Chi and Matter of Balance.

13. Developed by Stanford University’s patient education program
What is the Stanford Chronic Disease Self-Management Program (CDSMP) “Living Well with Chronic Conditions”
Developed by Stanford University’s patient education program
Leader Training 4 Days lead by 2 Master Trainers
Structured participants in a six-week workshop series done by 2 certified leaders
Participative instruction with peer support
Designed to enhance medical treatment
Outcome-driven: impacts show potential for reduced or avoided costs
Evidence-based: a tested model (intervention) that has demonstrated results

14. Living Well with Chronic Conditions Techniques
Action planning
Feedback/ problem solving
Decision Making
Management Tools
Physical
Psychological
Emotional
The process or the way CDSMP is taught is as important, if not more important than the subject matter that is taught.

15. Living Well With Chronic Conditions Workshops (CDSMP)

16. Keys to Success
The format addresses specific problems and goals for people with ongoing health problems. It is not a drop-in support group.
The workshops are not prescriptive. Participants choose their own goals and track their own progress toward success.
Pair of trained peer leaders offer guidance and support, but participants find practical solutions individually and together.
Living Well With Chronic Conditions Workshop

17. Better coping strategies and symptom management;
Evidence CDSMP participants experienced the following outcomes 6 months after starting the CDSMP program
Increased exercise;
Better coping strategies and symptom management;
Better communication with their physicians;
Improvement in their self-rated health, disability, social and role activities, and health distress;
More energy and less fatigue;
Decreased disability;
Fewer physician visits and hospitalizations.
Lorig et al., 1999

18. Stanford’s CDSMP is Evidence-based
Found to benefit targeted populations.
Including a decrease in health care costs
Demonstrated it does not cause harm.
Demonstrated it does not waste resources. CDSMP can facilitate the Triple Aim Goals
Lets do a quick demo!
CDSMP demo: healthy eating or action planning,brainstorm?
Preliminary Results:
~$740 per person savings in ER and hospital utilization
~$390 per person net savings after considering program costs at $350 per participant
Reaching even 10% of
Americans with one or more chronic conditions would
save ~$4.2 billion!
Better Care: improving the experience of care
Better Health: improving population health
Lower Cost: reducing health care costs
*Berwick et al. (2008). The Triple Aim: Care, Health, And Cost. Health Affairs.

19. Options for Involvement
Offer the program(s) at your clinic/organization with your staff, and/or volunteer peer leaders. Training is available through the Area Agencies on Aging
Offer the program at your clinic/organization in partnership with a community provider
Refer your patients to programs that your organization offers or to community partners; visit for a listing of workshops
or call Senior Linkage Line

20. Resources Minnesota Board on Aging: http://www.mnaging.org/
National Council on Aging (NCOA):
NCOA: Center for Healthy Aging
Online Training Modules:
training-modules/
Highest Tier Evidence-Based Health Promotion/Disease Prevention Programs
library/Title-IIID-Highest-Tier-Evidence-FINAL.pdf
Stanford Patient Education Research Center:

21. A Matter of Balance: Managing Concerns about Falls (Falls Prevention)

22. What do we know about falls?
Up to 30% of community dwelling adults fall each year
About 20% of falls cause physical injury
Leading cause of hospitalized injury
Leading cause of ER-treated injury
MN ranks 3rd in the nation in fall related deaths – twice as many per capita as the national average

23. What we know about Falls
1/2 to 2/3 of falls occur around the home
A majority of falls occur during routine activities
Falls usually aren’t caused by just one issue. It’s a combination of things coming together
A large portion of falls are preventable!

24. What we know about Falls
Falls are :
Common
Predictable
Preventable
Falls are not a natural part of aging!

25. What do we know about fear of falling?
It is reasonable to be concerned about falls - safety is important
1/3 to 1/2 of older adults acknowledge fear of falling
Fear of falling is associated with:
decreased satisfaction with life
increased frailty
depression
decreased mobility and social activity
Fear of falling is a risk factor for falls

26. What is A Matter of Balance?
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

27. A Matter of Balance: Managing Concerns About Falls
During 8 two-hour classes, participants learn:
To view falls and fear of falling as controllable
To set realistic goals for increasing activity
To change their environment to reduce fall risk factors
To promote exercise to increase strength and balance

28. A Matter of Balance: Managing Concerns About Falls
What Happens During Classes?
Group discussion
Problem-solving
Skill building
Assertiveness training
Exercise training
Videotapes
Sharing practical solutions

29. Who could benefit from A Matter of Balance?
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.

30. Administration on Aging Grant
In 2003, AoA launched a three year public/private partnership to increase older people’s access to programs that have proven to be effective in reducing their risk of disease, disability and injury Grant Goals: •Develop a volunteer lay leader model and test whether it is successful when compared with original research •Share our approach with others in Maine and around the country

31. A Matter of Balance Outcomes
Participant Outcomes
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
* % who agree to strongly agree
Comments:
I am more aware of my surroundings. I take time to do things and don’t hurry.
I have begun to exercise and am looking forward to a walking program.
I have more pep in not being afraid.

32. Participants Report:
Increased confidence in taking a walk, climbing stairs, carry bundles without falling
More confidence that they can increase their strength, find ways to reduce falls, and protect themselves if they do fall
An increase in the amount they exercise on a regular basis
Fewer falls after taking MOB

33. Impact in MN Steady increase of participants
2012; 845 participants with 721 completers
2011; 777 participants
2010; 444 participants
Less than 1% report no improvement in:
Finding a way to get up from a fall
More steady on feet
Finding a way to reduce a fall
Protecting yourself incase of a fall
Physical activity

34. Do a MOB Activity 2. 4 – “stop light” part and then do Handout 2
Do a MOB Activity 2.4 – “stop light” part and then do Handout 2.1 – Brainstorming Confidence Building thoughts.

35. Options for Involvement
Offer the program(s) at your clinic/organization with your staff, and/or volunteer peer leaders. Training is available through the Area Agencies on Aging
Offer the program at your clinic/organization in partnership with a community provider
Refer your patients to programs that your organization offers or to community partners; visit for a listing of workshops
or call Senior Linkage Line

36. Resources Minnesota Board on Aging: http://www.mnaging.org/
National Council on Aging (NCOA):
NCOA: Center for Healthy Aging
Online Training Modules:
training-modules/
Highest Tier Evidence-Based Health Promotion/Disease Prevention Programs
library/Title-IIID-Highest-Tier-Evidence-FINAL.pdf
Stanford Patient Education Research Center:

38. The Question:
Is there an evidence-based fall prevention program that would be culturally appropriate for and accessible to non-English speaking older adults?
Have great discussion-based programs with CDSMP/Living Well and MOB
However, not translated into all languages and not all older non-English speaking adults can read/write in their language

39. Tai Chi: Moving For Better Balance (TCMFBB)
Developed by Dr. Fuzhong Li, Oregon Research Institute
8 forms of Yang style Tai Chi adapted specifically for fall prevention
Reduces the risk of falls by improving balance, muscle strength, flexibility and mobility
Twice/week for 1 hour plus practice, 2 twelve week sessions
One certified leader
Researched evidence-based programs that had physical activity and no discussion
Found TCMFBB
Checked other states that had tried it – very positive response with everyone I spoke with
Contacted Dr. Li – felt it would be a good one to pilot test in 2012
- NOTE: Also looked at Tai Chi for Arthritis, but at that time it was not on the NCOA list of evidence-based programs – AAAs mandated to focus only on the top tier evidence-based programs

40. Tai Chi origins Monks in the mountains of China 600 years ago
Created as a self-defense martial art
Evolved into a health & wellness exercise program
- Has anyone done Tai Chi? How much? Experience?

41. “Moving meditation” 8 forms that emphasize - weight shifting
- postural alignment
- coordinated movements
4 S’s
slow - soft
smooth - safe
Integrated breathing

42. Seated
&
Standing
OF course, for English speaking as well as non-English
Typically part seated, part standing – but all can be done seated and emphasize to sit when needed!

43. Leader qualifications
No previous Tai Chi experience required
Experience working with older adults & group exercise programs very helpful
Enjoy leading groups
Willing to learn, practice and continually improve

44. Leader training 2 day intensive workshop Led by Dr. Li
Follow-up sessions with local leader
Leader sharing sessions
DVD and tips

45. 2012 pilot test Timeframe: April – December, 2012
10 bilingual leaders trained:
Initial 2-day training
3 two hr. follow-up sessions
Quarterly leader sharing and updates
7 languages: Laotian, Korean, Khmer, Hmong, Somali and Vietnamese and English
Classes: Two 12 week sessions, twice/week for 1 hour
Stipends: To $30/class
- Comment on data
- But maybe the most telling are the comments people have made

46. Pilot test results Participants: 124 first session, 129 second
Retention: 64% attended half or more, 49% attended 3/4 or more
Retention higher in organizations with active existing programming and leaders - 86% attended half or more, 68% attended 3/4 or more
Participation and retention higher with Asian older adults than East African older adults
“Timed up and go” test – avg. 2 second improvement
- Comment on data
- But maybe the most telling are the comments people have made

47. What participants said…
“The Tai Chi class helped me be able to use old muscles I have not used in a while. Now I can stretch my arms up very high.”
“I was walking with a cane for a couple of years. After I join the class I am able to walk without a cane.”
“The Tai Chi exercise program helped me a lot with emotional stress and physical improvement.”
“Because of a stroke, I couldn’t use my arm. But I am able to move and use my arm and lift up to my head.”
– you can read for yourself – but span from concrete physical improvements to enhanced more and reduced stress.

48. What we learned Bilingual leaders are effective
Organizations with existing active older adult programs had stronger participation/retention
Cultural backgrounds may make a difference in participation/retention
Older adults will attend and do benefit
Bilingual leaders were able to learn the program and deliver it effectively to older adults in their communities in their native language.
Leaders who already had some kind of program role and relationship with older adults in the community had a higher participation and retention rate.
Previous knowledge of Tai Chi was not a critical success factor but previous experience leading groups of older adults in physical activities was valuable.
Participation and retention tended to be higher in sites with participants from Asian cultures than participants with East African cultures where Tai Chi specifically and organized exercise in general have been less prominent. However, the Asian organizations represented also tended to already have programs in place and a relationship with the Tai Chi leader, which could well have contributed to the participation differences

49. 2013 participating organizations
Brian Coyle Center Oromo, Somali
Centro Spanish
Common Bond English, Somali, Spanish
Korean Service Center Korean
Lao Advancement Org. of Am Laotian
Presbyterian Homes & Services English
United Cambodian Assn. of MN Khmer
VOA/Park Elder Center Hmong
Vietnamese Social Services Vietnamese
Also, Mahube-Otwa RSVP in Land of the Dancing Sky AAA and Central MN Council on Aging (both in English)

50. A word on funding
MAAA Title IIID funds target non-English speaking older adults
MAAA pays IIID organizations to host Tai Chi classes and funds the leader training
As space allows, other organizations attend leader training and reimburse MAAA for costs

51. What’s next… Metropolitan Area Agency on Aging
3rd training, new organizations and leaders
Land of the Dancing Sky AAA & Mahube-Otwa RVSP
2nd training, more leaders
Central MN Council on Aging
Getting started

52. Additional TCMFBB info
NCOA link to TCMFBB:
Research basis for TCMBB:
“Tai Chi and fall reductions in older adults: a randomized controlled trial,” Journal of Gerontology, 2005:
“Translation into Community-based Falls Prevention Program,” 2008, American Journal of Public Health:
“Tai Chi and Postural Stability in Patients with Parkinson's Disease,” 2012, New England Journal of Medicine:

53. MN Healthy Aging website

54. Options for Involvement
Offer the program(s) at your clinic/organization with your staff, and/or volunteer peer leaders. Training is available through the Area Agencies on Aging
Offer the program at your clinic/organization in partnership with a community provider
Refer your patients to programs that your organization offers or to community partners; visit for a listing of workshops
or call Senior Linkage Line

55. Contact Information:
Mary Hertel, RN EBHP Coordinator/Trainer
Central MN Council on Aging
Direct:
Agency:
Debra Laine, Special Programs Developer
Arrowhead Area Agency on Aging
Dave Fink, Program Developer
Metropolitan Area Agency on Aging

56. Questions ?
“Those things that we do for ourselves, day-to-day that improve or maintain our health and make us feel better”