1. Healthy Aging: Why Does it Matter? How Do We Get There?
Nancy Whitelaw, PhD
Senior Vice President, Healthy Aging
National Council on Aging
September, 2008

2. 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

3. 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.

4. Average Spending on Health (per capita)
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

5. Spending as Percent of Gross Domestic Product
Source: Congressional Budget Office, June 2008
A Joint Proposal of NASUA and n4a 5

6. Life Expectancy by Health Care Spending
Our nation spends more on health care than any other country in the world.
Mensah:

7. Determinants of Health – Proportions of Premature Mortality
Genetic Predisposition
30%
Social Circumstances 15%
Environmental Exposures 5%
Access to Medical Care
10%
Behavior
40%
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.

8. Misalignment in Spending Undermines Optimal Health
$1.2 Trillion
Health Behaviors 4%
Other
40%
Health Behaviors 8%
30%
Genetics
88%
Access to Care
Social &
Environment
20%
10%
Access to Care
Sources: Centers for Disease Control and Prevention, University of California at San Francisco, Institute of the Future, 2000.

9. Total Cardiovascular Disease Deaths, 1999 (per 100,000 population)
190.5–230.8
231.1–250.0
255.5–284.8
285.1–354.9
United States - 172
National Vital Statistics System, National Center for Health Statistics, CDC

10. 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
Byers et al. Prev Med, 1998

11. Disability Increases with Age, But at Much Higher Rates Among the Obese*
*Data based on 1996 National Health Interview Survey
Sources: National Business Group on Health; Rand Corp.
Age Group
18-29
30-39
40-49
50-59
60-69
1,200
900
600
300
per 10,000 people
Obese
Non-Obese

12. Disability by Age and Health Risk
Progression of disability delayed approximately 7 years in low risk vs. high risk.
Study of University of Pennsylvania Alumni
Risk based upon BMI, smoking, exercise
Note: A disability index of 0.1 = minimal disability.
Vita et al. NEJM, 1998.

13. Threats to Health and Well-Being Among Seniors
73% age 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

14. 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

15. 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

16. 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

17. 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:  

18. Social Ecologic Model of Healthy Aging
Individual
Interpersonal
Organizational
Community
Public Policy
McLeroy et al., 1988, Health Educ Q; Sallis et al., 1998, Am J Prev Med

19. What the Social-Ecological Perspectives Says
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.

20. The ‘Innovation’ Challenge

21. Evidence-Based Prevention Movement: Leveraging and Strengthening the Community
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

22. National Investments – Modest but Effective
US Administration on Aging & Aging Services Network
2003 Community Grantees: $8,400,000/$12,000,000
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

23. More Investments Centers for Disease Control and Prevention Medicare
QIO 9th Scope of Work
Medicaid
Proposed: Kerry–Grassley S 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

24. 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

25. Multi-Component Strategy to Achieve Impact
Evidence-based interventions
Improved organizational capacity
Broad-based coalitions and networks
Population-focus
Strategic partnerships
Effective, targeted advocacy

26. 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 …

27. 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

28. 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

29. Evidence-Based Disease Prevention GrantsAK WA VT ME MT ND MN OR NH ID WI NY MA SD WY MI RI CT PA NJ IA NE
Hawaii NV OH DE IL IN UT CO WV VA MD KS KY CA MO
Guam
Northern
Marianas NC TN OK AZ NM AR SC GA MS AL TX LA FL
Metropolitan Area Projects of HHS Hispanic Elders Health Initiative
Funded by or Working with NCOA
Local Projects on Linkages between Aging Services and Health Care Providers for Evidence-based Programming
State Projects Funded by AoA

30. 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

31. 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

32. 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

33. 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
Jointly presented the concept to the ASA/NCOA conference the last week in March.
A Joint Proposal of NASUA and n4a 33 33

34. Components of the Project 2020 Proposal
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
A Joint Proposal of NASUA and n4a
A Joint Proposal of NASUA and n4a 34

35. Proposed Number of Participants
Component
Eligibility Criteria
Estimated Number of Recipients
(5 years)
(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 35

36. 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