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, 2013 8:00 am to 9:15 Lake Superior Ballroom, City side

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

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.

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

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

EBP’s have Demonstrated Outcomes

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

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, 1443-1463.

How can Evidence Based Programs help?

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.

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

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.

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 10-15 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

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.

Living Well With Chronic Conditions Workshops (CDSMP)

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

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

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.

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 www.mnhealthyaging.org for a listing of workshops or call Senior Linkage Line 1-800-333-2433

Resources Minnesota Board on Aging: http://www.mnaging.org/ National Council on Aging (NCOA): http://www.ncoa.org/   NCOA: Center for Healthy Aging http://www.ncoa.org/improve-health/center-for-healthy-aging/ Online Training Modules: http://www.ncoa.org/improve-health/center-for-healthy-aging/online- training-modules/ Highest Tier Evidence-Based Health Promotion/Disease Prevention Programs http://www.ncoa.org/improve-health/center-for-healthy-aging/content- library/Title-IIID-Highest-Tier-Evidence-FINAL.pdf Stanford Patient Education Research Center: http://patienteducation.stanford.edu/

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

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

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!

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

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

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

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

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

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.

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

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.

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

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

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.

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 www.mnhealthyaging.org for a listing of workshops or call Senior Linkage Line 1-800-333-2433

Resources Minnesota Board on Aging: http://www.mnaging.org/ National Council on Aging (NCOA): http://www.ncoa.org/   NCOA: Center for Healthy Aging http://www.ncoa.org/improve-health/center-for-healthy-aging/ Online Training Modules: http://www.ncoa.org/improve-health/center-for-healthy-aging/online- training-modules/ Highest Tier Evidence-Based Health Promotion/Disease Prevention Programs http://www.ncoa.org/improve-health/center-for-healthy-aging/content- library/Title-IIID-Highest-Tier-Evidence-FINAL.pdf Stanford Patient Education Research Center: http://patienteducation.stanford.edu/

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

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

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?

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

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!

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

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

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 organizations @ $30/class - Comment on data - But maybe the most telling are the comments people have made

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

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.

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

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)

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

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

Additional TCMFBB info NCOA link to TCMFBB: http://www.ncoa.org/improve-health/center-for-healthy-aging/tai-chi-moving-for-better.html Research basis for TCMBB: “Tai Chi and fall reductions in older adults: a randomized controlled trial,” Journal of Gerontology, 2005: http://www.ncbi.nlm.nih.gov/pubmed/15814861 “Translation into Community-based Falls Prevention Program,” 2008, American Journal of Public Health: http://www.ncbi.nlm.nih.gov/pmc/articles/PMC2424086/ “Tai Chi and Postural Stability in Patients with Parkinson's Disease,” 2012, New England Journal of Medicine: http://www.nejm.org/doi/full/10.1056/NEJMoa1107911

MN Healthy Aging website

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 www.mnhealthyaging.org for a listing of workshops or call Senior Linkage Line 1-800-333-2433

Contact Information: Mary Hertel, RN EBHP Coordinator/Trainer Central MN Council on Aging Direct:320-202-6945 Agency: 320-253-9349 Mary.hertel@cmcoa.org Debra Laine, Special Programs Developer Arrowhead Area Agency on Aging 218-529-7534 dlaine@ardc.org Dave Fink, Program Developer Metropolitan Area Agency on Aging 651-917-4633 dfink@tcaging.org

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