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The Aging States Project:Promoting Opportunities forCollaboration Between the PublicHealth and Aging Services Networks

A Report to:Centers for Disease Control and Prevention &Administration on AgingUnited States Department of Health and Human Services

From:Chronic Disease DirectorsNational Association of State Units on Aging

January 2003

Project DirectorRuth Palombo, MS, RDDirector, Office of Elder HealthMassachusetts Department of Public Health

Assistant Project DirectorsAnne Annunziada, PhD, RD, ConsultantAnne McHugh, MS, ConsultantMassachusetts Association of Older Americans

Project Statistical AnalystWee Lock Ooi, DrPHSenior Evaluation CoordinatorMassachusetts Department of Public Health

Acknowledgements

ChairBetty H.Wiser, EdDDirector, Older Adult Health BranchNorth Carolina Department of Health and Human Services

MembersMargo C. BlakeMedical/Health Care Program AnalystFlorida Department of Health

Jean Chabut, BSN, MPHDirector, Division of Chronic Disease and Injury ControlMichigan Department of Community Health

Anne Connaughton, MAExecutive DirectorMassachusetts Association of Older Americans

Allan B. Goldman, MPHDirector of Health Promotion and Disease PreventionProgramsGeorgia Division of Aging Services

Gerry Mackenzie, MSS, MLSPSupervisor, Older Adult Health and WellnessDivision of Senior AffairsNew Jersey Department of Health and Senior Services

Chris Maylahn, MPHDirector, Bureau of Risk ReductionNew York State Department of Health

Ramona Schaffer, MSEd, CHESChronic Disease Prevention Program DirectorVirginia Department of Health

Jody L. Stones, MSCardiovascular Health Program ManagerDivision of Chronic Disease Prevention and NutritionVirginia Department of Health

Joan Ware, RN, MSPHDirector, Cardiovascular Health ProgramUtah Department of Health

Ex Officio Members

Greg Case, MAProgram DirectorNational Association of State Units on Aging

Rick Greene, MSWProgram Specialist, Office of State and Community ProgramsAdministration on Aging

Andree R. HarrisProgram Analyst, Health Care and Aging Studies BranchNational Center for Chronic Disease Prevention and HealthPromotionCenters for Disease Control and Prevention

Elizabeth C. KingProgram ManagerAssociation of State and Territorial Chronic Disease Directors

John KornPublic Health Advisor, Division of Adult and CommunityHealthNational Center for Chronic Disease Prevention and HealthPromotionCenters for Disease Control and Prevention

Maggie Kownaski, MPHPublic Health Advisor, Healthcare and Aging Studies BranchNational Center for Chronic Disease Prevention and HealthPromotionCenters for Disease Control and Prevention

Theresa Lambert, MEd Deputy DirectorNational Association of State Units on Aging

Jason E. Lang, MPH, MSPublic Health Advisor, Healthcare and Aging Studies BranchNational Center for Chronic Disease Prevention and HealthPromotionCenters for Disease Control and Prevention

Suzanne M. Smith, MD, MPH, MPAChief, Health Care and Aging Studies BranchNational Center for Chronic Disease Prevention and HealthPromotionCenters for Disease Control and Prevention

Fran C.Wheeler, PhDDirector of Technical Assistance and Program Services Association of State and Territorial Chronic Disease ProgramDirectors

We would like to especially acknowledge the state agencystaff who took the time to respond to this needs assess-ment.We also want to thank the Graphics Center at theMassachusetts Department of Public Health.

For further information about the Aging States Project or foradditional copies of this report or the Aging States Project: DataSupplement, please contact Greg Case ([email protected]) at the National Association ofState Units on Aging, 202-898-2578 or Heather Kyrouz ([email protected])at the Associationof State and Territorial Chronic Disease Program Directors(Chronic Disease Directors), 703-610-9033.

For an up-to-date list of the Directors of the State Units onAging, go to the NASUA Web site at www.nasua.org. For anup-to-date list of the state Chronic Disease Directors, go tothe CDD Web site at www.chronicdisease.org.

Ad Hoc Health and Aging Advisory Committee

Background: the Aging States ProjectThe role of the public health and aging services networks in healthy agingThe benefits of collaborating to promote healthy aging

Pilot questionnaireFinal questionnaireData analysisLimitations of data

Responding to the health needs of older adults: priorities and barriersProgram support needsCollaboration between state units on aging and state health departmentsFundingPromising programs

Responding to the health needs of older adultsProgram support needsCollaboration issuesFunding Summary Next steps

California Department of Health Services:Preventive Health Care for the Aging ProgramDelaware Division of Services for Aging and Adults with Physical Disabilities:Millennium March to WellnessMaine Bureau of Elder and Adult Services:A Matter of BalanceMassachusetts Department of Public Health:Keep Moving ProgramMissouri Department of Health and Senior Services:The Missouri Arthritis and Osteoporosis ProgramNew Jersey Department of Health and Senior Services:Health Promotion InitiativeNew York State – Office for the Aging and Department of Health:Adult Immunization CampaignPennsylvania Department of Aging:PrimeTime Health: Peer Exercise Program Promotes Independence

A. Needs assessment questionnaireB. Respondents to needs assessment C. Coding categories for open response questionsD. Older Americans Act,Title III-D

Table of Contents

Introduction

Methodology

Results

Discussion

Recommendations to Improve the Health of Older Adults

Promising Programs:Case Studies

Glossary

Appendices

References

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25

35

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44

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Exhibit 1: The demographic revolution. Projected change in the age distribution of US population, 2000-2050

Exhibit 2: Projected increase in the number of people aged 65 years or older,by state, 1993-2020

Exhibit 3: Schematic representation of the public health and aging servicesnetworks

Exhibit 4: Needs assessment questions

Exhibit 5: Top health issues for older adults, by state units on aging and statehealth departments

Exhibit 6: Relationship between identified top health issues for older adults and moderate-to-high involvement, reported by state healthdepartments

Exhibit 7: Relationship between identified top health issues for older adults and moderate-to-high involvement, reported by state units on aging

Exhibit 8: Moderate-to-high involvement in health problems of older adults,by state units on aging and state health departments

Exhibit 9: Barriers to promoting health among older adults, by state units onaging and state health departments

Exhibit 10: Perceptions of transportation in relation to the health needs of older adults, by state units on aging and state health departments

Exhibit 11: Level of involvement in transportation for older adults, by state unitson aging and state health departments

Exhibit 12: Unmet program support needs, by state units on aging and statehealth departments

Exhibit 13: Use of data sources, by state units on aging and state health departments

Exhibit 14: Level of access to research expertise, by state units on aging andstate health departments

Exhibit 15: Collaborative activities between state unit on aging and state health department, with and without health promotion/diseaseprevention lead, by state units on aging and state health departments

Exhibit 16: Barriers to coordination with counterpart, by state units on agingand state health departments

Exhibit 17: Funding sources for health promotion for older adults, by state unitson aging and state health departments

List of Exhibits

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The Demographic Revolution: From Pyramid to Rectangle

Source: National Projections Program, Population Division, US Census Bureau

Projected Resident Population, United States, 2050

20502050

PercentMale Female

5.0 4.0 3.0 2.0 1.0 0.0 1.0 2.0 3.0 4.0 5.0

Projected Resident Population, United States, 2000

20002000

5.0 4.0 3.0 2.0 1.0 0.0 1.0 2.0 3.0 4.0 5.0

PercentMale Female

Age>10095-9990-94

80-8485-89

75-7970-7465-69

45-49

60-6455-5950-54

40-4435-3930-3425-2920-2415-1910-14 5-9

<5

Age>10095-9990-94

80-8485-89

75-7970-7465-69

45-49

60-6455-5950-54

40-4435-3930-3425-2920-2415-1910-14 5-9

<5

Exhibit 1: The demographic revolution: projected change in the age distribution of U.S. population,2000-2050

Poor health is not an inevitable consequence of aging.Increasing numbers of Americans in their 70s, 80s, and90s enjoy independent, active living with minimalhealth problems1. Yet steps that we as a nation couldtake to further assure healthy aging for greater num-bers of people are not consistently implemented.Many older adults suffer from chronic and infectiousdiseases, injuries, and functional limitations that areavoidable or can be delayed. Scientifically provenmeasures are available now that can improve health,reduce the impact of disease, and delay disability andthe need for long-term care.

The gain in life expectancy in the United States dur-ing the 20th century was a triumph for public health.The success of public health initiatives in areas such asinfectious disease control, immunizations, and chronic

disease prevention has resulted in longer, healthierlives for Americans.The new challenge for publichealth is to develop a focus on healthy aging–to assurethat older adults maintain optimal health status andquality of life in their later years.

As a result of successful public health efforts, the num-ber of adults age 65 years and older will more thandouble to over 70 million by 2030 (Exhibit 1). Onein every five Americans will be 65 years or older, asixty percent increase over the proportion of olderAmericans in 2000.

Within this demographic revolution, the fastest grow-ing segment of the U.S. population will be evenolder: 8.5 million people will be over the age of 85 by2030. Increases in the older adult population willoccur in all states; some states, in fact, will experiencemore than a 100% increase in the population of resi-dents age 65 and older between 1993 and 2020(Exhibit 2).

This growing population of older adults placesincreased demands on the health care system.Currently, almost one-third of total U.S. health careexpenditures, $300 billion each year, is spent on olderadults2. Targeted health promotion and disease pre-vention measures may be among the most effectivestrategies for stemming growing health care expendi-tures in the coming years.

Introduction

As the American population ages, therole of states in assuring that the healthstatus of older Americans is protectedand enhanced will become more cru-cial. Currently, however, most stateshave a fragmented and limited approachto addressing the health needs of olderadults. In particular, inadequateresources and attention are focused onhealth promotion and prevention of dis-ease or secondary disability for olderadults–the very population that experi-ences the highest rates of chronic dis-ease and disability. One cause of thisfragmentation is the lack of collabora-tion between state agencies that areresponsible for assuring healthy residentsand those that are responsible foraging adults.

Background:The Aging States Project

At the state level, the public health andaging services networks share the mis-sion of addressing the health needs ofolder adults. The public health network, spearheaded bystate health departments (SHDs), and the aging servicesnetwork, led by state units on aging (SUAs), bring differentstrengths and resources to this mission, frequently servingthe older adult population using different strategies andmechanisms. In many cases, these networks work inde-pendently of each other within the same state. Developingan integrated system of health promotion and diseaseprevention services for older adults will require strongercollaboration and cooperation between these two essen-tial networks.

The Aging States Project: Promoting Opportunities for Collaboration between the Public Health and Aging ServicesNetworks was developed to help bridge this gap. Its goal isto bring together the strengths and expertise of state pub-lic health and aging networks to better meet their sharedresponsibility for ensuring optimal health for our nation’solder residents.

Initiated in spring 2001, the Aging States Project is a col-laborative effort of the Association of State and TerritorialChronic Disease Program Directors, hereafter referred to asChronic Disease Directors (CDD), and the NationalAssociation of State Units on Aging (NASUA), with sup-port from the Centers for Disease Control and Prevention(CDC) and the Administration on Aging (AoA). NASUAand CDD are each non-profit membership organizationscomprised of, respectively, the state and territorial SUAs

and the chronic disease programs of state and territorialSHDs. NASUA’s mission is to advance social, health, andeconomic policies responsive to the needs of a diverse agingpopulation and to enhance the capacity of its membershipto promote the rights, dignity, and independence of olderpersons, adults with disabilities, and their families. CDDsupports SHD efforts in chronic disease prevention andcontrol through education, training, advocacy, partnershipdevelopment, and policy analysis. Each of these organiza-tions recognizes the central role of protecting the health ofolder adults within its mission. NASUA and CDD haveenthusiastically embraced the opportunity to collaborate inthis needs assessment of their members and to develop thecapacity of their members to collaborate more closely inefforts to improve the health of older adults.

The Aging States Project has compiled information onhealth needs, activities, and partnerships related to olderadults through a needs assessment questionnaire sent to allstate and territorial SUAs and SHDs. The informationcollected provides an overview of their current health pro-motion and disease prevention efforts for older adults. Itidentifies barriers, program support needs, and the status ofcollaborations between SUAs and SHDs across the UnitedStates. It identifies opportunities to strengthen these col-laborations and improve resource use that will betteraddress the health needs of older adults.

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Exhibit 2: Projected increase in the number of people aged 65years or older, by state, 1993-2020

Source: US Census Bureau

It is our hope that in partnership with the CDC and AoA,the state aging and public health networks will use thisinformation to further integrate the expertise and capacityof both networks. This will help to define the critical nextsteps in addressing the health challenges of the growingpopulation of older adults.

The role of the public health and aging servicesnetworks in healthy aging

Public health

The public health network in the United States protectsand promotes the health and well being of all Americansacross the life span through efforts at the national, state, andlocal levels. Primary functions of the public health networkinclude collecting health status information, prioritizinghealth problems, developing health-related policies, andestablishing systems that prevent disease and promotehealth. The public health network relies on partnershipsamong the CDC, other federal agencies, state and localhealth departments, voluntary and professional organiza-tions, academic institutions, community-based organizations,and others.

State health departments (SHDs) are responsible for protect-ing and promoting the health of all their residents. Theyaccomplish this in part by focusing on specific at-risk popu-lations. However, few SHDs have programs targeting olderadults, even though they are at high risk for chronic disease,injury, and disability. There is some irony in the fact that,while the “graying of America” has been largely a product ofa century of public health successes in extending lifeexpectancy, SHDs still do not have a clearly defined role inhealth promotion and disease prevention for older adults.

The CDC, as the lead federal agency that provides funding,technical assistance, research-based practices, and training forhealth promotion and disease prevention, is a key player ininfluencing state-level programmatic initiatives. As theCDC developed best practices and funding opportunitiesin chronic disease prevention and control, many SHDsresponded by developing programs that addressed variouscategorical diseases, e.g., breast and cervical cancer, dia-betes, arthritis, and cardiovascular disease. However, CDCfunding levels are not sufficient to support these programsin all SHDs. Those SHDs that have successfully obtainedfederal funding for chronic disease programs typically focuson early primary or secondary prevention and do notspecifically target older adults.

In addition, all SHDs receive block grant funding throughCDC for preventive health services. These grants are rela-tively small but allow for state flexibility in their use.Some SHDs use a portion of these block grant funds tosupport chronic disease initiatives. Some SHDs also receivestate-appropriated funds for chronic disease prevention and

control or other aspects of health promotion relevant toolder adults.

The overall result of such public health structures andfunding sources is a wide variety in the configuration ofhealth promotion and chronic disease prevention programswithin SHDs. This organizational configuration can bechallenging for SUAs or other partners concerned withaging programs as they seek appropriate partners for col-laboration.

Aging servicesAcross the nation, the aging services network provideshealth and supportive services to approximately nine mil-lion older Americans each year.This network is comprisedof the federal Administration on Aging; 57 state and terri-torial agencies on aging, also known as state units on aging(SUAs); 660 state-designated area agencies on aging(AAAs); and over 27,000 local service provider organiza-tions.With a policy framework and funding from theOlder Americans Act (OAA), the aging services networkassists older adults to continue to live independently intheir communities.

The Administration on Aging is the lead federal agencyfor the concerns and needs of older Americans. AoAadministers the Older Americans Act, which funds awide range of services and programs with a special focuson low-income and minority older adults, and alsothose at risk of losing their independence.These servicesand programs are specified in several sections, or titles,of the OAA and include:

• supportive services, such as information and assistance,transportation, case management, adult day care, seniorcenters, personal care, homemaker/chore assistance,home health, respite, home repair, housing services, andemployment services;• nutrition services, including congregate and home-deliv-ered meals;• elder rights, including the long-term care ombudsman,elder abuse prevention, health insurance and benefitscounseling, pension counseling, and legal assistance;• family caregiver support, including information aboutservices, assistance with access to services, individualcounseling, support groups, caregiver training, andrespite care; and• health promotion/disease prevention

At the state level, the OAA is administered by state unitson aging–agencies of state government designated bythe governor and state legislature to be the focal pointfor all matters affecting older citizens in the state.Established nationwide with the passage of the OlderAmericans Act in 1965, SUAs share a common missionof assuring older people every opportunity to achieve

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maximum self-reliance, independence, and well-beingwhile maintaining close family and community ties.

SUAs provide OAA funding to their communities throughdesignated area agencies on aging, which may be public,governmental agencies or non-profit organizations servingdefined geographic regions within each state. Based onlocal needs and priorities,AAAs contract with localprovider organizations for services and/or provide servicesdirectly.

In response to the challenges of the growing number andincreasing longevity of older adults, SUAs have continuedto evolve, significantly expanding their scope of responsi-bilities since 1965.Today, they oversee complex servicesystems that are funded by a variety of federal resources,state resources, and private foundations. For example, amajor priority of SUAs continues to be the developmentof policies and programs to assist those with disabilities,chronic conditions, or functional limitations to remain intheir own homes.Toward this end, SUAs administer homeand community-based long-term care programs that arefunded by both state and federal Medicaid monies.

SUAs have been involved in health promotion and diseaseprevention activities since the early days of the OAA.However, in 1992 Congress added new language to theOlder Americans Act authorizing disease prevention andhealth promotion services. Known as Title III-D (formerlyTitle III-F), it also establishes a statutory basis for the col-laboration between public health and aging services bydirecting AoA to consult with the CDC in carrying out

this disease prevention and health promotion mandate.Although the amount of funding allocated for Title III-Dis modest in comparison to many other OAA programs,its availability assists states in addressing this critical needamong older persons.

Promoting collaboration between the publichealth and aging services networks

As the discussion above illustrates, the public health andaging networks operate through a complex web of publicand private agencies at different levels of government, withan array of providers and multiple funding sources.Despite this complexity, there is a clear symmetry betweenthe two service networks (Exhibit 3).

At each level of government (national, state and local), thepublic agencies and their private partners in both agingand public health have a clearly defined role. At each level,there are opportunities for collaboration that couldenhance health promotion/disease prevention for olderadults.

There has been recognition for some time that, throughcloser collaboration, these networks could more effectivelyaddress the health needs of older adults. In 1994, a majorconference to address the intersection of public health andour aging society was sponsored by CDC,AoA, theNational Institute on Aging, the American Association ofRetired Persons and the Gerontological Society ofAmerica3. In 1996, the CDC and AoA jointly publishedand disseminated the Guide to State Health Departments

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Department of Health and Human Services

Administration on Aging Centers for Disease Control & Prevention

NationalAssociation of State

Units on Aging

57 State & TerritorialUnits on Aging and243 Indian TribalOrganizations

57 State & TerritorialHealth Departmentsand 56 Indian Tribal

Organizations

Association of Stateand Territorial Health

Officials, includesChronic Disease

Directors

National Associationof Area Agencies on

Aging

660 Area Agencies onAging

3000 Local HealthDepartments

National Associationof County and City

Health Officials

Community Organizations Community Organizations

Exhibit 3: Schematic representation of the public health and aging services networks

and State Aging Agencies Working Together4, which containedspecific recommendations to facilitate coordinationbetween the two agencies at a state level.This prior work in defining areas of increased collabora-tion sets the stage for the Aging States Project, which is thefirst effort to solicit systematic direct feedback from SUAsand SHDs to assess these issues.

The benefits of collaborating to promotehealthy aging

The focus on health promotion, disease prevention, anddelay of disability is well established for younger popula-tions, but their benefits have not been as widely recognizedor implemented for older adults. Yet there is a growingbody of research that demonstrates that health promotionfor older adults has tangible benefits5. This research canguide the development of best practices that can be imple-mented through the programs of SHDs, SUAs, and theirmany state and community partners. Examples of key areasthat contribute to older adult health are highlighted below.

• Physical Activity

The single most important step that most adults, includingolder adults, can take to improve their overall health is tobecome more physically active6. Research continues toaccumulate demonstrating the health benefits of increasingphysical activity even among “old-old” adults.

Regular, moderate physical activity, for at least 30 minuteson most days, has a number of positive health benefits.These include preventing or reducing disability fromchronic diseases such as heart disease, hypertension, dia-betes, and arthritis. Physical activity, along with diet, is akey factor in maintaining a healthy body weight.Additionally, physical activity that includes muscle strength-ening can improve mobility and balance, reducing the riskof falls. Regular exercise also positively affects mental healthby improving alertness and reducing depression.

Despite clear evidence of its benefits, few older adultsengage in recommended levels of physical activity and sig-nificant numbers do not participate in any physical activity.Only 16% of adults aged 65-74 report participating in 30minutes or more of moderate activity five or more daysper week, while 28-34% of adults in this age bracket reportno physical activity7.

Accessible, age-appropriate programs to promote increasedphysical activity are increasingly available. Many AAAs usetheir Title III-D health promotion funds to support com-munity-based programs that improve strength, endurance,or flexibility. These include resistance training classes,walking clubs, yoga, tai chi, and water aerobics. Strategiesand resources to expand these programs, and to reachhigh-risk and isolated groups, can contribute to improvingthe overall health of older adults.

• Immunizations

Older adults are at higher risk for death from severalvaccine-preventable diseases than are younger adults.Pneumonia and influenza account for more than 50,000deaths annually of people ages 65 and older8. Althoughimmunization can reduce the incidence of these diseases byas much as 80%, many older adults do not receive these vac-cinations. In 1999, 33% of older adults reported not havingreceived an influenza vaccine in the previous year, and 46%reported never having received a pneumococcal vaccine9.

Strategies to increase vaccination rates are dependent onstate and local health departments conducting successfuloutreach to older adults. However, many SHDs may nothave the knowledge or resources to reach older adults atthe community sites where immunization campaigns canoccur. The aging services network has these resources andknowledge and could serve as an invaluable partner tohealth departments in these efforts.

• Fall prevention

One of every three Americans age 65 years and olderexperiences a fall each year and 20-30% of these individu-als sustain moderate to severe injuries that reduce mobilityand independence, and increase the risk of prematuredeath. In 1994, the total direct cost of these fall-relatedinjuries for people age 65 and older was $20.2 billion10.

The high incidence of falls among older adults is due to anumber of modifiable factors. Improving strength andbalance through physical activity programs focusing onresistance training has been shown to be effective.Environmental adaptations in the home reduce safety haz-ards that can contribute to falls. Effective management ofmedication use can reduce the side effects that can con-tribute to falls.

Programs that address related issues of physical activity, homemodification, and medication use are authorized throughOAA funding. Many, however, do not have ready access tothe research expertise and implementation strategies neces-sary to integrate fall prevention into such programs.

Physical activity, immunizations and fall prevention arethree important areas in which SUAs and SHDs couldcollaborate more effectively to address health promotionand disease prevention efforts for older adults. By draw-ing on their combined expertise and resources, thishealthy aging network can continue the work ofimproving the health status and quality of life for olderAmericans.

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This needs assessment was designed to compile informa-tion from state health departments and state units onaging on health promotion and disease prevention activi-ties, partnerships, and needs related to older adults, andto identify opportunities for enhanced collaboration andimproved resource use.The results of the needs assess-ment will be used to bring together the respectivestrengths and expertise of the public health and agingnetworks to better meet a shared responsibility for ensur-ing optimal health for our nation’s older adults.

The development of the needs assessment was guidedby the Ad Hoc Health and Aging Advisory Committeeand selected outside experts.Through a series of tele-phone conference calls and electronic communication,a pilot questionnaire was developed and tested.Theresults of the pilot were reviewed and utilized to planthe final needs assessment questionnaire. After approvalby the Advisory Committee, the final needs assessmentwas sent to all state and territorial health departmentsand units on aging.

Pilot questionnaire

In March 2001, a questionnaire was piloted to test pro-posed questions and the viability of electronic submissionof responses through Zoomerangtm, a Web-basedresponse format. A set of open-response questions was

developed based on suggestions from the AdvisoryCommittee. Questions explored the core activities ofSUAs and SHDs related to health promotion and diseaseprevention for older adults and the relationship betweenthe two agencies in each state or territory.Ten stateswith diverse regional and demographic criteria as well asvarying capacity and expertise regarding health promo-tion and disease prevention for older adults were selectedfor the pilot. Seven SUAs and nine SHDs completed andreturned the questionnaire.These respondents were sub-sequently contacted by telephone to clarify answers andto seek input on the utility of the electronic submissionof responses through Zoomerangtm.

Final questionnaire

Based on responses to the pilot and the telephone inter-views with respondents, questions were refined.Questions that had clusters of common responses in thepilot were modified to have fixed-choice responses.Responses to pilot questions about unmet needs and bar-riers overwhelmingly referred to funding and staffing.While these are acknowledged to be significant underly-ing issues, these response options were omitted from thefinal questionnaire in order to gain greater insight intoother needs and barriers.

While most of the information being sought through theneeds assessment was common to both SUAs and SHDs,two questions were tailored to the SHD and one to theSUA in order to solicit information particular to eachagency. Therefore, the final SUA questionnaire con-tained 29 questions, while the final SHD questionnairecontained 30 questions. All other questions weresymmetrical in each version of the needs assessmentquestionnaire. Each version contained 12 open-endedresponse questions, with the remainder being fixed-choice questions. (See Exhibit 4 for a list of all needsassessment questions and Appendix A for a copy of thefull questionnaire.)

The Zoomerangtm Web-based questionnaire was used asthe primary data collection instrument. Although therewere some known limitations, such as a predefinedmaximum of 30 questions and the requirement that allquestions be completed and submitted in one sessionbecause of the lack of a “save” function, it was felt thatusing this modality would increase the response rate andreduce respondent fatigue.

In June 2001, the questionnaire and cover letter weremailed to all state and territorial SHD chronic diseasedirectors (or an individual they designated) and SUAdirectors, using the mailing lists of CDD and NASUA.The cover letter was also sent via e-mail with hyper-link access to the Web-based questionnaire to the same

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Methodology

participants. Respondents were given the option of sub-mitting their completed questionnaires usingZoomerangtm, postal mail, or fax. Technical assistance bytelephone was available to respondents who chose to useZoomerangtm. Project staff entered data submitted viapaper questionnaires into the Web-based application.The cover letter urged the SHD chronic disease directorand SUA director to seek input for the responses fromother staff within their agencies with responsibilities forhealth promotion and disease prevention for older adults.This request to make the responses a collaborative effortwithin their respective agencies was made to ensure thatanswers would be as accurate and comprehensive as possible.The issue of whether to collaborate with their counterpartagency (either SUA or SHD) in their response was notaddressed in the cover letter.

Up to five follow-up contacts by e-mail and telephonewere made during the month of September 2001 toensure an adequate response rate. Responses were receivedfrom 38 state/district and one territorial SUA and from 43state/district and no territorial SHDs (see Appendix B forlist of respondents). Eighty-seven percent (87%) of SUAsand 70% of SHDs that responded used the electronic for-mat. Responses were received from both the SUA andSHD for 31 states. Neither the SUA nor SHD respondedfor one state and six territories. Final state/district responserates were 75% for SUAs and 84% for SHDs. Finalresponse rates, including all states and territories, were 68%for SUAs and 75% for SHDs.

Five responding agencies submitted multiple responses,replying by both electronic submission and mail. Projectstaff contacted these respondents and clarified whichresponse set to use.

Data analysis

SUA and SHD responses were separately analyzed.Descriptive statistics, including frequency distributionsand cross-tabulations of selected questions, were used tocharacterize the responses. The 31 paired-state responseswere also examined for congruence of selected responses.Because the needs assessment was an exploratory study,tests for statistical significance were not conducted.

The project team developed a set of codes to analyzequestions with open-ended responses. A qualitative,analytical approach was used, whereby a master list often major thematic categoriesi was developed based onthe observed responses. Within these major categories,70 more specific sub-categories were developed.This

coding methodology facilitated cross-tabulation ofresponses and in-depth analysis of the data.

Results displayed in this report are based on the most fre-quent responses given by SUAs and SHDs. A full displayof all responses in tabular format can be found in the com-panion document, The Aging States Project: Data Supplement.To obtain a copy of the Aging States Project: DataSupplement, contact Greg Case ([email protected]) at theNational Association of State Units on Aging,202-898-2578 or Heather Kyrouz ([email protected])at the Association of State and Territorial ChronicDisease Program Directors (Chronic Disease Directors),703-610-9033.

Limitations of Data

Technical issues in access to and use of the questionnairepresented the first limitation to data yielded from thisneeds assessment. Some respondents reported difficultieswith the Web-based format of the assessment questionnairethat resulted in submissions being lost and requiring re-submission.

Subjective interpretation of questions on the part of therespondent, as well as the knowledge base of the respon-dent, presented additional limitations. The instructions forthe needs assessment requested that respondents useknowledgeable staff in their agencies to assist in answeringthe questionnaire. However, it is not known which indi-vidual(s) from each agency actually contributed to theresponses.

It is also important to note that the characteristics of non-responding states and territories may differ from those thatresponded. Six of seven territories did not respond. Theonly discernable pattern in geography or state size was thatall states in the northeast region responded.

Finally, the classification of open-ended questions into the-matic categories by project staff may be subject to bias.

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i The 10 major categories were chronic disease prevention and control; risk reduction/behavioral change; mental health, behavioral health and dementia; concrete services;health care access, coverage and quality; systems and program management; quality of life; training/knowledge issues; program implementation and evaluation; andstaffing. See Appendix C for a complete list of codes.

1. Please list the top 5 health issues affecting older adults in yourstate. OR

2. Within your agency, is there an organizational unit or personspecifically designated for health promotion/disease preventionactivities related to older adults? FC (2)

3. Does your agency have a plan for serving older adults thataddresses health promotion/disease prevention? Please check allthat apply. FC (6)

4. In your state, which state agency has lead (or primary)responsibility for health promotion/disease prevention activitiesfor older adults? FC (5)

5. Please identify other state agencies/public programs involvedin (or responsible for) health promotion/disease preventionactivities for older adults. Please check all that apply. FC (8)

6. Please identify other partners you work with around healthpromotion/disease prevention activities for older adults. Pleasecheck all that apply. FC (20)

7. Describe the organizational relationship between the state healthdepartment and the state unit on aging in your state. FC (4)

8. What are the collaborative activities engaged in by the stateunit on aging and the state health department? Please check top3. FC (12)

9. On average, how often do you engage in healthpromotion/disease prevention activities for older adults withyour counterparts in the other state agency? FC (6)

10. What do you see as the strengths of your agency in healthpromotion/disease promotion activities for older adults?(Identify the top 3). OR

11. What do you see as the strengths of your counterpart stateagency in health promotion/disease prevention activities forolder adults? (Identify the top 3). OR

12. Choose the three most important organizational, programmat-ic, geographic, or political barriers other than funding that limit orprevent coordination with your counterpart agency. FC (11)

SHD 13. Are you aware of the health promotion/disease preven-tion provisions of Title III-D of the Older Americans Act? FC (2)

SUA 13. Please identify the 3 types of activities for which yourOAA Title III-D funds have been used most frequently. FC (18)

14. Does the state health department participate in any healthpromotion/disease prevention activities funded under Title III-Dof the Older Americans Act? FC (5)

15. Aside from funding, what are the 3 main barriers to fullypromoting health and preventing disease among older adults inyour state? FC (20)

16. What are the funding sources used for healthpromotion/disease prevention for older adults by your agency?FC (13)

17. Other than funding or staffing what are the 3 top unmetsupport needs for health promotion/disease prevention for older

adults in your state? FC (11)

18. If greater funding were available, what 3 healthpromotion/disease prevention issues for older adults would youaddress? OR

19. The following is a list of health problems affecting olderadults. Please indicate the current level of involvement of youragency in addressing each problem. FC (38)

20. Please describe one health promotion/disease preventionsuccess story in your state that you would like others to know.How do you define success? OR

21. What data sources do you use to identify, plan, monitor orevaluate the health needs of older adults in your state? Pleasecheck all that apply. FC (12)

SHD 22. What Administration on Aging resources do you use?FC (8)

SUA 22 / SHD 23. What are the 3 top areas where you couldbenefit most from technical assistance and training to moreeffectively address the health promotion/disease preventionneeds of older adults? OR

SUA 23 / SHD 24. Do you have access to up-to-date researchexpertise for health promotion/disease prevention program plan-ning, implementation and evaluation for older adults? Pleasecheck all that apply. FC (7)

SUA 24 / SHD 25. Give one example of a health promo-tion/disease prevention program in your state that you wouldnominate for best practices for older adults. Provide the name ofthe program, a description and how outcomes were evaluated, ifthey were. OR

SUA 25 / SHD 26. In what areas of health promotion/diseaseprevention would you most like to see best practices (evidence-based programs) developed? OR

SUA 26 / SHD 27. What do you perceive as the Centers forDisease Control and Prevention’s current role in health promo-tion/disease prevention for older adults? OR

SUA 27 / SHD 28. If additional funds were made available tothe Centers for Disease Control and Prevention, what would bethe priorities for state-based programs targeting health promo-tion/disease prevention for older adults? OR

SUA 28 / SHD 29. What are the urgent hot button issues inyour state related to older adults e.g. interests of the governor,the legislature, media or advocates? OR

SUA 29 / SHD 30. Is there anything else you would like totell us regarding gaps in health promotion/disease preventionprograms/services/activities related to older adults at youragency? OR

*See Appendix A for the full needs assessment questionnaire,including response options.

Exhibit 4: Needs assessment questions*(OR = Open Response; FC (n) = Fixed Choice Response with number of choices)

8

9

Results

Responding to the health needs of olderadults: priorities and barriers

The top health issue for older adults identified by both SUAsand SHDs is chronic disease prevention and controli(Exhibit 5). Other issues selected by at least a third ofrespondents were risk reduction/behavior change (includ-ing nutrition, physical activity and fall prevention) (SUA39%, SHD 48%), prescription drug access/coverage (SUA45%, SHD 38%), mental/behavioral health (SUA 42%,SHD 38%), and health care access (SUA 29%, SHD 36%).

Within chronic disease prevention and control, cardiovas-cular disease was the single most common health issuementioned (SUA 55%, SHD 57%). Additionally, bothSUAs and SHDs frequently identified other chronic dis-eases as top health concerns: diabetes (SUA 39%, SHD36%), cancers (SUA 34%, SHD 45%), and arthritis (SUA26%, SHD 40%).

Several areas of health concern received little attention inthis assessment. Few SUAs and no SHDs identified oralhealth or dental care as a top concern. Tobacco and alco-hol abuse were each mentioned only once, by SHDs.

Exhibit 5: Top health issues by state units onaging and state health departments

i Question 1 of needs assessment. See Exhibit 4 for a list of all needs assessment questions.

Health issueSUAs(n=38)

SHDs(n=42)

Chronic disease prevention& control

74% 81%

– Cardiovascular disease 55% 57%

– Diabetes 39% 36%

– Cancer 34% 45%

– Arthritis 26% 40%

Prescription medications 45% 38%

Mental/behavioral health 42% 38%

Risk reduction & behaviorchange

39% 48%

Health care access 29% 36%

10

Cardiovascular

disease

Prescription

medications

Diabetes

Cancer

(breast)

Arthritis

55%

40%

34%

45%

26%47%

39%

42%

46%

75%

Exhibit 7: Relationship between identified top health issues for older adults and moderate to high involvement, reported by state units on aging

Percent of state units on aging identifying issue as a top health issue (n=42)

Percent of state units on aging with moderate or high programmatic involvement in issue (n=43)

Health Issue

Percent Response

0 10 20 30 40 50 60 70 80 90

The level of involvement of SUAs andSHDs in addressing issuesi does not necessar-ily relate to the top health issues for olderadults that they identified (Exhibits 6 and7). Although cardiovascular disease wasthe health concern mentioned most fre-quently, fewer than half of the respondingagencies reported moderate to highinvolvementii in this area (SUA 40%,SHD 37%). For prescription drugaccess/coverage, three-fourths of SUAs(75%) but only 15% of SHDs reportedmoderate to high program involvement.

In general, the level of programmatic involve-ment is higher in those programs that receivefederal funding (Exhibit 8). Most SHDshad moderate to high levels of involve-ment in breast cancer programs (SUA46%, SHD 85%) and immunization pro-grams (SUA 54%, SHD 72%), which arefunded in all states by the CDC. ManySHDs also have CDC funding in theareas of arthritis and diabetes–programsin which more than half of SHDs hadmoderate to high levels of involvement.A high proportion of SUAs had moder-ate to high levels of involvement in anumber of areas that are supportedthrough Older Americans Act funding,including nutrition, caregiver issues,dementia, domestic violence, and legalassistance/advocacy.

Cardiovascular

disease

Cancer

(breast)

Arthritis

Prescription

medications

Diabetes

57%

37%

45%

86%

40%

57%

36%

84%

38%

15%

Exhibit 6: Relationship between identified top health issues for older adults and moderate to high involvement, reported by state health departments

Percent of state health departments identifying issue as a top health issue (n=38)

Percent of state health departments with moderate or high programmatic involvement in issue (n=39)

Health Issue

Percent Response

0 10 20 30 40 50 60 70 80 90

i Question 19 of needs assessment.ii Respondent were given the following definitions ofpossible involvement levels: None: Not involved in thisarea at all. Limited: Participate in a task force, plan-ning/advisory committee, conference, etc., without spe-cific focus on older adults or at a low level of involve-ment. Moderate: Have program efforts specifically tar-geted to older adults, e.g., training or development ofeducation materials but limited in scope, geographicreach, and/or diversity of older populations served.High: Statewide program targeted to older adults, withsignificant commitment of staff and funding. The dis-cussion of results combines response choices for moder-ate and high involvement.

11

Exhibit 8: Moderate to high involvement in health problems of older adults, by state units on aging and state health departments

State units on aging (n=38) State health departments (n=42)

Health Problem of Older Adults

Percent Response: Moderate to High Involvement

10%

12%

3%

3%

10%

3%

0%62%

62%

82%

84%

83%42%

46%85%

47%

37%40%

48%57%

57%

44%98%

15%74%

72%54%

90%

21%92%

95%

21%92%

7%56%

19%

87%

85%

Nutrition

Caregiver issues

Domestic violence

Dementia/Alzheimer's

Legal assistance

Hunger/food security

Transportation

Senior employment

Medication management

Prescription drug access/coverage

Housing

Financial resources

Physical activity

Depression

Immunizations

Arthritis

Cancer (breast)

Diabetes

Cardiovascular disease

0 20 40 60 80 100

12

Exhibit 9: Barriers to promoting health among older adults, by state units on aging and state health departmentsExhibit 9: Barriers to promoting health among older adults, by state units on aging and state health departments

Barriers to Promoting HealthBarriers to Promoting Health

Percent Response

Lifestyle issues

Inadequate transportation

Lack of consumerawareness

Lack of organized systemof programs & services

Medicare requirements/lackof reimbursement for

preventive services

Fragmented services

Perceptions of aging & illness

Difficulties with healthcare access

Inadequate insurancecoverage

Geography

Lack of supportiveenvironments and safe

communities

49%

24%

41%

9%38%

26%

36%

31%

35%

28%

24%

26%

21%

28%

15%21%

14%

8%

5%

18%38%

49%


14%

00 1010 2020 3030 4040 5050 6060

13

Both agencies identify a range of important barriersto promoting health among older adults.i No singlebarrier was identified by a majority of SUAs orSHDsii (Exhibit 9). However, the top choicesof SUAs and SHDs were differentiated by theclusters of issues selected. The types of barri-ers identified by SUAs focused more heavilyon the individual (lifestyle issues, inadequatetransportation, and lack of consumer aware-ness), which is consistent with their mission ofproviding community-based direct services toolder adults. In contrast, the barriers selectedmore frequently by SHDs were systems barri-ers to providing programs and services on apopulation basis: lack of an organized systemof programs and services, health care access,and fragmented services.

Many SUAs, but few SHDs, identify transportationas an important issueiii. SUAs were five timesmore likely to identify transportation as a tophealth issue (SUA 26%, SHD 5%) (Exhibit10), more likely to have moderate to high pro-gram involvement in it (SUA 85%, SHD 3%)(Exhibit 11), and four times more likely toidentify it as a barrier to promoting health(SUA 38%, SHD 9%) (Exhibit 9).Transportation is a community support servicethat SUAs provide with OAA funding,while SHDs generally do not provide orfund transportation.

Prescription drug access/coverage is the issue mostfrequently identified as having high visibilitywithin states. The majority of SUAs andSHDs (SUA 59%, SHD 58%) identified pre-scription drug access/coverage as an urgent,hot-button issue (data not shown)iv. Thiscoincides closely with the identification ofprescription drug access/coverage as a tophealth issue (see Exhibit 5) and one inwhich many SUAs, but few SHDs, havemoderate to high levels of program involve-ment (see Exhibit 6). Prescription drugaccess/coverage also appear to be one of thefew issues in which program involvement isbased on state, rather than federal, funding.

i Question 15 of needs assessment.ii States were asked to identify main barriers to promotinghealth for older adults from a fixed-choice list. Funding andstaffing were not included as options.iii Questions 1, 19, and 15 of needs assessment.iv Question 28/29 of needs assessment.

Exhibit 10: Perceptions of transportation in relation to the health needs of older adults, by state units on aging and state health departments

State units on aging State health departments

How Transportation is Perceived

Percent Response

Transportation identified as abarrier to promoting health(SUA n= 39 SHD n= 43)

0

5

10

15

20

25

30

35

5%

26%

9%

38%

Transportation identified as a top health issue (SUA n= 38 SHD n= 42)

Exhibit 11: Level of programmatic involvement in transportation for older adults, by state units on aging and state health departments

Involvement Level

Percent Response

State units on aging (n=39)

State health departments (n=43)

None–low involvement

0

20

40

60

80

100 97%

15%

3%

85%

Moderate–high involvement

14

Program support needs

Public education materials, media, and social marketing wereidentified by both SUAs and SHDs as their top unmet programsupport needs (Exhibit 12)i. SHDs also frequently selectedadvocacy for older adults (SUA 31%, SHD 40%) and lead-ership continuity (SUA 26%, SHD 37%) as top unmetneeds, while SUAs identified programmatic expertise astheir second most frequent program support need (SUA38%, SHD 14%). Almost one-third of SUAs and SHDsalso cited the need for staff development/training (SUA28%, SHD 30%).

SUAs and SHDs want additional information about best practices,particularly in risk reduction and chronic disease, to more effectivelyaddress the health promotion and disease prevention needs of olderadults (data not shown)ii. Most frequently mentioned byboth SUAs and SHDs was a need for best practices in riskreduction/behavior change, including physical activity,nutrition, and weight control (SUA 36%, SHD 59%). Morethan a quarter of respondents also asked to see best practicesdeveloped in chronic disease prevention and control (SUA25%, SHD 31%), with cardiovascular disease and diabetes

i Question 17 of needs assessment. Funding and staffing were not included as response options, since these were already known to be frequently identified needsfrom the pilot.ii Question 25/26 of needs assessment.

Unmet program support need, by state units on aging and state health departments


Unmet Program Support Need

Percent Response

Public education materials, media& social marketing

Programmatic expertise

Advocacy for older adults

Caregiver assistance

Staff development/training

Leadership continuity

Program evaluation

Access to target population

54%40%

38%

14%

31%40%

23%

31%

28%

30%

26%

37%

26%

26%

23%

26%

0 10 20 30 40 50 60

Exhibit 12: Unmet program support need, by state units on aging and state healthdepartments

15

being the most commonly mentioned specific conditions.

Other than the CDC’s state-based Behavioral Risk FactorSurveillance System (BRFSS), which both agencies use, SUAsand SHDs generally use different data sources to identify, plan,monitor, and evaluate the health needs of older adults (Exhibit

13)i. All but one SHD and the majority of SUAs use theBRFSS (SUA 64%, SHD 98%). SUAs most frequently useU.S. Census data (SUA 74%, SHD 67%) as well as theirinternal programmatic data (SUA 72%, SHD 35%) forplanning and evaluation. Apart from the BRFSS, SHDs

Exhibit 13: Use of data sources, by state units on aging and state health departments


Data Source

Percent Response

77%

US Census

SUA programmatic data

BRFSS

State aging unit plan

Vital statistics

Local program data

Nursing home data

Hospital dishcharge data

Cancer registry

0 20 40 60 80 100

74%

67%

35%

72%

98%

64%

23%

62%

88%

59%

35%

56%

21%

49%

74%

18%

18%

i Question 21 of needs assessment.

16

most often utilized vital statistics (SUA 59%, SHD 88%)and cancer registry (SUA 18%, SHD 77%) data.

SHDs were also asked about their use of Administrationon Aging (AoA) resources. The AoA publishes extensive

publicly available data and other resources on aging, muchof which SUAs, but not SHDs, receive directly. A majorityof SHDs (53%) reported using AoA resources, including itspublications and Web site (data not shown)i. Twenty-eight


10%

10%

24%

15%

7%

10%

12%

13%

21%

10%

Exhibit 14: Level of access to research expertise, by state units on aging and state health departments

State units on aging (n=39)

State health departments (n=42)

Access to Research Expertise

Percent Response

0 10 20 30 40 50

Planning & implementation -regularly use

Planning & implementation -difficult to access

Evaluation - regularly use

Evaluation - difficult to access

All - regularly use

All - difficult to access

No access

37%

36%

12%

23%

17

percent (28%) of SHDs reported specifically using AoA data.

Most respondents do not regularly use research expertise resourcesfor planning, implementation, and evaluation of health promo-tion/disease prevention programs for older adultsi (Exhibit 14).Both SUAs and SHDs would like to receive technical assistanceand training in these areasii. About a third of SUAs and SHDshad resources that they regularly used for program planningand implementation (SUA 36%, SHD 37%). Only ten percentof either SUAs or SHDs had resources they regularly used forprogram evaluation. Very few respondents reported that theyhad resources they regularly used for both planning/imple-mentation and evaluation of programs (SUA, 10%, SHD 7%).

In some cases, research expertise was available but difficult toaccess. Up to a quarter of respondents reported difficulty ingaining access to existing research expertise for program plan-

ning or implementation (SUA 23%, SHD 12%), evaluation(SUA 15%, SHD 24%), or both (SUA 13%, SHD 12%).More SHDs than SUAs reported having no access to researchexpertise for health promotion programming for older adults(SUA 10%, SHD 21%).The most frequently requested areasof need for training and technical assistance were programplanning, needs assessment, and evaluation (SUA 42%, SHD59%) (data not shown).

Collaboration between state units on aging and statehealth departments

Most SUAs and SHDs collaborate to some extent with theircounterpart agency (Exhibit 15). The types of interagencycollaboration most often identified were participation oncommittees/boards (SUA 79%, SHD 53%), jointprograms/activities at the state level (SUA 67%, SHD 49%),

i Question 23/24, 22/23 of needs assessment.ii Questions 8 and 9 of needs assessment.

Participation on committees/boards 76 90 69 44

Joint programs/activities at state level 66 70 81 30

Joint planning/development of programs 55 60 63 37

Conference attendance/planning 55 20 63 37

Joint programs/activities at community level

45 30 63 30

Advocacy 35 20 25 11

Joint grant writing 24 20 13 0

Joint training 24 10 38 4

Joint contracts 10 0 25 0

None 0 0 0 15

Don’t know 0 0 0 7

Exhibit 15: Collaborative activities between state units on aging and state healthdepartments with and without health promotion/disease prevention lead

Collaborative ActivitySUA w/lead

(n=29)%

SUA w/o lead(n=10)

%

SHD w/lead(n=16)

%

SHD w/o lead(n=27)

%

18

and joint planning/development of programs (SUA 56%,SHD 47%). SUAs reported a broader range of collaborativeactivities with SHDs, indicating collaborations with morediverse organizational units within SHDs than was reportedby the counterpart SHD respondent. About a quarter ofrespondents collaborate in some activity at least monthly(SUA 33%, SHD 24%) (data not shown).

A major barrier to coordination is the lack of a designated lead unitor person for health promotion/disease prevention for older adults.

SUAs were twice as likely to have a designated lead unit orstaff as were SHDs (data not shown) (SUA 74%, SHD37%)i. Those SHDs with a lead unit or person collaborat-ed with their counterpart more frequently and around abroader scope of activities than those without a designatedlead. For SUAs, the presence of a lead unit or personincreased the frequency, but not the scope, of collaboration.

Both SUAs and SHDs identified the lack of an SHD-desig-nated lead individual for health promotion/disease prevention

Exhibit 16: Barriers to coordination with counterpart, by state units on aging and state health departments


Barrier to Coordination

Percent Response

No inividual designatedas lead for aging

issues in SHD

Low priority to services forolder adults within the SHD

Complexity and fragmentationof delivery services

Organizational culturedifferences

Staff have too manyresponsibilities

Lack of knowledge ofopportunities for

coordination

44%

58%

40%

41%

30%

36%

26%

36%

49%

31%

56%

31%

0 10 20 30 40 50 60 70 80


19

for older adults as an important barrier to collaboration(SUA 44%, SHD 58%) (Exhibit 16). A majority of SHDsalso identified that staff having too many responsibilitieswas a barrier (SUA 31%, SHD 56%).

Respondents frequently do not agree on which agency has the leadresponsibility within the state for health promotion and diseaseprevention for older adults (data not shown)i. SUAs most fre-quently stated that the responsibility was shared (SUA 44%,SHD 21%), while SHDs more often stated SUAs had thelead responsibility (SUA 18%, SHD 40%). Only six (19%)of the 31 matched-pair states had internally consistentanswers on lead responsibility, indicating a lack of clearlydefined roles to promote healthy aging.

Most states do not have a formal plan for health promotionand disease prevention for older adults (data not shown)ii.Almost half the SUAs but very few SHDs reported hav-ing a formal plan (SUA 44%, SHD 9%). Those SHDswith a formal plan all had a designated lead unit or per-son for older adult health. Some respondents without aformal plan reported other levels of planning activity.About a quarter had identified goals, objectives, and priori-ties for older adults (SUA 26%, SHD 23%). The majorityof SHDs did not have either a formal plan or any otherplanning activities for health promotion/disease preventionfor older adults (SUA 20%, SHD 51%).

A majority of both SUAs and SHDs (SUA 74%, SHD 57%)see the aging services network and its infrastructure as strengths ofthe SUAs (data not shown)iii. Through this network, a widerange of health and social services for older adults is avail-able in nearly every community nationwide. AlthoughSHD strengths were not as clearly defined, both respon-dent groups frequently identified SHDs as having strengthin health programming, including needs assessment, pro-gram development, and evaluation (SUA 35%, SHD 32%).About a third of respondents also identified collaborationsand partnerships as a strength for both their own agency(SUA 31%, SHD 36%) and their counterpart agency (SUA29%, SHD 30%).

Both agencies involve external partners in their health promotionand disease prevention activities (data not shown)iv. Senior cen-ters (SUA 95%, SHD 84%) and local health departments(SUA 59%, SHD 79%) were identified as partners by amajority of both SUA and SHD respondents. Commonprivate sector partners included numerous nonprofitorganizations dedicated to specific diseases, such as theArthritis Foundation (SUA 44%, SHD 91%) and theAlzheimer’s Association (SUA 77%, SHD 37%).

SHDs and SUAs differed somewhat in their identificationof public partners, consistent with their different priorities.While SHDs named state Peer Review Organizations-nowknown as Quality Improvement Organizations(QIOs)–most frequently (SUA 49%, SHD 60%), SUAsmost frequently named their state departments of mentalhealth (SUA 62%, SHD 37%). QIOs are state-basedorganizations designated by the federal Centers forMedicare and Medicaid Services to oversee the quality andutilization of services for Medicare beneficiaries. Theirpriorities include several preventive health areas in whichthey collaborate with SHDs, including mammographyscreening, immunization, diabetes, and cardiovascular disease.

For SUAs, their mandate to provide community supportservices involves assisting many older adults with mentalillness. Local aging network service providers such as sen-ior housing, senior centers, and case management programsanecdotally report that coordinating services for theseclients is time-consuming and difficult. Grassroots efforts ina number of states have resulted in coalitions betweenaging and mental health at both local and state levels tobegin to develop programs and policies to assist this popu-lation. A number of national organizations, including theNational Coalition on Mental Health and Aging, have pro-vided an impetus to develop stronger partnerships betweenSUAs and state mental health departments.

Other common public partners for both SUAs and SHDsincluded state agriculture departments (SUA 54%, SHD49%), which administer the senior farmers’ market nutri-tion programs, and state Medicaid agencies (SUA 49%,SHD 47%).

Funding

Funding sources drive priorities in SUAs and SHDs. SUAs arefunded through the Older Americans Act,Title III-D (seeAppendix D for statute) specifically to carry out healthpromotion and disease prevention activities, which are tra-ditional strengths of the public health system. SUAs canchoose how to use Title III-D funds from a menu of possi-ble options. The most frequently reported uses are forhealth screenings (56%) and physical fitness/exercise pro-grams (51%) (data not shown)v. SHD programs are similarlydriven by their funding sources. SHDs obtain funding forhealth promotion and disease prevention programs fromfederal sources such as CDC’s disease-focused cooperativeagreements (72%) and Preventive Health and HealthServices Block Grants (65%)vi (Exhibit 17). Cooperativeagreements are generally categorical; that is, they address a

i Question 4 of needs assessment.ii Question 3 of needs assessment.iii Questions 10 and 11 of needs assessment.

iv Questions 5 and 6 of needs assessment.v Question 13 (SUA) of needs assessment.vi Question 16 of needs assessment.

20

Older Americans Act

Social services block grant

CDC cooperative agreements

CDC prevention servicesblock grant

Community services block grant

Maternal child healthblock grant

Other federal funds

State tobacco settlement funds

Casino/lottery funds

Other state funds

Private grants

None

9%

95%

5%

18%

65%

2%

5%

5%

5%

9%

0%

0%

2%

72%

13%

19%

15%

37%

13%

44%

56%

15%

16%

5%

Exhibit 17: Funding sources for health promotion for older adults, by state units on aging and state health departments

Funding Source

Percent Response


0 20 40 60 80 100

State sources

Federal sources

Other sources

21

specific disease or public health issue. Neither of thesepublic health funding sources requires older adults to be apriority population. SUAs generally do not qualify forcooperative agreement funds, which are restricted toSHDs. Both SUAs and SHDs received state funding,including state tobacco settlement funds.

Fifty percent of SHDs are not familiar with Title III-D of theOlder Americans Act (data not shown)i. An additional 37%did not know what type of involvement their healthdepartment had with Title III-D funding. About a fifth ofSHDs (19%) reported participating in health promotionactivities funded through Title III-D, such as conferencesand training (data not shown)ii.If additional monies were made available for health promotion forolder adults, SUAs and SHDs would like the funding to addresschronic disease prevention/control and risk reduction/behaviorchange (data not shown)iii. The majority of SUAs andSHDs selected risk reduction (SUA 61%, SHD 74%), withan emphasis on physical activity and nutrition. Almost halfof respondents also selected the area of chronic disease(SUA 45%, SHD 43%), with cardiovascular disease beingthe most common specific health problem mentioned asneeding additional funding. Many SUAs also identifiedmental and behavioral health as funding needs (SUA39%, SHD 21%).

Promising programs

SUAs and SHDs were asked to provide examples, with briefdescriptions, of success storiesiv and best practicesv in health pro-motion/disease prevention for older adults. A best practicewas defined as being evidence-based, and respondents wereasked to describe how they evaluated outcomes. SUAs andSHDs described a wide variety of programs, sometimes ref-erencing the same program as both a success story and bestpractice. Few, however, stated specific outcomes ordescribed an evaluation process. Some SUAs and SHDsfrom the same state described the same program. For thisreason, the program types discussed below are based on thetotal number of responding states/territories (n= 51), ratherthan by type of state agency.

Seventeen states provided descriptions of physical activityprograms. These were primarily walking and/or resistancetraining programs for the general population of olderadults. Several programs targeted adults with general orspecific disabilities, such as arthritis. Other programs men-tioned with some frequency were osteoporosis screening,education, or awareness (ten states); immunization (sevenstates); medication management or access (six states); andfall or injury prevention (four states).

Programs that appeared to have evaluation componentsand that represented a cross-section of disease preventionand health promotion areas were contacted to collect addi-tional information. Eight of these programs, representing adiversity of approaches, are described in the section entitledCase Studies: Promising Programs. These programs demon-strate that SUAs and SHDs are in fact addressing healthpromotion and disease prevention for older adults. Theirefforts cut across diverse areas of health programming,including physical activity, fall prevention, immunizationcampaigns, health screening, disease management, andcommunity provider training. Some programs are wellfunded while others started on a “shoestring.” Some haveweathered state budget cuts, agency re-organizations, andmergers. More than one has faced an uncertain future indifficult fiscal times.

A common theme is the importance of collaboration inthe successful development and maintenance of programs.One program is an explicit SHD-SUA collaboration.Others are local-level collaborations that include healthdepartments,AAAs, hospitals, community service providers,and academic institutions.

These promising programs are presented to stimulate otherSHDs and SUAs to consider partnerships and opportunitiesavailable in their states to develop similar programs. Theexperiences of the eight programs in Case Studies: PromisingPrograms demonstrate that there are many ways to begin toaddress the health promotion needs of older adults andmany ways to structure effective collaborations that canresult in successful programs.

i Question 13 (SHD) of needs assessment.ii Question 14 of needs assessment.iii Question 18 of needs assessment.

iv Question 20 of needs assessment.v Question 24/25 of needs assessment.

22

Responding to the health needs of older adults

Most SUAs and SHDs recognized that chronic diseasesare major health problems affecting older adults. Inparticular, cardiovascular disease (CVD), the leadingcause of mortality among older adults, was the mostcommon health problem identified by both SUAs andSHDs. However, the level of involvement in CVD pro-grams was low for both agencies, with only six SHDsindicating that they currently have funding for compre-hensive CVD programs.

This finding is consistent with the limited availability offederal or state funding for state CVD programs.Nationally, only 19 SHDs have CDC planning grants,which focus on policy and environmental approaches toCVD reduction. SHD involvement in this importanthealth issue will likely increase in the future. However,SHDs are not currently mandated to collaborate withSUAs in these program-planning efforts or to target theolder adult population.

SHDs reported moderate to high involvement in pro-gramming for several other chronic diseases. MostSHDs, for example, reported moderate to highinvolvement in breast cancer programs, a CDC-fundedinitiative in every state. This response may reflect therecent increased efforts by SHDs to deliver breast cancerscreening services to women over age 50. More thanhalf of SHDs also had moderate to high involvement indiabetes and arthritis programs–two areas funded by theCDC through cooperative agreements with selectedstates. Almost half of responding SUAs also had moder-ate to high involvement in arthritis programs.Althougharthritis programs are not specifically referenced in theOAA, the aging services network serves many olderadults with this condition through home care, casemanagement, health promotion, transportation, andother community services. It is also possible that SUAsare collaborating with SHDs or local ArthritisFoundation chapters in their arthritis programming.

Many respondents identified the reduction of risk fac-tors for chronic disease, particularly physical activity andnutrition, as top health concerns. More SUAs thanSHDs reported moderate to high levels of involvementin risk reduction programs, with the exception thatSHDs were somewhat more involved in obesity pro-grams. The higher level of SUA involvement in nutritionprobably reflects the extensive congregate and home-delivered nutrition programs funded through the OAA.Their higher level of involvement in physical activitycoincides with the reported use of Title III-D healthpromotion programs on physical fitness and exercise bya majority of SUAs.

Tobacco use was rarely mentioned as a top health issue,despite its major contribution to cardiovascular diseaseand cancer. It is possible that tobacco prevention andcessation programs are not a priority per se, but may bea component, for example, of broader cardiovascularhealth programs. A lower prevalence of tobacco useamong older adults may also help to explain this finding.

In addition to chronic disease and underlying risk factors,many SUAs and SHDs identified access to prescriptionmedications and mental health services as top healthissues for older adults. These important issues, whichcan affect overall health status, have received increasedpublic attention in the past several years. Access to pre-scription medication was noted by both SUAs andSHDs to be the most common urgent, hot button issuereceiving public attention in their states. While mostSUAs reported moderate to high involvement levels inmedication access programs, most SHDs did not. Itmay be that many state-funded programs that provide

Discussion

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coverage for prescription drugs are administered by SUAsand do not involve SHDs. Similarly, a majority of SUAsbut few SHDs were involved at a moderate to high level insome aspect of mental health programming. SHDs mayhave valuable, untapped resources and capacity to con-tribute in addressing these health issues.

As expected, SHD efforts are less focused on older adultsthan are those of SUAs. For both agencies, levels of pro-gram-specific involvement appear to be dictated largely bycurrent federal funding opportunities. SHDs rely primarilyon limited CDC funding that is awarded on a competitiveand often disease-specific basis to a limited number ofstates to support disease prevention and health promotionprogramming. This more limited funding likely impairstheir ability to address healthy aging more broadly.

SUAs have high levels of involvement in programs that arefunded through the Older Americans Act, which disbursesfunding to every state and territory on a formula basis.This funding approach and the corresponding structure ofthe aging services network, which directly reaches almostevery community in the nation, ensures high levels ofstatewide involvement. While these OAA programs aredirected predominately at maintaining the independence ofolder adults in the community, they do not necessarilyemphasize disease prevention. Because of their OAA fund-ing and community-based involvement with direct services,SUAs identified several issues that may be key to healthpromotion but were not widely recognized by SHDs. Forexample, SUAs reported transportation as a major concernand service barrier. This suggests that efforts to improvehealth promotion and disease prevention should addresstransportation barriers in order to ensure access to programs.

Program support needs

SUAs and SHDs agree that they need more informationon best practices, as well as practical assistance in develop-ing, implementing, and evaluating effective programs thatprotect and improve the health of older adults. This find-ing was supported by the limited number of programssubmitted as best practices that had a clearly defined evi-dence basis.

There was no single issue that the majority of respondentsidentified as a barrier to promoting health among olderadults. In fact, SUAs’ and SHDs’ perceptions of barriersappeared to differ. SUAs selected individual behavior issuesas barriers (such as lifestyle, consumer awareness, and per-ceptions of aging and illness) more frequently than healthcare system issues (such as lack of an organized service system

and Medicare restrictions). SHDs, conversely, selected thesesystemic issues more frequently. These differences mayreflect their differing perspectives (e.g., services for individ-uals vs. population-based improvements) in approachinghealth issues.

No single program support need was identified by a major-ity of SUAs or SHDs. The most frequent needs identifiedby both SUAs and SHDs were public education material,media, and social marketing. Agencies may see develop-ment of skills and resources in these areas as particularlyimportant for implementing chronic disease prevention andrisk reduction programs.

Responses to questions about programmatic and dataexpertise yielded mixed messages. When asked about theiraccess to and use of research expertise, fewer than half ofSUAs and SHDs reported regular use of research expertisefor program planning and implementation. Yet in responseto another question, only about a quarter of respondentsidentified programmatic expertise, program evaluation, anddata expertise as unmet program needs. Similarly, whilefew reported regular access to research expertise for pro-gram evaluation, just one-quarter of respondents selectedprogram evaluation as an unmet program support need.

Responding to an open-ended question about technicalassistance and training needs, the most frequent need, statedby almost half of all respondents, was in the general area ofprogram planning and evaluation. About a quarter identi-fied data and surveillance issues, and almost a third madebroad statements related to needs in research or best prac-tices.

While many SUAs and SHDs identified expertise in data,research, program implementation, and evaluation as needs,there appear to be others that, while lacking such expert-ise, do not perceive it as an unmet need.

Collaboration and organizational issues

While most SUAs and SHDs collaborate to varyingdegrees with their counterpart agency, the extent of thiscollaboration is limited in many states.About one-halfreported collaborating on the joint planning or develop-ment of programs; three-fourths of SHDs and two-thirdsof SUAs reported collaborating less than once a month.

Meaningful collaborations appear to be hindered by thelack of staff specifically assigned to health promotionefforts for older adults. This limitation more frequentlyarises from the SHD side of the potential partnership,with only about a third of SHDs reporting a designatedindividual or unit. In addition to affecting cross-agency

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collaborations, lack of designated staff appears to influenceSHD internal planning for health promotion for olderadults; only SHDs with designated staff indicated they hada formal plan.

Because SHDs do not typically have funding specificallydedicated to services and programs for older adults, thelack of a designated individual or unit is not surprising.Unfortunately, without a unit or staff person responsible forthis program area, missed opportunities for collaborationand the development of more focused, funded programmat-ic initiatives are inevitable.There appears to be widespread confusion about whichagency in a state has lead responsibility for health promo-tion and disease prevention among older adults. This mayhinder efforts to further develop programs since it isunclear who would take the lead role in these efforts. Ingeneral, both SUA and SHD responses shifted lead respon-sibility to the other agency, leaving a void in perceivedleadership.

Despite these limitations, SUAs and SHDs recognizestrengths in their own agencies and in their counterpartagencies that could form the core of stronger partnerships.The SUAs’ lead role in the comprehensive aging servicesnetwork was widely recognized, and skills in health pro-gramming were frequently mentioned for SHDs. While itmay be surprising that SHDs were not widely recognizedas having expertise in chronic disease prevention and con-trol, this gap may be due to their acknowledged lack ofactivity specifically for older adults in this area.

Funding

As noted above, funding availability drives program priori-ties for both SUAs and SHDs. The categorical nature offunding for chronic disease prevention and control, in par-ticular, may force SHD programs to be more narrow thanis desirable for a broad risk reduction approach thataddresses older adults. Given the limited funds available forchronic disease prevention and control efforts, as well asthe lack of any specific requirement to target older adults,SHDs usually do not include this population in their pro-grammatic initiatives.

Several SUAs stated in narrative comments that they wouldlike to be eligible to apply directly for CDC chronic diseasefunding to address the needs of their target population.Such flexibility in funding criteria, as well as enhancedSUA-SHD collaborations, could improve the ability of exist-ing programs to address healthy aging. Increased fundingwould allow states to expand and more directly affect healthpromotion and disease prevention for older adults.

Summary

The results of the Aging States Project needs assessmentindicate that state units on aging and state health depart-ments have very similar perspectives on a variety of issues.For example, they identify the same top health needs ofolder adults, although their programs to address theseneeds differ, consistent with their policy priorities, fundingmandates and histories. The unique areas emphasized inprograms conducted by public health departments andstate units on aging may also influence differences in howbarriers to promoting health are assessed and how programsupport needs are identified.

SUAs and SHDs each recognize strengths in their counter-part agencies.These strengths are often complementary toidentified needs and are potential resources. However,SUA-SHD coordination and collaboration is limited inmany states and may restrict the opportunity to developshared resources. A major barrier to collaboration, particu-larly for SHDs, is the lack of staff specifically assigned tohealth promotion for older adults. The results also indicatethat there is a particular need for information and assis-tance in the development of science-based programs in thearea of health promotion for older adults. Finally, there islimited availability of funding that specifically targets healthpromotion and disease prevention for older adults, whichmay impose constraints on states’ abilities to develop com-prehensive healthy aging initiatives.

Next Steps

These results point to a range of possible interventions toimprove the capacity of SUAs and SHDs to address thehealth promotion and disease prevention needs of olderadults. NASUA and CDD, together with the Ad HocHealth and Aging Advisory Committee, developed therecommendations in the following section as next steps inthis effort.

These recommendations identify a range of activities andinitiatives that are intended to promote collaboration andcoordination across agencies and to support the furtherdevelopment of effective health promotion and diseaseprevention programs for older adults. Recommendationsare addressed to public agencies at both the federal andstate level as well as to NASUA and CDD, as partners inthis project.

Our hope is that the results and recommendations of theAging States Project will be useful tools for stakeholders tohelp advance our collective efforts to improve the health ofolder Americans.

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For the Centers for Disease Control and Prevention (CDC)and the Administration on Aging (AoA)

Promote improved collaboration between state health departments andstate units on aging:

– Support active networking among state health departments andstate units on aging around older adult health issues, e.g., through list-serves, conference calls, regional networking meetings and nationalconferences.

– Reward evidence of inter-agency collaboration between stateunits on aging and state health departments in competitively fundedprograms.

– Encourage state units on aging to involve state health departmentsin planning, implementing, and evaluating health promotion/diseaseprevention programs for older adults.

– Encourage state health departments to involve state units on agingin planning, implementing, and evaluating projects and programs thattarget older adults.

– Support development of state healthy aging plans that are jointlydeveloped by state units on aging and state health departments.

Support health promotion/disease prevention programs for older adults:

– Develop the scientific evidence needed to determine the mosteffective approaches to health promotion/disease prevention programsfor older adults.

– Develop mechanisms to disseminate and promote “best practices”and effective and innovative program models.

– Reward applicants that can document an evidence base in com-petitively funded programs.

– Provide technical assistance and support to conduct rigorous eval-uations of promising programs.

– Develop and promote data standards and guidelines to encourageshared program planning and evaluation.

– Assure that current and future funded programs address olderadults and draw on strengths and outreach capabilities of the agingand public health networks.

Provide needed training and technical assistance:

– Develop training materials for use at the state level to achieve visi-bility for healthy aging issues.

– Develop and promote training materials and educational opportu-nities for practitioners about evidence-based health promotion anddisease prevention strategies for older adults.

– Provide technical assistance and support to replicate, adapt, andevaluate successful evidence-based health promotion/disease preven-tion programs.

Recommendations to Improve the Health of Older Adults

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For State Health Departments and State Units on Aging

Promote collaboration and communication across agencies:

– Designate a “point person” for communication with the counter-part agency around health promotion/disease prevention for olderadults.

– Clarify state organizational relationships related to lead roles andjoint planning for healthy aging programs.

– Enlist health department collaboration in the design, implementa-tion and evaluation of state unit on aging programs.

– Enlist state unit on aging assistance in the design, implementationand evaluation of health department programs for older adults.

– Include a focus on older adults in all appropriate health promo-tion and disease prevention initiatives directed by the state healthdepartment.

– Foster development and expansion of community-level partner-ships between area agencies on aging, local public health departments,and their respective provider organizations.

– Share available data and analytic resources.


– Assure current and future programs use evidence-based interven-tions and evaluations where available.

– Enlist state health department collaboration in the use of OlderAmericans Act Title III-D (disease prevention/health promotion)funding within the state unit on aging.

– Enlist state unit on aging collaboration in the use of funds forchronic disease prevention and control activities within the statehealth department.

– Jointly seek additional funds for new collaborative initiatives tar-geting older adults.

Provide needed training:

– Provide and promote participation in training opportunities relat-ed to healthy aging for both the aging and public health networks.

For the Association of State and Territorial Chronic DiseaseProgram Directors (ASTCDPD) and the NationalAssociation of State Units on Aging (NASUA)

Promote collaboration and communication:

– Continue the associations’ collaborative activities at the nationallevel to enhance relationships and partnerships between state units onaging and state health departments.


– Explore legislative changes that would ensure the inclusion ofolder adults as a priority target population in relevant health promo-tion/disease prevention programs.

– Identify new opportunities to gain support for resources thatenhance healthy aging.

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California Department of Health Services

Preventive Health Care for the Aging Program

Project Description

Preventive Health Care for the Aging (PHCA) was firstenacted and funded by the California State Assembly in1975 to provide preventive health services for seniors.Over the last 25-plus years, the program has expandedand developed to meet the preventive health needs ofCalifornia’s older adults, ages 55 and over. PHCA’s goalsare to promote healthy lifestyles, increase access tohealth services, and to improve quality of life. Its majorobjectives include assisting older adults in managingchronic health conditions and promoting healthybehaviors.

The core service of PHCA is a comprehensive individualassessment and development of a health plan conductedby a public health nurse.The assessment includes a healthhistory, assessment of physical activity and nutritional sta-tus, and basic physical screening tests.The individualizedhealth plan is a written, signed contract, jointly devel-oped by the nurse and client, that reflects the client’scommitment to take steps to improve his or her health.Steps may include behavior change, scheduling medicalor other care, and seeking other needed communityservices. Follow-up visits are scheduled to checkprogress and to provide focused health education orcounseling as indicated by the assessment and plan.While program outreach is directed at seniors who areunder-served, low-income, and ethnically diverse, allseniors may receive services and participate. PHCAservices are offered free of charge. In some locations,small fees or donations are requested for special labora-tory screening tests.

The Department of Health Services contracts with 16county and city health departments, covering aboutone-third of California, to implement PHCA. The stateallocates approximately $1.2 million to PHCA (fiscalyear 2002) and requires that participating health depart-ments provide at least a 50% match of funds or in-kindservices for implementation. Public health nurses fromthe health departments conduct assessments and visits ina variety of community settings, including senior cen-ters, congregate meal sites, senior housing complexes,and churches.

In addition to individual client services, PHCA nurses

provide an array of broader community-based services.For example, they typically conduct lectures and writearticles for local senior publications on issues such as fallprevention, osteoporosis, and medication management.They work to improve the quality of life for seniorswhile collaborating with local aging networks and com-missions. PHCA collaborates closely with local AAAs inreferring clients to service programs and in sponsoringhealth fairs and educational events. All but one PHCAprogram is contracted and managed by the local pub-lic health department; the other is managed by thelocal AAA.

PHCA reaches a broad cross-section of California eld-ers. Almost half (47%) are more than 75 years old, 62%live in rural areas, 59% are low-income, and 29% areminorities (with Hispanic clients being the predominantgroup). One-third have more than six chronic condi-tions, with cardiovascular disease (54%) and arthritis(48%) being the most commonly reported chronicconditions.

In fiscal year 2000, PHCA nurses served more than8900 clients, with an average of 1.8 visits per client.More than 5200 medical referrals were made, of which64% resulted in a new diagnosis or treatment.

Lessons Learned

PHCA has incorporated process and outcome evalua-tion into its program model to improve its efficacy.Among the range of research that has been done, a1995 study found that a written, signed health plan sig-nificantly increased the likelihood of client behaviorchange.This component is now a standard part ofPHCA assessments.Thirteen Healthy People 2010objectives are now being tracked using computerizedencounter forms.

Effective outreach has been the key to the success ofPHCA in identifying under-served older adults. Eachlocal health department uses multi-lingual outreachworkers and senior volunteers who are familiar withtheir communities’ older adult populations.

Contact

Laurie Vazquez, Chief PHCA Program California Department of Health Services601 North 7th St., MS-253P.O. Box 942732Sacramento, CA 94234-7320(P) 916-324-1323(F) [email protected]

Promising Programs: Case Studies

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Delaware Division of Services for Aging andAdults with Physical Disabilities

Millennium March to Wellness

Project Description

The Millennium March to Wellness is a comprehensivewellness initiative for older adults begun in 1999 by theDivision of Services for Aging and Adults with PhysicalDisabilities. In developing the project as a specific healthpromotion effort for older adults, the Division took itsguidance from the national Healthy People 2010 andHealthy Delaware 2010 plans. The major objectives ofthe Millennium March to Wellness are to encourageolder adults to increase physical activity, to increase theirconsumption of fruits and vegetables, and to adopthealth-sustaining behaviors and lifestyles. Its major com-ponents are described below.

1.Walk Delaware promotes physical activity by challeng-ing older adults to walk the equivalent of the length (96miles) or width (35 miles) of Delaware during one year.

– In Walk Delaware’s initial stages, the Division spon-sored a kick-off event for organizations in the state’s agingnetwork to develop an advisory council and seek partnersin forming local walking groups and promoting the pro-gram. This was a critical and successful outreach effortthat led to multiple partnerships that have contributed tothe growth and success of the project. The Division thenkept in touch with its partners through monthly corre-spondence as the Millennium March developed.

– The Delaware Senior Olympics adopted WalkDelaware as their major non-competitive effort to pro-mote physical activity. The Senior Olympics recentlyapplied for and received a Healthy Delaware 2010 mini-grant from the SHD to continue its development ofwalking groups.

– Many additional partners, including local seniorcenters, also promote the program and have developedwalking groups.The Division provides training to com-munity partners.

– The Division developed and distributed a free WalkingLogbook for participants to use to record their progress.Participants are asked to complete a registration form withbasic demographic data prior to receiving a logbook.

– The Division developed First State Fitness Certificates,which are awarded to everyone who sends in a completedlogbook documenting their achievement in walking theprescribed distance.

In 2000, more than 500 individuals registered for WalkDelaware and approximately 300 certificates were award-

ed. Some participants in their 80s and 90s have sent inwalking logs to receive certificates for the past threeyears. Many people send in logs that record walkinghundreds of miles each year.

2. 5 a Day for Better Health is the Division’s effort toimplement the national 5 a Day program to increaseconsumption of fruits and vegetables and to focus onnutrition education for older adults. The Division iscurrently sponsoring a pilot program to increase fruitand vegetable consumption at Title III congregate andhome delivery meal programs. A nutritionist and dia-betes educator have developed an education modulebased on the stages of change model. The module waspresented at a quarterly Title III directors’ meeting thisfall, and they were asked to use it as their required quar-terly consumer nutrition education program. TheDivision is currently evaluating its impact on two levels:a) its usefulness for nutrition education, and b) whetherthe intervention resulted in changes in participant eatinghabits. If the evaluation shows positive outcomes, theyhope to replicate it statewide.

The overall budget within the Division for health pro-motion is about $80,000 annually, all OAA Title III-Dfunds. The start-up costs for Walk Delaware were about$20,000. This included developing and printing the logsand certificates, and bringing in outside experts for guid-ance. The public health educator, who oversees theDivision’s health promotion program, is paid withstate funds.

Next steps

The Division is now using the registration forms andcompleted logbooks to develop a participant database,and has contracted with the University of Delaware todevelop an evaluation component examining health out-comes and quality of life measures for participants.

The Division is also developing a five-year strategic planfor its health promotion programs in conjunction withthe University of Delaware, the Senior Olympics, theGovernor’s Council on Physical Activity, the Departmentof Health and Social Services, and input from its com-munity partners. With the success of the Millennium’sefforts in the past two years as a base, the Division hopesto increase its health promotion infrastructure, to widenits range of physical activity programs, and to incorporateinto their initiatives greater focus on adults with physicaldisabilities.

Lessons learned– The Division found that developing and sustaining keycommunity partnerships has been critical to the success of

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the Millennium March to Wellness.

– The sustainability of the project was an initial con-sideration that has proven to be important, as the Marchto Wellness has become a base upon which additionalprojects can be built.

– Division staff acknowledge that, in retrospect, itwould have been preferable to involve experts in out-comes and evaluation earlier in the development of theproject.

Contact:Chris Oakes, Public Health EducatorDelaware Division of Services for Aging and Adults with Physical Disabilities(P) 302-577-4791, x 53(F) [email protected] site: http://www.dsaapd.com

Maine Bureau of Elder and Adult Services

A Matter of Balance

Project Description

In 2000, the Maine Bureau of Elder and Adult Services(BEAS) was contacted by its sister agency, the Bureauof Health (BoH), to request assistance in developing acollaborative response to a CDC grant programannouncement for a fall and fire prevention program.Recognizing that these are two significant issues for theolder adult population that it serves, BEAS readilyagreed, and the two agencies jointly developed andsubmitted the grant proposal.

In the course of researching fall prevention programs forthe CDC application, BEAS and BoH learned that anevidence-based curriculum,A Matter of Balance, wasalready in use in several counties in southern Maine.This curriculum, developed at Boston University’sRoybal Center for the Enhancement of Late-LifeFunction, had been purchased by a major health systemin Maine, MaineHealth, for use in their GerontologyProgram. MaineHealth, through its network of commu-nity providers, supported the implementation as part ofits goal of promoting physical activity to enhance thefunctioning of older adults. The curriculum focuses onmanaging the fear of falling, developing goals forimproving balance and strength, and self-evaluating risk

factors in one’s daily environment.

Although Maine did not receive a CDC grant, theprocess of developing the proposal had sown seeds ofinterest. Several of the five AAAs in Maine hadexpressed interest in a fall prevention program. TheBureau of Elder and Adult Services thought this was animportant initiative and agreed to fund a pilot programusing A Matter of Balance. BEAS funded three AAAsin rural northern, eastern, and western Maine (areas ofthe state where the curriculum was not being imple-mented by MaineHealth) to implement the program ona pilot basis. AAAs trained selected staff at their agen-cies to present the program. Seven classes have nowbeen completed and several others are underway.BEAS’ goal is to reach 250-300 older adults in thispilot phase, running through 2002.

The curriculum, which includes pre- and post-testevaluations, has been extensively evaluated for its effec-tiveness. Trainers re-contact participants after sixmonths to collect data on whether they have had falls,and whether they’ve continued to engage in the exer-cises and activities taught in the program.

The costs of the program are relatively modest. A totalof $50,000 of state funds was provided to the threeAAAs to pilot the program. Major costs include train-ing time and purchase of the curriculum. Volunteersare recruited to assist with training, and collaborationshave been formed with community providers such ashousing, hospitals, and home health agencies. As part ofthe program, participants receive free exercise bands aswell as safety devices such as grab bars. Volunteerhandymen from the AAAs’ home improvement pro-grams install the devices. Additional resource materialsrelated to health and safety are also offered in the formof printed handouts and videos. The program is free toparticipants.At this time, BEAS is uncertain about continued fund-ing of the program beyond the pilot stage. The AAAsreport interest and potential funding from various com-munity providers who recognize the benefit to thepopulation they are serving as well.

Contact:Doreen McDaniel, Community Program SpecialistBureau of Elder and Adult Services11 State House StationAugusta, ME 04333(P) [email protected]

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Massachusetts Department of Public Health

Keep Moving Program

Project Description

Keep Moving, the name of Massachusetts’ statewidewalking program for older adults, is also an apt motto forthe strategy used to keep a good program alive despitethe ebbs and flows of public funding.

The goal of the Keep Moving Program is to improve thelives of people over age 50 by promoting physical activi-ty to prevent and postpone chronic disease, build healthybodies and minds, and keep individuals socially con-nected. The program functions through a network ofabout 150 local walking clubs with more than 2500participants.

Started in 1985 as a project of the Massachusetts SUA,the Executive Office of Elder Affairs (EOEA), KeepMoving established walking clubs across the state forolder adults. During funding cutbacks in the recession ofthe late 1980s, state support was no longer available. Anad hoc group of participants and supporters recognizedthe value of Keep Moving and assumed responsibility forit, staying in touch as an advisory group and doing pri-vate fundraising to sustain a part-time coordinator. Theadvisory committee included, and continues to include,participants from the state’s aging network, business, aca-demia, health care, the state legislature, the SUA, theSHD, and the Governor’s Committee on Physical Fitnessand Sports. From the late 1980s through the mid-1990s,the Keep Moving Program sustained its activities througha private funding base.

As the economy improved, opportunities for state fund-ing arose through programs based at the MassachusettsDepartment of Public Health (MDPH). Massachusetts isone of relatively few SHDs with a dedicated organiza-tional unit for older adults, the Office for Elder Healthin the Division of Community Health Promotion. In2000, EOEA and MDPH agreed that the organizationalresponsibility for Keep Moving should shift to this officeat MDPH, while still maintaining the inter-agency col-laborative nature of the program.

The core programmatic activity has remained stablethroughout Keep Moving’s evolution: to recruit olderadults to join local walking clubs, each coordinated by atrained volunteer leader from the community, and toencourage them to take at least three 30-minute walksweekly. Most local clubs function through the auspicesof a community organization such as a senior center,

housing site, municipal parks and recreation depart-ment, or church. Walkers receive a walking manual anda logbook, in which they can record their activity andprogress. Each local club takes on a unique identity.Many have club names, and local sponsoring organiza-tions frequently provide club tee shirts and otherincentives. Several times a year, Keep Moving sponsorsregional walks, where local clubs come together for anevent. An annual statewide event brings clubs togetherand recognizes volunteer leaders.

Keep Moving conducts regional leader training programsthroughout the year. Marketing to identify potentialleaders and develop new clubs has traditionally beendone through the state’s aging network. In keeping witha recently developed strategic plan, Keep Moving hasmade several changes. It has identified target populationsof older adults–communities of color and men in urbanneighborhoods–who have not been adequately enrolledthrough previous efforts. Keep Moving has hired a part-time outreach worker and organizer, through the help ofa foundation grant, to specifically establish clubs andrecruit these target populations in Boston. Training alsohas been modified to focus on men’s health issues and tomeet the learning styles of a predominantly male audience.

In 2001, MDPH contracted with Tufts University toevaluate Keep Moving. Evaluators have completed anextensive survey of participating walkers and are nowsurveying participants in leader training programs. Bycontacting everyone who has completed a leader trainingin the past five years, they hope to learn more aboutwhat causes individuals to act on the health informationgained, and what barriers keep individuals from applyingthe information and forming local walking clubs.

Keep Moving has an annual budget of about $70,000and currently receives funding from Blue Cross/BlueShield of Massachusetts and the Robert Wood JohnsonFoundation, with additional in-kind support fromMDPH and the Governor’s Committee on PhysicalFitness and Sports. Funding supports two part-timestaff, materials development and printing, special events,leadership training, and evaluation. Staff emphasize thatKeep Moving has been able to exist in the past withmuch less funding and that walking clubs can be sus-tained at differing funding levels.

Next Steps and Lessons Learned

Now in its 17th year, Keep Moving continues to adaptand grow to meet the challenge of promoting physicalfitness among older adults. Future plans for KeepMoving include the expansion of physical activitychoices to encourage senior walkers to add strength, bal-

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ance, and flexibility training to their walking routines.Staff identified several key issues that have contributed topast successes and that will inform future programchanges:

– The importance of local infrastructure: being part ofa community organization gives walking clubs invaluablesupport, adds resources to local activities, and sustainscommunity-based physical activity programs.

– Targeting under-served and hard-to-reach popula-tions is crucial to achieving overall state goals for theprogram, but also requires additional resources to supportlocal leaders and community organizations.

– Identifying and training a minimum of two leadersfor each club increases the sustainability of local clubs.

– Last, but not least, collaboration works. Throughoutthe life of Keep Moving, the SUA and SHD have collab-orated–with each other and with a broad array of privatepartners. As one staff person put it,“We never let turfissues interfere with the value of the program to seniors.”

Contact:Jan Marble, Project Coordinator Keep Moving ProgramOffice of Elder HealthMassachusetts Department of Public Health250 Washington St.Boston, MA 02108(P) 617-994-9808(F) [email protected]

Missouri Department of Health and SeniorServices (MDHSS)

The Missouri Arthritis and Osteoporosis Program

Project Description

The Missouri Arthritis Program was established by theMissouri state legislature in 1984, the result of aneight-year, broad-based citizen coalition of health careprofessionals, policy makers, and community leadersthat produced a major report on the burden of arthritisin the state.This initial grassroots effort developed outof concern for the high prevalence of arthritis amongadult Missourians: 37% report having arthritis. In1996, after the legislature enacted an osteoporosis pro-gram with similar programmatic objectives to theArthritis Program, the two programs joined to become the

Missouri’s Arthritis and Osteoporosis Program (MAOP).

The goal of MAOP is to reduce the burden of chronicdisease and promote healthy aging by providing educa-tion and community-based services. The program isimplemented through seven Regional Arthritis Centers(RACs), which serve as local resources for arthritis andosteoporosis professional and public education, medicalreferrals, and services. RACs are situated within largerhosting institutions, such as teaching hospitals, that canprovide comprehensive arthritis care.

A state-level, 25-member advisory board with healthprofessional and consumer and community representa-tives provides ongoing consultation to the program.Each RAC has a local advisory board, many of whichhave representation from the state’s aging network.RACs also partner with many local organizations thatare part of the state’s aging network, including AAAs,senior centers, and independent living centers.

MAOP has developed specific, measurable objectives forincreasing physical activity, decreasing the prevalence ofoverweight, decreasing functional limitations due toarthritis, and increasing osteoporosis counseling amongmenopausal women. The program uses the state’sBehavioral Risk Factor Surveillance Systems (BRFSS) tocollect statewide data on these indicators. MAOP hasalso contracted with St. Louis University School ofPublic Health to conduct a program evaluation.

Funding for MAOP comes from a combination of stateand federal sources, which are used to create a continu-um of services. In addition to the state-specific arthritisand osteoporosis appropriations, MDHSS receives fund-ing for arthritis from the CDC through a cooperativeagreement as well as a Special Interest Project researchcontract. In total, MAOP receives approximately$880,000 annually.

Contact:Mary Ellen Ankeney, Manager Arthritis and Osteoporosis ProgramDivision of Chronic Disease Prevention and Health PromotionMissouri Department of Health and Senior Services920 Wildwood, P.O. Box 570Jefferson City, MO 65102-0570(P) 573-522-2800

New Jersey Department of Health and Senior

32

Services

Health Promotion Initiative

Project Description

In 1997, the New Jersey Department of Health andSenior Services (NJDHSS) was contacted by the NewJersey Geriatric Education Center (NJGEC) at theUniversity of Medicine and Dentistry of New Jersey-School of Osteopathic Medicine Center for Aging topropose the formation of a collaborative relationship.The NJGEC, one of more than 40 centers fundednationally by the federal Bureau of Health Professions toprovide health professional education in geriatrics, hadidentified a need for accessible and coordinated educa-tion to community-based service providers from boththe health and aging networks.

The Health Promotion Initiative (HPI) grew out of thisinitial overture. HPI has two major goals: to providetraining on health promotion and aging to professionalsin community-based health and aging programs, and tostrengthen networking and coalition-building betweenthose same community-level health and aging networks.

The NJDHSS conducted surveys of health and agingproviders to assess their training needs.This resulted inthe NJGEC developing three distinct training modulesin mental health, fall prevention, and medicationuse/misuse. In addition to curriculum development, theNJGEC is responsible for identifying expert presentersand delivering training programs across the state.NJDHSS takes the lead role in identifying counties toparticipate in the program and in supporting and sus-taining coalition-building efforts. NJDHSS staff and theNJGEC convene a meeting of key representatives fromhealth and aging networks, including the county officeon aging, the county or municipal health department,and the county mental health office. This core groupidentifies which of the three curriculum modules willmeet a specific need in their region, selects representa-tives/agencies from their counties to participate in thetraining, and handles the logistics of the two-day train-ing. The program is offered free of charge to traineesand the county. Each training workshop can accom-modate 30 participants, equally representative of thehealth and aging networks.

Training workshops are provided at the county leveland targeted to address local needs. The workshopsinclude a session featuring local experts and provide animportant opportunity for networking among thetrainees.These two factors are critical to the success of

the overall initiative. Trainings are two full days, held aweek apart. Participants are required to attend bothdays. Presenters of each module are specifically qualifiedin the topic and may include geriatricians, psychiatrists,nurse practitioners, pharmacists, and physical therapists.Trainings are designed to be interactive, with partici-pants learning not just from the presenters, but fromeach other. Opportunities for networking and learningabout community resources for health and aging arestructured into the session.

Participants must also agree to join an ongoing coali-tion that will address community needs in the topicarea. Everyone receives a homework assignment on thefirst day to identify gaps in local resources related to thetraining topic. NJGEC staff collect these assignments,compile the information, and present it to the groupon the next day. The information is used as the startingagenda for the first follow-up meeting of the countycoalition.

Since 1998, the Health Promotion Initiative has con-ducted 15 trainings with more than 400 participants.Participants have included visiting nurses, social workers,mental health counselors, local health officers, seniorcenter coordinators, and police officers. The mostrequested training module has been mental health.

One HPI coalition focusing on mental health selected acommon depression-screening tool for all sites to use ina depression screening campaign.The NJ DHSS workedwith the coalition to secure a small grant to underwritethe campaign. The coalition also developed an insert forthe local paper on mental health and stress.

Another county developed a “gatekeeper” training toassist first-responders and others to recognize symptomsof mental illness, including depression, and to be awareof referral resources when they are called to a situationinvolving an older adult. Police officers, emergencymedical technicians, and clergy were among the com-munity participants in the training.

NJGEC is able to provide these trainings free of chargeto counties and participants as part of its grant from theHRSA Bureau of Health Professions. NJGEC esti-mates that the cost per training is approximately $9400.Additionally, curriculum development for the threetraining modules was $10,500.

Next Steps and Lessons Learned

Pre- and post-knowledge tests that are part of the cur-riculum indicate that participants learn substantial newinformation. NJDHSS staff indicate that the coalitionsthat grow out of the trainings have had mixed success.

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As is typical with community coalitions, they requiresubstantial staff support to nurture and maintain.Thosewith a community-based individual who takes the leadare most successful. Coalitions report that smallamounts of funding to support community effortswould be of benefit.The availability of mini-grants of$5000 to $10,000, such as the grant the coalitionsecured in the example above, would support theirefforts to implement activities.

Ideally, HPI staff would also like to expand the range oftopics on which training is offered, and to more sys-tematically involve local health departments in theplanning process. NJGEC and NJDHSS will continueto offer the trainings for at least the two remainingyears of the current grant cycle.

Contact:Gerry Mackenzie, SupervisorOlder Adult Health and WellnessDivision of Senior AffairsNew Jersey Department of Health and Senior ServicesP.O. Box 807Trenton, NJ 08625(P) 609-943-3499(F) [email protected]

New York State Office for the Aging

New York State Department of Health

Adult Immunization Campaign

Project Description

Four years ago, staff from the New York State Office for theAging (NYSOFA) and the State Department of Health(DoH) began discussions around data showing that manyhigh-risk older adults were not receiving recommendedinfluenza and pneumococcal vaccinations. The DoH hadCDC funding for immunization campaigns and had epi-demiological expertise, while NYSOFA had both the accessto the aging network and the knowledge base of socialgerontology that the health department required.

The Health Department contracted with NYSOFA foroutreach to older adults. NYSOFA then utilized its agingnetwork, arranging flu clinics at senior centers, adult dayhealth programs, and senior congregate housing sites, andalso promoted the campaign to providers. Flyers were dis-tributed at elder programs. NYSOFA also developed acomprehensive flu Web site page (http://flu.state.ny.us) aspart of its comprehensive Aging Well Web site

(http://agingwell.state.ny.us).

In the past two years, outreach and vaccination programshave expanded to non-traditional settings and have targetedparticularly high-risk groups such as the homeless andnear-homeless. Staff from both the DoH and NYSOFAconduct outreach at off-track betting sites, bus depots, andtrain stations. They have developed an array of promotionalgive-aways, including pencils and cups. They have alsofocused on developing successful partnerships with the faithcommunity. Immediately following a sermon including ahealth message about the benefits of vaccination, state staffoffer vaccination clinics in the church or synagogue hall.

NYSOFA has worked with New York’s AAAs to incorpo-rate vaccinations into their Title III-D funding. All TitleIII-D funds are spent on specified priorities, of which vac-cination is one. If the AAA chooses this priority, it receivesguidance from NYSOFA in implementing a successfulprogram.

These coordinated efforts have been extraordinarily success-ful. In three years, the immunization rates for influenza andpneumonia among New York residents ages 65 and olderhave improved by almost 24%, to 79% in the 2000/01flu season.

Lessons Learned

As in many other states, New York’s SUA and SHD areseparate agencies, with many inherent obstacles to col-laboration. Four years ago, there was little in the way offormal joint activities, with each agency regarding the othersomewhat dubiously from a distance. However, some colle-gial relationships did exist, and from these, a group of DoHand NYSOFA staff began to talk informally, exploring in ageneral way how they could work together to betteraddress the health needs of New York’s older adults.Recognizing that relationship-building was key, staff beganextending mutual invitations to gerontology forumssponsored by the SUA. As a result of these contacts anddiscussions, opportunities arose for joint program develop-ment on a number of disease prevention and control initia-tives. Today, the two agencies collaborate closely across abroad range of programs that are improving the health ofthe older adults of New York.

Contact:

Edward J. Kramer, Assistant Director for OperationsNew York State Office for the AgingTwo Empire State PlazaAlbany, NY 12223(P) 518-474-5478(F) [email protected]

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Pennsylvania Department of Aging

PrimeTime Health: Peer Exercise Program Promotes Independence

Project DescriptionPrimeTime Health is the umbrella statewide health pro-motion and disease prevention program of thePennsylvania Department of Aging. At the initiation ofPrimeTime Health in 1993, the Department convenedan advisory committee, which set priority areas for pro-gram development: exercise, nutrition, incontinence,mental health, chronic disease, alcoholism, injury preven-tion, and medication management. Pennsylvania’s 52AAAs are each required to use their Title III-D funds inone or more of these priority areas, overseen by a localdesignated PrimeTime Health coordinator. While theAAAs have discretion in their health promotion pro-gramming, the Department also develops programs thatcan be implemented by AAAs in their communities.One of PrimeTime Health’s major programs, PeerExercise Program Promotes Independence (PEPPI), isdescribed below.

PEPPI was instituted in 1996. Drawing on researchshowing the efficacy of weight training in older adults,PrimeTime Health has developed a statewide model oflocal weight training classes led by volunteer older adultswho receive initial training and ongoing technical assis-tance from a contracted exercise physiologist.

Volunteer class leaders participate in a one-day trainingled by a certified exercise physiologist. PEPPI sponsorsabout three to five classes per year for new trainers.There are approximately 30-40 people in each class and75% go on to become leaders. Leaders are encouraged tohold class two to three times per week, for 30 to 60minutes per class. Participants keep logs in which theydocument progress, such as the number of repetitionsand size of weights used. In some classes, blood glucoseand cholesterol testing has taken place. There areapproximately 350 regular classes occurring acrossPennsylvania, with about 3500 regular participants.While PEPPI is an optional program for AAAs to adopt,36 of the 52 AAAs offer the program and each yearmore choose to become involved.

In the past year, PEPPI has developed supporting videosthat can be used by leaders to reinforce proper tech-niques or can be used to lead a class if the leader isunavailable for a session. PEPPI also publishes a monthlynewsletter for leaders and participants.

PEPPI is based on published research showing the effec-tiveness of strength training for older adults. Originalresearch was conducted at Tufts University. The originalprogram was based on the eight exercises in the bookBiomarkers11, with the consultation of the book’s primaryauthor.With the help of the exercise physiologist, PEPPIhas since modified some of the exercises to increase easefor older adults. To date, there is substantial anecdotalevidence of the program’s effectiveness from adults whohave, for example, given up walkers and canes, lostweight, and changed their lifestyles.

A year ago, PEPPI took the first steps to develop quanti-tative program outcomes, but found that there wereinternal inconsistencies in program implementation thatmade this difficult. Not all leaders were consistent intheir class exercises. At that point, the program steppedback and developed some of the additional tools nowavailable to leaders: a revised, more detailed manual, andthe video. The Department of Aging is now in theprocess of doing a survey to benchmark success. Data isbeing collected on improvement in physical activitiessuch as ability to walk, climb stairs, and rise from a seatedposition, as well self-reported improvement in overallhealth and social and emotional well-being.

The Department of Aging, a cabinet-level agency, fundsa full-time PrimeTime Health coordinator who developsand promulgates PEPPI and other health promotion pro-grams, which AAAs may implement at their discretion.Each AAA is required to have a local PrimeTime Healthcoordinator to oversee their health promotion programs,though not all are full-time staff.

The Department of Aging spends about $18,000 peryear on PEPPI’s implementation. Major expenses includethe contracted exercise physiologist, videos, in-state travel,purchase of weights, and production of the newsletter.Most classes are offered in senior centers or commonareas in congregate housing developments.Training ofleaders is free to AAAs.

Contact:Linda Bowers, PrimeTime Health CoordinatorPennsylvania Department of Aging555 Walnut Street, 5th FloorHarrisburg, PA 17101-1919(P) [email protected]

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AAA Area Agency on Aging. Public, governmental agen-cies or non-profit organizations serving the older adults indefined geographic regions within each state. Based on localneeds and priorities,AAAs contract with local providerorganizations for services and/or provide services directly.

AoA Administration on Aging. The federal agency with-in the United States Department of Health and HumanServices responsible for overseeing the implementation ofthe Older Americans Act and for monitoring and respond-ing to the needs of older adults.

ASTCDPD Association of State and Territorial ChronicDisease Program Directors. See CDD below.

BRFSS Behavioral Risk Factor Surveillance System.Arandom digit dial telephone survey of adults age 18 andolder, conducted in all states as a joint collaboraion betweenthe CDC and SHDs.The BRFSS collects data on a varietyof health characteristics, risk factors for chronic conditionsand preventive behaviors.

CDC Centers for Disease Control and Prevention.Thefederal agency within the United States Department ofHealth and Human Services responsible for protecting thehealth of all Americans through disease prevention andcontrol.

CDD Chronic Disease Directors. (Officially known as theAssociation of State and Territorial Chronic DiseaseProgram Directors, or ASTCDPD). The national non-profitmembership organization of state health departments’chronic disease programs.

CVD Cardiovascular disease

NASUA National Association of State Units on Aging.The national non-profit membership organization of stateunits on aging.

OAA Older Americans Act. Passed by Congress in 1965and amended and reauthorized most recently in 2000, theOlder Americans Act is the federal statute that mandatesand funds a range of community-based services for olderadults.

SHD State health department.The state agency in eachstate or territory responsible for overseeing public healthprograms, including health promotion and disease preven-tion programs.

SUA State unit on aging (also referred to as state agencyon aging). The state agency in each state or territory desig-nated by the governor and state legislature to be the focalpoint for all matters affecting older citizens in the state.

Title III-D The title, or section, of the Older AmericansAct that directs states to provide health promotion and dis-ease prevention services to older adults (See Appendix D forthe full text of Title III-D).

Glossary

36

1. Please list the top 5 health issues affectingolder adults in your state.

2.Within your agency, is there an organizationalunit or person specifically designated for healthpromotion/disease prevention activities related toolder adults?

Yes ___ No___

3. Does your agency have a plan for servingolder adults that addresses health promotion/dis-ease prevention? Please check ALL that apply.

–Yes. Formal plan developed– No, no formal plan developed– No, BUT mission statement developed– No, BUT goals, objectives and priorities identified– No, BUT activities and programs identified– Other, please specify

4. In your state, which state agency has LEAD(or primary) responsibility for health promo-tion/disease prevention activities for older adults?

– Health department (SHD)– State unit on aging (SUA)– Shared between SHD & SUA– None– Don’t know

5. Please identify other state agencies/public pro-grams involved in (or responsible for) health pro-motion/disease prevention activities for olderadults.

– Department of Mental Health– Department of Mental Retardation– Department of Substance Abuse– Department of Medical Assistance (Medicaid)– Department of Food & Agriculture (5-a-Day,

Farmer’s Market Nutrition Program)

– State Peer Review Organization (State PRO)– Department of Veterans Affairs (VA)– Other, please specify

6. Please identify OTHER partners you workwith around health promotion/disease preventionactivities for older adults. Please check ALL thatapply.

– Faith-based organizations–YWCA/YMCA– Social Clubs (e.g., Elks, Kiwanis)– Women’s Groups (e.g., Older Women’s League,

Junior League)– Senior centers– Councils on Aging–Visiting Nurse Associations (VNAs)– Hospital networks– Local health departments– Health Maintenance Organizations (HMOs)– AARP– Arthritis Foundation– American Cancer Society– American Diabetes Association– American Heart Association– American Lung Association– National Osteoporosis Foundation– Alzheimer’s Association– Pharmacists– Other, please specify

7. Describe the ORGANIZATIONAL relation-ship between the state health department and thestate unit on aging in your state.

– Located within the same agency– Separate agencies– Don’t know– Other, please specify

8.What are the collaborative activities engaged inby the state unit on aging and the state healthdepartment? (Please check top 3)

– Joint programs/activities at the state level– Joint programs/activities at the community level– Joint planning/development of programs– Joint contracts– Joint training– Conference attendance/planning– Participation on committees/boards

Appendix ANeeds Assessment Questionnaire

37

– Joint grant writing

– Advocacy

– None

– Don’t know

– Other, please specify

9. On average, how often do you engage in healthpromotion/disease prevention activities for olderadults with your counterparts in the other stateagency?

– Do not work together in this area

– Annually

– Quarterly

– Monthly

– Two times or more per month

– Don’t know

10.What do you see as the strengths of your agencyin health promotion/disease promotion activitiesfor older adults?

11.What do you see as the strengths of your coun-terpart agency in health promotion/disease preven-tion activities for older adults?

12. Choose the three most important organization-al, programmatic, geographic, or political BARRI-ERS OTHER THAN FUNDING that limit or pre-vent coordination with your counterpart agency:

– Low priority given to services for older adults withinthe SHD

– No individual designated as the lead for aging issuesin SHD

– Organizational culture differences

– Lack of knowledge of opportunities for coordination

– Non-overlapping planning & service areas

– Complexity & fragmentation of delivery services

– Lack of access to adequate computer technology &support

– Staff has too many other work responsibilities

– Physical distance between SHD and SUA offices

– Don’t know


SHD 13. Are you aware of the healthpromotion/disease prevention provisions of TitleIII-D of the Older Americans Act?

Yes___ No___

SUA 13. Please identify the 3 types of activities forwhich your OAA Title III-D funds have been usedmost frequently.

– Senior Center – Speakers – Physical fitness/exercise programs – Health screening – Consumer education & training – Provider training – Materials production & dissemination – Nutrition screening & assessment – Nutritional education & counseling – Mental health screening – Programs targeting specific chronic diseases – Educational health programs – Intergenerational programming – Support groups – Medication management, screening & education – Falls/injury prevention & home safety – Purchase & distribution of health/safety-related aids – Other, Please Specify

14. Does the state health department participate inany health promotion/disease prevention activitiesfunded under Title III-D of the Older Americans Act?

– No–Yes, we receive Title III-D funds for contracted health

promotion/disease prevention activities– Yes, we participate through conferences, trainings,

programmatic efforts, etc.; but receive no Title III-Dfunds

– Don’t know– Other, please specify

15. Aside from funding, what are the 3 main BAR-RIERS to fully promoting health and preventingdisease among older adults in your state?

– Life-style issues– Inadequate transportation– Housing– Language– Literacy– Lack of culturally competent providers– Educational limitations of providers/recipients– Inadequate insurance coverage– Fragmented services– Medicare requirements/lack of reimbursement for

preventive services

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– Lack of organized system of programs & services– Geography– Difficulties with health care access– Lack of caregiver support– Frailty & mobility issues– Lack of consumer awareness/perceptions– Perceptions of aging & illness– Lack of supportive environments & safe communities– Don’t know– Other, Please specify

16.What are the funding sources used for healthpromotion/disease prevention for older adults byyour agency? Check ALL that apply.

– Centers for Disease Control and PreventionCooperative Agreement Funds

– Preventive Health Services Block Grant– Social Services Block Grant– Community Services Block Grant– Older Americans Act Funds– Maternal and Child Health Block Grant– Other federal funds– State tobacco settlement funds– Casino/lottery funds– Other state funds– None– Don’t know– Private grants, please specify

17. Other than funding or staffing, what are the 3TOP UNMET PROGRAM SUPPORT NEEDS forhealth promotion/disease prevention for older adultsin your state?

– Caregiver assistance– Leadership continuity– Advocacy for older adults– Public education materials, media, social marketing– Programmatic expertise– Grant writing expertise– Staff development/training– Data expertise– Access to target populations– Program evaluation– Other, please specify

18. If greater funding were available, what 3 healthpromotion/disease prevention issues for older adultswould you address?

19.The following is a list of health problems affect-ing older adults. Please indicate the current level ofinvolvement of your agency.

1= None 2= Limited 3= Moderate 4= High– Arthritis __– Asthma __ – Cancer-colorectal __– Cancer-breast__– Cancer-prostate__– Cancer-lung__– Cancer-other malignancy__– Cardiovascular disease__– Caregiver issues__– Compassionate care/end of life issues__– Dementia (including Alzheimer’s disease)__– Depression__– Diabetes__– Domestic violence/elder abuse__– Falls/injury prevention__– Financial resources inadequacy/poverty__– HIV__– Housing__– Hunger/food security__– Hypertension__– Immunizations__– Incontinence__– Legal assistance/advocacy__– Medication management__– Menopause__– Nutrition__– Obesity___– Oral health/access to dental services__– Osteoporosis__– Patient/provider communication___– Physical inactivity/sedentary lifestyle__– Prescription drug access/coverage___– Senior employment___– Social isolation___– Smoking___– Suicide prevention__– Transportation___– Vision and hearing problems___

20. Please describe one health promotion/diseaseprevention success story in your state that you wouldlike others to know. How do you define success?

39

21.What data sources do you use to identify, plan,monitor, or evaluate the health needs of olderadults in your state? Please check ALL that apply.

– Behavioral Risk Factors Surveillance Survey (BRFSS)

– State aging unit data

– State aging unit plan

– Mortality/death (vital statistics)

– Medicare claims data

– Cancer registry

– Census data

– Nursing home data

– Health plan data/report cards

– National Center for Health Statistics/Centers for Disease Control Healthy Aging Web site

– Local program data


SHD 22.What Administration on Aging resourcesdo you use?

– Publications

– Data

– Conferences

– Direct contacts

– Web site

– Don’t know

– Don’t use


SUA 22. / SHD 23.What are the 3 TOP AREASwhere you could benefit most from technical assis-tance and training to more effectively address thehealth promotion/disease prevention needs of olderadults?

SUA 23. / SHD 24. Do you have access to up-to-dateresearch expertise for health promotion/disease pre-vention program planning, implementation, and eval-uation for older adults? Please check ALL that apply.

– None

– Generally available in our state but difficult to accessfor program planning & implementation

– Generally available in our state but difficult to accessfor program evaluation

–Yes, have resources we regularly use for program planning & implementation

–Yes, have resources we regularly use for program evaluation

– Don’t know


SUA 24. / SHD 25. Give one example of a healthpromotion/disease prevention program in yourstate that you would nominate for BEST PRAC-TICES FOR OLDER ADULTS. Provide the nameof the program, a description, and how outcomeswere evaluated, if they were.

SUA 25. / SHD 26. In what areas of health promo-tion/disease prevention would you most like to seebest practices (evidence-based programs) developed?

SUA 26. / SHD 27.What do you perceive as theCenter for Disease Control and Prevention’s currentrole in health promotion/disease prevention forolder adults?

SUA 27. / SHD 28. If additional funds were madeavailable to the Centers for Disease Control andPrevention, what would be the priorities for state-based programs targeting health promotion/diseaseprevention for older adults?

SUA 28. / SHD 29.What are the urgent hot buttonissues in your state related to older adults (e.g.,interests of the governor, the legislature, media, oradvocates)?

SUA 29. / SHD 30. Is there anything else youwould like to tell us regarding gaps in health pro-motion/disease prevention programs/services/activ-ities related to older adults at your agency?

State SUA SHD

Alabama X X

Arkansas X

Arizona X X

California X X

Colorado X X

Connecticut X X

Washington DC X

Delaware X

Florida X X

Georgia X X

Guam X

Hawaii X X

Iowa X X

Idaho X

Illinois X X

Indiana X X

Kentucky X X

Kansas X

Louisiana X

Massachusetts X X

Maryland X

Maine X X

Michigan X X

Minnesota X X

Missouri X X

Mississippi X X

Montana X

North Carolina X X

North Dakota X

Nebraska X

New Hampshire X X

New Jersey X X

New Mexico X

Nevada X

New York X X

Ohio X X

Oklahoma X X

Oregon X

Pennsylvania X X

Rhode Island X X

South Carolina X X

Tennessee X

Texas X X

Utah X X

Virginia X

Vermont X X

Washington X

Wisconsin X

West Virginia X X

Wyoming X

Appendix BRespondents toNeeds Assessment

States for which both agencies responded are shaded

40

41

Appendix CCoding Categories forOpen Response Questions (#1, 10, 11, 18, 22, 25, 26, 27, 28)

Chronic disease prevention & control Housing

General - not disease-specific Hunger/food security

Cardiovascular disease and stroke Transportation

Diabetes Legal assistance/advocacy

Osteoporosis Senior employment

Arthritis Medication management

Cancer Caregiver issues, including support & respite

Chronic obstructive pulmonary disease (COPD) Support services & case management

HIV Long-term care

Asthma Home care

Vision & hearing problems Domestic violence/elder abuse

Incontinence Other

Other Health care - access, coverage & quality

Mental health, behavioral health & dementia Access to health care, including rural & minority issues

General mental health Health insurance coverage

Depression Oral health/access to dental care

Suicide prevention Prescription drug access/coverage

Alcohol and substance abuse Patient/provider communication

Dementia & Alzheimer’s Immunizations

Other Other

Risk reduction/behavior change Quality of life

General health promotion/wellness/healthy lifestyles Functional disabilities

Exercise/physical activity/sedentary lifestyle Independence

Nutrition/diet/eating habits Social isolation

Tobacco cessation Compassionate care/end of life

Obesity/weight control Mobility

Fall & injury prevention Other

Assistive technologies/home & environmental modifications Systems & program management

Other Leadership/advocacy

Concrete services Policy development & legislation

Financial resources Data & surveillance

42

Collaboration between state agencies (SUA-SHD) Program implementation & evaluation issues

Other collaboration, coalition-building & partnerships General program expertise

Funding - levels, grant availability Needs assessment

Marketing, outreach & education (to public, not staff) Program development & implementation

Cultural competency/addressing disparities Outcome measures/program implementation

Aging provider network Intergenerational models

Infrastructure Other program issues

Staffing issues Other (not any of above)

Development, expertise, training issues Don’t know

Numbers/too much work, too few people None

Lack of designated/lead individual Limited

Other staff issues Blank

Training/knowledge issues

Research & best practicesTechnical assistance

Conferences, trainings, special meetings

Grant writing

Other training/knowledge issues

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Appendix DOlder Americans Act,Title III-DDisease Prevention and Health Promotion Services

Title 42, Chapter 35, Subchapter III,Title F (amended to D, 2000)

Sec. 3030m. - Program authorized

(a) Grants to States The Assistant Secretary shall carry out a program for making grants toStates under State plans approved under section 3027 of this title to pro-vide disease prevention and health promotion services and information atmultipurpose senior centers, at congregate meal sites, through home deliv-ered meals programs, or at other appropriate sites. In carrying out suchprogram, the Assistant Secretary shall consult with the Directors of theCenters for Disease Control and Prevention and the National Institute onAging.

(b) Community organizations and agencies The Assistant Secretary shall, to the extent possible, assure that servicesprovided by other community organizations and agencies are used to carryout the provisions of this part.

Sec. 3030n. - Distribution to area agencies on aging

The State agency shall give priority, in carrying out this part, to areas ofthe State - (1) which are medically underserved; and (2) in which there are a large number of older individuals who have thegreatest economic need for such services

Sec. 3030o. - ‘’Disease prevention and health promotion services’’ defined

As used in this part, the term ‘’disease prevention and health promotionservices’’ means - (1) health risk assessments;(2) routine health screening, which may include hypertension, glaucoma,cholesterol, cancer, vision, hearing, diabetes, and nutrition screening;(3) nutritional counseling and educational services for individuals andtheir primary caregivers;(4) health promotion programs, including programs relating to chronicdisabling conditions (including osteoporosis and cardiovascular disease)prevention and reduction of effects, alcohol and substance abuse reduction,smoking cessation, weight loss and control, and stress management;(5) programs regarding physical fitness, group exercise, and music, art, anddance-movement therapy, including programs for multigenerational partic-ipation that are provided by - (A) an institution of higher education;(B) a local educational agency, as defined in section 8801 of title 20; or (C) a community-based organization;(6) home injury control services, including screening of high-risk homeenvironments and provision of educational programs on injury prevention(including fall and fracture prevention) in the home environment;(7) screening for the prevention of depression, coordination of communi-ty mental health services, provision of educational activities, and referral topsychiatric and psychological services;(8) educational programs on the availability, benefits, and appropriate useof preventive health services covered under title XVIII of the SocialSecurity Act (42 U.S.C. 1395 et seq.);(9) medication management screening and education to prevent incorrectmedication and adverse drug reactions;(10) information concerning diagnosis, prevention, treatment, and rehabil-itation of age-related diseases and chronic disabling conditions, includingosteoporosis, cardiovascular diseases, and Alzheimer’s disease and relateddisorders with neurological and organic brain dysfunction;(11) gerontological counseling; and (12) counseling regarding social services and followup health servicesbased on any of the services described in paragraphs (1) through (11).The term shall not include services for which payment may be madeunder title XVIII of the Social Security Act (42 U.S.C. 1395 et seq.)

(Source: http://www4.law.cornell.edu/uscode/42/ch35schIIIpF.html)

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10. Centers for Disease Control and Prevention,National Center for Injury Prevention and Control.The Costs of Fall Injuries among Older Adults. Available at:http://www.cdc.gov/ncipc/factsheets/fallcost.htm.

11. Evans W, Rosenberg, IH, and Thompson, J.Biomarkers:The 10 Determinants of Aging You Can Control.NY: Simon & Schuster, 1991.

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