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Evidence-Based Programs

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Scaling Evidence-Based Health Promotion and Disease Prevention Programs to Promote Healthy Aging

Authored for GIA by Kathleen Cameron, Senior Director of the Center for Healthy Aging at the National Council on Aging (NCOA) and Paige Denison, National Director of Project Enhance: EnhanceFitness/EnhanceWellness and Chair of the Evidence-Based Leadership Council 

Today on average, a person reaching the age of 65 years can expect to live another 20 years. For most older adults, good health ensures independence, security, and productivity as they age. Unfortunately, millions struggle every day with challenges such as chronic conditions like diabetes and arthritis, frequent falls, mobility impairments, nutritional deficiencies, depression and substance use disorders.

Over the past 15 years, several evidence-based programs (EBPs) have been developed to address these challenges and augment the care received in healthcare settings by preventing the progression of existing chronic conditions, the onset of new chronic conditions, as well as falls and injuries, and maintaining or improving healthy behaviors.

Overview: Why Evidence-based Programs are Essential for Healthy Aging

Healthy aging and wellness do not begin and end at the doctor’s office. Health status is affected by socioeconomic factors, social integration, and many other concerns outside the medical setting. Optimal health and well-being is also affected by individual behaviors. Failure to address the clinical, behavioral, and social determinants of health in an integrated manner contributes to poorer outcomes, higher costs and fragmented care. Evidence-based programs address common concerns, such as those described below, in the older adult population that medical settings alone are not able to fully address.

Chronic Conditions

  • Older adults are disproportionally affected by chronic conditions, such as diabetes, arthritis, and heart disease. Eighty percent have at least one chronic condition, and nearly 70% of Medicare beneficiaries have two or more.
  • The leading causes of death among older adults in the U.S. are chronic diseases—heart disease, cancer, stroke, chronic lower respiratory diseases, Alzheimer’s disease, and diabetes.
  • Chronic diseases can limit a person’s ability to perform daily activities, cause them to lose their independence, and result in the need for institutional care, in-home caregivers, or other long-term services and supports.
  • Multiple chronic diseases account for two-thirds of all health care costs and 93% of Medicare spending. Yet, less than 1% of U.S. health care dollars is spent on prevention to improve overall health.

Falls

  • Falls are the leading cause of fatal and nonfatal injuries among older adults, causing hip fractures, head trauma, and death.
  • One out of four older adults falls each year. Twenty percent of all falls result in a serious injury.
  • As a result of falls, every 13 seconds, an older adult is treated in the emergency room; every 19 minutes, an older adult dies.
  • Our nation spends $50 billion a year treating older adults for the effects of falls. Medicare and Medicaid pay for 75 percent of costs associated with falls.
  • Fear of falling can lead older adults to limit their activities, which actually can result in more falls, further physical decline, depression, and social isolation.

Physical Activity

  • Regular exercise can help older adults stay independent and prevent many health problems that come with age. According to the 2008 Physical Activity Guidelines for Americans, older adults should do two types of physical activities each week to improve their health—aerobic and muscle-strengthening.
  • These guidelines recommend that older adults engage in at least 150 minutes of moderate-intensity or 75 minutes of vigorous aerobic activity a week and muscle-strengthening activities on two or more days a week.
  • Less than 16% of Americans aged 65+ meet the physical activity recommendations.

Behavioral Health

  • One in four older adults experiences a behavioral health problem such as depression, anxiety, or substance use disorders.
  • These problems can complicate the treatment of other medical conditions, reduce quality of life, increase use of health care services, and lead to premature death.
  • In 2014, nearly 11,000 people 60+ died by suicide. Men aged 85+ have a suicide rate that is about four times higher than the rate for all ages.
  • Excessive alcohol use accounts for more than 23,000 deaths among older Americans each year.
  • Depression and other behavioral health problems are not a normal part of aging and can be treated. Despite the availability of effective interventions, 66% of older adults are not receiving the care they need.

History, Definition and Examples of Evidence-based Programming

In the early 2000s, NCOA in partnership with Stanford University Patient Education Center and others began an initiative to identify and document promising evidence-based practices that could be used by aging services providers; disseminate and embed evidence-based practices in aging services delivery; and use these practices to improve the health and well-being of older people.

This work on testing models of self-management led to the launch of a national multi-year effort to disseminate the Chronic Disease Self-Management Program (CDSMP), originally developed by Stanford University, through the aging services network. The initiative employed federal funds under Title IV of the Older Americans Act (2006), the American Recovery and Reinvestment Act (2010), and the Patient Protection and Affordable Care Act Prevention and Public Health Fund (PPHF) (2012). In addition, the initiative was supported by generous support from The Atlantic Philanthropies, the John A. Hartford Foundation, and the Robert Wood Johnson Foundation. The initiative was further enhanced by the development of other programs, including an online version of CDSMP, addressing a variety of health concerns in older adults,

In 2012, the federal Congressional appropriations law included, for the first time, an evidence-based requirement for use of health promotion and disease prevention funding within Title III-D of the Older Americans Act. This change followed over a decade of progress by the Administration on Aging and the aging services network to move efforts toward implementing disease prevention and health promotion programs that are based on scientific evidence and demonstrated to improve the health of older adults. In response to the new requirement, the aging network is now offering these programs nationwide. However, the current national funding of $25million per year for Title III-D is solely inadequate to meet the need for these important programs across the country. 

EBPs are based on rigorous research and provide documented health benefits, so older adults, caregivers, health care providers and the aging network can be confident they work. They demonstrate reliable and consistently positive changes in important health-related and functional measures, such as improved balance and strength as a result of attending a physical activity program or decrease in chronic disease symptomatology as a result of a self-management program. 

These tested model programs have been translated into practical, effective community-based programs. Community-based implementers, such as senior centers, area agencies on aging and senior housing, receive a packaged program with a variety of supportive materials. As a result, a program’s content and fidelity are consistent in all settings, and the program is easy to deliver. Program packages typically include implementation manuals and specialized training materials.

Examples of evidence-based programs are:

  • The Chronic Disease Self-Management Program is a workshop given once a week, for six weeks, for two and a half hours per session. Subjects covered include: techniques to deal with problems such as frustration, fatigue, pain and isolation; appropriate exercise for maintaining and improving strength, flexibility, and endurance; appropriate use of medications; communicating effectively with family, friends, and health professionals; nutrition; decision making, and; how to evaluate new treatments. The process in which the program is taught is what makes it effective. Classes are highly participative, where mutual support and success build the participants’ confidence in their ability to manage their health and maintain active and fulfilling lives.
  • EnhanceFitness is an ongoing class, held three times per week in hourly sessions. Classes include the exercises commonly used to maintain and build physical health in older adults – warm up, cardiovascular workout, cool down, dynamic and static balance exercises, posture and strength training, and stretching. Strength training focuses on upper and lower body muscles, using soft cuff wrist and ankle weights. Cardio training can be anything from walking for 20 minutes to having 20 minutes of more intense exercises, with (optional) music. Classes are appropriate for near frail to more active adults with exercises adapted for those who are more frail.
  • A Matter of Balance is a community-based, small-group program that helps older adults reduce their fear of falling and increase activity levels. It is a train-the-trainer program with highly trained Master Trainers training the Coaches (lay leaders). Coaches work in pairs to lead small group community classes consisting of eight two-hour sessions. The program includes behavior change strategies, as well as practical exercises. The behavior change curriculum helps participants to view falls and the fear of falling as controllable.
  • Healthy IDEAS (Identifying, Depression, Empowering Activities for Seniors) incorporates four evidence based components into the ongoing delivery of care-management or caregiver-support services to older individuals in the home environment:  screening for symptoms of depression and assessing their severity, educating older adults and caregivers about depression; linking older adults to primary care and mental health providers; empowering older adults to manage their depression through a behavioral activation approach that encourages involvement in meaningful activities. It is implemented over a 3-6-month period, through at least three face-to-face visits in the client’s home and at least three telephone contacts. Healthy IDEAS ensures older adults get the help they need to manage symptoms of depression and live full lives.

With the aging of the population and increase in chronic conditions, evidence-based programs will continue to play a critical role in maintaining or improving quality of life, increasing self-efficacy in managing one’s health, promoting positive health behaviors, reducing disability through fewer falls, reducing pain and improving mental health, including positive effects on depressive symptoms.

Trends Related to Evidence-Based Programming

Many evidence-based programs have been able to quantify return on investment (ROI) for the better health of populations that are at disproportionate risk of poor outcomes. Built-in assessments to measure improvements at the participant level make these programs a good choice for data driven decision makers committed to addressing needs in a growing higher risk population. Here are some trending issues where funders can drive impactful change:

Business Acumen: National efforts are underway to prepare the aging network to be more business savvy for more of these partnerships to occur. One example is the National Association of Area Agencies on Aging’s Aging and Disability Business Institute (ADBI) funded by the Administration for Community Living and several Grantmakers in Aging members, including the John A. Hartford Foundation and the SCAN Foundation. The ADBI provides the aging network with tools and resources to successfully adapt to a changing health care environment, enhance their organizational capacity and capitalize on emerging opportunities to diversify funding. The ADBI and other efforts will be critical to prepare the aging network to meet the demands of the aging population and to ensure that older adults receive the care that empowers them to live with dignity and independence in their homes and communities as long as possible.

Pain Management: Evidence-based programs such as Chronic Pain Self-Management and Physical Activity programs that are proven to reduce arthritic pain  meet the first two recommendations on the National Pain Strategy:  1) People experiencing pain would have timely access to patient centered care that meets their biopsychosocial needs and takes into account individual preferences, risks and social contexts, including dependence and addiction and 2) People with pain would have access to educational materials and learn effective approaches for pain self-management programs to prevent, cope with and reduce pain and its disability. Further support in this area could focus on connecting evidence-based programs to existing pain management supports and services to strengthen the continuum of care as well as recruiting leaders who are recovering from opioid dependency.

Falls Prevention: Falls are not a normal part of the aging process, and most falls can be prevented. The risk factors associated with falls include lower body weakness, advanced age, balance difficulties, cognitive changes, co-morbidities, environmental safety risks. Another risk factor sometimes overlooked is the relationship between medications, including opioids, drowsiness and falls. Focused support on routine physician risk assessment and referral into community falls prevention programs could result in health and human cost reduction on a large scale.

Social Isolation:  Social isolation and loneliness can have a major impact on the well-being of older adults. Participation in health promotion programs may have a dual effect of not only addressing the health need intended such as depression, diabetes management, fall prevention etc. but may also improve social activation. Focused support is needed on screening for social isolation as part of routine health screening and follow up referral to evidence-based programs to reduce risk for social isolation (not just reduce social isolation for those already isolated). Additional research in this area on existing programs in a variety of community settings and languages could lead to increased scaling to impact multiple dimensions of wellness.

Supportive Strategies/Housing Security:  Evidence-based programs in partnership with public health can support older adults continuing to age in place. Funding to understand upstream best practice models of building capacity and sustainability in affordable housing would have a policy goal of physical space and budget for these services being established at outset, working upstream to disrupt homelessness and substance abuse.

Social Determinants of Health/Healthcare Integration: An important and necessary recent development is the increasing number of partnerships among community-based organizations and health care entities such as hospitals, Medicare Advantage Plans, Federally Qualified Health Centers, Medicaid managed care providers and others to provide evidence-based programs to their members at risk. These partnerships are mutually beneficial because they provide a sustainable funding source to aging network offering for these programs while also addressing a variety of common and costly concerns to older adults and health care entities. As community based organizations and healthcare providers align to improve access to lower cost upstream services and improving health outcomes, evidence-based programs are a natural point of connection. Funding is needed in communities to pilot these programs as a first step toward integration and realization of triple aim goals and the Age-Friendly Health Systems model. Additional trends in this area include piloting telehealth adaptations for outreach in rural communities.

Caregiver Support and Respite: Targeted respite services can make a real difference in caregiver health.  These low cost, high impact programs make it possible for older adults and their caregivers to live independently and safely in the community and have also been proven to reduce healthcare expenditures. Startup funding could help reach more unpaid caregivers across the nation.

Health Equity: Expanding the scope, availability and access to evidence-based programs to serve diverse populations with multiple languages is a growing need and woefully underfunded. Perhaps not fitting the categorization of “trending”, this is an ongoing need for these high impact programs.

Grantmaker Support

Philanthropic support will be essential to continue to scale evidence-based programs across the country. Grantmakers have been involved in supporting these proven programs in many ways, such as:

  • The Retirement Research Foundation funded Chinese American Service League’s translation of evidence-based programs A Matter of Balance, EnhanceFitness and Healthy IDEAS into Mandarin to improve program access and uptake. This has now opened up the programs to the Chinese community beyond Chicago, having national impact.
  • The AARP Foundation is currently supporting research to assess the impact of the PEARLS a skill-building program to address late-life depression on social isolation and health service utilization, the implementation and evaluation of the Healthy Eating for Successful Living program on improving food access and behavior change, as well as multiple other studies nationally, all with the goal of scaling evidence-based programs to serve increased numbers of low-income adults.
  • The SCAN Foundation has been instrumental in developing tools to address business acumen gaps in community based organizations as they initiate referral pathways to evidence-based programs with healthcare organizations.
  • The Cleveland Foundation, through its Encore Initiative, is supporting Fairhill Partners to recruit, screen and train adults 50+ in Cleveland, Ohio area to become lay leader/coaches and capacity builders for a diverse array evidence-based programs.
  • The Archstone Foundation supported programming costs for the very first online evidence-based Chronic Disease Management program, Better Choices Better Health which led to a larger study funded by the Robert Wood Johnson Foundation. Archstone also supported the first pragmatic trial for the Building Better Caregivers program. Additionally, they funded developers and delivery organizations coming together collaboratively to create the EBLC infrastructure to support increased reach of evidence-based programs.
  • The Tufts Health Plan Foundation has supported Elder Services of Merrimack Valley for more than ten years.  The last six have been directed at building and expanding the Healthy Living Center of Excellence Network and implementing a wide variety of evidence-based programs, with an aim of improved community/clinical linkages.
  • The Health Foundation of South Florida supported two agencies in Florida to implement and evaluate the Healthy IDEAS program, including Cubano adaptation/refinement of resources previously available in Spanish.

Resources

Evidence Based Leadership Council 
The Evidence-Based Leadership Council (EBLC) includes 15 programmatic and organizational leaders, representing 19 nationally recognized evidence-based programs and six community-based organizations that provide evidence-based programming.  The Council has more than 200 combined years in developing, evaluating, scaling, implementing and sustaining evidence-based self-management programs. Our directors have experienced broad and increasing demands for their programs, and together, have taken on the challenge of integrating infrastructures to bring the true promise of these programs to scale. 

National Council on Aging
The National Council on Aging’s (NCOA) Center for Healthy Aging supports the expansion and sustainability of evidence-based health promotion and disease prevention programs in the community and online through collaboration with national, state, and community partners. NCOA’s goal is to help older adults live longer and healthier lives. The Center for Healthy Aging houses two Administration for Community Living-funded Resource Centers: 

National Chronic Disease Self-Management Education Resource Center

National Falls Prevention Resource Center

Both resource centers serve organizations seeking to implement, evaluate, and sustain evidence-based programs. Technical assistance is provided through a collection of resources on evidence-based program implementation and sustainability, webinars, an annual meeting, a monthly e-newsletter, individualized support, and more.

Additional Resources:

Administration for Community Living: Aging and Disability Evidence-Based Programs and Practices
Centers for Disease Control and Prevention: Recommended and Promising Programs
Centers for Disease Control and Prevention: Healthy Aging
 

 

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