Evidence-Based Prevention Improves Chronic Care Management Nancy A. Whitelaw, Ph.D. Director, Center for Healthy Aging The National Council on the Aging February, 2005

As of February 4, approximately 160,172 people have died from chronic disease this year vs. 2001: US adults reported: Deterioration in:  physical health  mental health  ability to do their usual activities Increase in “unhealthy days”  5.2 to 6.0 days Adults years old had consistently greater deterioration than younger or older adults.

“Honest doc--if I had known I was gonna to live this long, I’d have taken better care of myself.”

Center for Healthy Aging Increase the quality and accessibility of health programming at community agencies serving older adults  National Resource Center on Evidence-based Prevention  Evidence-based Model Health Programs  Falls Free: National Falls Prevention Action Plan  Moving Out: Best Practices in Physical Activity  MD Link: Connecting Physicians to Model Health Programs  New Connections: Partnerships between PH and Aging  Get Connected: Partnerships between MH and Aging

Overview What are the real threats to health and function of older adults? How should these threats be addressed? How do we strengthen community resources and self-management support for prevention?

Health Status of Older Adults 88% - at least one chronic condition 50% - at least two chronic conditions 37% experience some activity limitation 27% assess health as fair or poor  42% of older African Americans  35% of older Hispanics

Chronic Conditions Among Persons 70+ Chronic diseases account for 95% of health care expenditures

Leading Causes of Death, Age 65+ (2001) Heart Disease32% Cancer22% Stroke 8% Chronic respiratory 6% Flu/Pneumonia 3% Diabetes 3% Alzheimer’s 3%

Underlying Risk Factors – “The Actual Causes of Death” Behavior% of deaths, 2000  Smoking18%  Poor diet & nutrition/15% Physical inactivity  Alcohol 4%  Infections, pneumonia 3%  Racial, ethnic, economic ? disparities

Threats to Health and Well-being Among Seniors 35% age 65 – 74 report no physical activity 46% age 75+ report no physical activity 24% - obese 33% - fall each year 20% - prescribed “unsuitable” medications 34% - no flu shot 45% - no pneumococcal vaccine

Low Rates of Physical Inactivity Older adults with low-socioeconomic status are at even greater risk of inactivity No physical activity age 75+  33% of males  50% of females

Obesity* Trends Among U.S. Adults BRFSS, 2001 (*BMI  30, or ~ 30 lbs overweight for 5’4” woman) (Marx) <10% 10%–14% 15%–19% 20%-24%  25% Source: Behavioral Risk Factor Surveillance System, CDC.

Age Group , per 10,000 people Disability Increases with Age BUT Much Higher Rates Among the Obese* (Marx) *Data based on 1996 National Health Interview Survey Sources: National Business Group on Health; Rand Corp. Obese Non-Obese

Severe Obesity and Mortality Severe obesity (BMI >45) lowers years of life by 13 years for white men and 8 years for white women age 20–30. For blacks the loss was 20 years for men and 5 years for women. Fontaine et al. JAMA 2003;289:187–193

Total Cardiovascular Disease Deaths, 1999 Age-adjusted death rates per 100,000 population (Marx) Source: National Vital Statistics System, National Center for Health Statistics, CDC 190.5– – – –354.9 United States - 172

Variation in Heart Disease Rates, Why? (Marx) 200% difference between high and low states Nearly 2/3 of the difference in death rates is explained by differences in modifiable risks  tobacco  overweight  high blood pressure  high cholesterol  physical inactivity  diabetes Source: Byers et al. Prev Med 1998;27(3):311–16

High Rates of Diabetes 17 Million Americans  6% of population  18% of 65+  Greater in minority populations Diabetes diagnosed at age 40 leads to a loss of 11.6 years in men and 14.3 years in women. More years of life are lost in blacks than in whites. Narayan et al. JAMA 2003;290:1884–1890

Smoker Overweight InactiveRatio 11%58%5.5 Source: Jones et al. Arch Intern Med 2002;162:2565–71 Non Smoker Normal Weight Active Predicted Likelihood of Developing Coronary Heart Disease, Stroke, or Diabetes by Age 65 (Marx) Men, Aged 50

Disability Index, by Age and Health Risk University of Pennsylvania Alumni Disability Index Age Risk based on body mass index, smoking, exercise; 0-3 point scale for each; low = 0–2 points, moderate = 3–4 points, high = 5–9 points. Note: A disability index of 0.1 = minimal disability. Source: Vita et al. N Engl J Med 1998;338(15):1035–41 High risk Moderate risk Low risk Progression of disability delayed approximately 7 years in low risk vs. high risk.

Serious Consequences of Falls Falls are common  30% age 65+ years  50% age 80+ years As a result of a fall injury:  1.6 million were treated in EDs  400,000 were hospitalized  11,600 died At age 75+, those who fall are 4-5 times more likely to stay in a long term care facility >1 year Falls cost > $15 billion/year

Falls Are Predictable (RF= Risk Factor) % who fall

Risk Factors  strength, balance/ gait  vision, postural BP Depression, arthritis Foot problems Medications Environmental hazards Fear of falling

Negative Effects of Depression 15-20% of older adults - clinically significant depression Major depression prevalence:  Primary care (5-10%)  Home care (15% - 26%) Late-life depression associated with:  Functional impairment, lower quality of life, poorer medical outcomes, increased costs and suicide

Serious Consequences of Medication Errors Seniors consume 1/3 of all prescription drugs 33 inappropriate prescription drugs  6.5 million older adults use one or more 7,000 deaths per year due to adverse drug events 5 th leading cause of death for older adults The annual cost of treating medication-related errors exceeds $177 billion/year Institute of Medicine. (1999) To err is human: Building a safer health system. Kohn, L., Corrigan, J., Donaldson, M. (Eds.) National Academy Press, Washington D.C.

Federal Spending in Billions, 2000

“No longer is each risk factor and chronic illness being considered in isolation. Awareness is increasing that similar strategies can be equally effective in treating many different conditions.” Epping-Jordon, WHO, 26 March 2004 How Should these Threats be Addressed?

Informed, Activated Patient Productive Interactions Prepared, Proactive Practice Team Improved Outcomes Delivery System Design Decision Support Clinical Information Systems Self- Management Support Health System Resources and Policies Community Health Care Organization Chronic Care Model Outcomes

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 Perspective Says The health and well-being of older adults 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.

Community Resources, Why? Ensure that care is centered on older adult and family Support self management and behavior change Provide critical prevention programming: physical activity; falls prevention; dietary modification Provide key supportive services Facilitate care coordination Outreach, information and referral

Self-Management Support, What? Emphasize the patient’s central role in managing her/his health Use effective self-management support strategies  assessment, goal-setting, action planning, problem solving and follow-up  peer support groups; peer health mentors Include physical activity More intensive problem-solving therapy if depressed.

How Do We Strengthen Community Resources and Self- Management Support for Prevention? Old question: Does what we are doing work? New question: Can we do what is known to work?  What do we know works?  How well do we know it and understand it?  About whom do we know it?

AoA Initiative - Evidence-Based Programs Disease self-management (5)  Diabetes  Heart disease  Depression  Chronic Disease Self-Management Program (2) Physical activity (3) Falls prevention (2) Nutrition (2) Medication management (1)

Doing What Works Evidence of problem: The burden is great. Evidence of effective interventions: The science is convincing. Core features of an effective program: Fidelity is possible. Requirements for successful implementation  Reach  Effectiveness  Adoption  Implementation  Maintenance

RE-AIM

Partners and Planning – (P)RE-AIM Find your partners - aging, health, research Identify and review evidence of health conditions and risk factors for older adults in the community  Surveillance data  Other surveys Review scientific evidence on proven, effective interventions or models  Identify core components of effective programs  Which specific program components contributed to the positive results?

Partners and Planning – (P)RE-AIM Select interventions/models  Appropriate for targeted conditions or risk factors  Suitable for targeted populations and locations  Feasible to implement – can preserve core components  Suitable for adoption by a variety of agencies, staff with different skills Communicate – to community leaders, media, older adults, other stakeholders

Detail the Translation: Developing “Your” Program Detail the following: (RE-AIM)  Reach; Effectiveness  Adoption; Implementation; Maintenance Fidelity A: The program you develop retains the core components from the original intervention studies.  Tracking Changes Tool Fidelity B: The program you implement retains the core components from the developed program.

Reach and Retention - People The number, proportion, and representativeness of individuals who participate in a given program. Key questions:  How many people are in the target population?  How do I reach and retain these high risk, diverse older adults?  What percent of the target population actually learns about the program?  Are those who become “enrolled” the ones who have the most to gain?  Do participants truly reflect the targeted population?

Adoption - Organizations The number, proportion, and representativeness of settings and staff who are willing to offer the program. Key questions:  How many organizations could implement this program? “Readiness”  Are these organizations connected to high risk populations?  How many of these organizations will actually operate the program?  What will motivate these organizations to participate?

Implementation - Organizations How closely do the agency and staff follow the program that was developed. This includes “fidelity” of delivery and the time and cost of the program. Key questions:  How many staff within a setting will try this?  Does training and supervision support implementation?  Do data systems support implementation?  Do work flow processes support implementation?  Do policies and procedures support implementation?

Maintenance – People and Organizations The extent to which a program or policy becomes part of the routine organizational practices and policies. At the individual level, the long-term effects of a program on outcomes (perhaps 6 or more months). Key questions:  Can organizations sustain the program over time?  Does the program produce lasting effects at individual level?  Are those persons and settings that show maintenance those most in need?

Effectiveness - People The impact of the model program on important outcomes.  Unintended, adverse consequences or negative effects  Quality of life  Health status of participants  Health status of the targeted community  Costs  Satisfaction of participants, staff and agencies Can you replicate findings from original studies?

The Challenge and the Opportunity Older adults suffer from chronic diseases, injuries and disabling conditions. Preventable diseases account for nearly 70% of all medical care spending. Growing evidence base indicates that changes in lifestyle at any age can improve health & functioning. People want to change unhealthy habits, but need support. The health care sector alone can not improve the health of older adults with chronic conditions. Community agencies are important partners in facilitating improved health and lower costs.

NCOA’s Center for Healthy Aging and AoA’s National Resource Center Collaborate with diverse organizations to contribute to a broad-based national movement. Identify, translate and disseminate evidence on what works – scientific studies and best practices. Promote community organizations as essential agents for improving the health of older adults. Advocate for greater support for strong and effective community programs. Provide clearinghouse and technical assistance.

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