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

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.

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

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

Life Expectancy by Health Care Spending Our nation spends more on health care than any other country in the world. Mensah: www.nga.org/Files/ppt/0412academyMensah.ppt#22

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.

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.

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

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

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

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.

Threats to Health and Well-Being Among Seniors 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

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 

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

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.

The ‘Innovation’ Challenge

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

National Investments – Modest but Effective 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

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 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

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

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 AK 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

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

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

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

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

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