Promoting Health and Preventing Disability in Older Adults Lessons from Intervention Studies Carried Out Through an Academic Community Partnership

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1 Fam Community Health Vol. 26, No. 3, pp c 2003 Lippincott Williams & Wilkins, Inc. Promoting Health and Preventing Disability in Older Adults Lessons from Intervention Studies Carried Out Through an Academic Community Partnership Elizabeth A. Phelan, MD, MS; Allen Cheadle, PhD; Sheryl J. Schwartz, MPA; Susan Snyder, MS; Barbara Williams, PhD; Edward H. Wagner, MD, MPH; James P. LoGerfo, MD, MPH Summary: This article describes a partnership between an academic center and community-based organizations for the purpose of improving the health of older adults. Three sequential randomized trials of interventions that have been conducted by this partnership, along with an effectiveness study of one of the interventions, are presented as evidence of the partnership s success. Characteristics of an effective partnership are highlighted; these include: (1) a shared vision and a commitment to achieving similar goals; (2) complementary expertise and resources; (3) a willingness to contribute time and effort on projects that are jointly undertaken; (4) regularly scheduled meeting times to review progress and barriers to progress; and (5) time spent getting to know each other on a personal level. The iterative nature of research and programming that is carried out as part of this partnership is described. Key words: aged, health services for the aged, organization and administration, outcome and process assessment (health care), risk factors, self-care THE HEALTH Promotion Research Center (HPRC) at the University of Washington (UW) in Seattle forms the academic arm of the academic community partnership. The HPRC is part of the Centers for Disease Control and Prevention (CDC) Prevention Re- From the Department of Medicine (Drs Phelan and LoGerfo) and the Department of Health Services (Drs Cheadle, Williams, and LoGerfo and Ms Schwartz), University of Washington; the Senior Services of Seattle/King County (Ms Snyder); and the MacColl Institute for Health Care Innovation (Dr Wagner), Seattle. Corresponding author: Elizabeth A. Phelan, MD, MS, Division of Gerontology and Geriatric Medicine, University of Washington, 325 9th Avenue, Box , Seattle, WA search Centers Program, a network of 28 academic prevention research centers (PRCs) that work with community members to develop strategies to prevent disease and disability. The Prevention Research Centers (PRCs) program, an activity authorized by Congress in 1984, is notable for engaging communities as partners in all phases of research projects. PRCs build relationships with community partners who help define research questions and conduct research. As a result, many community partners develop programs for ongoing services while contributing to new knowledge. Each PRC has a particular theme or focus for its research. Until recently, the PRC at the UW was the only center focusing on the health of older adults. The core theme 214

2 Promoting Health and Preventing Disability in Older Adults 215 has been Keeping Older People Healthy and Independent through Community Partnerships. The core research question is: What approaches work best in promoting the mental and physical health of older adults? The mission of the HPRC is to improve health by conducting methodologically rigorous prevention research that emphasizes healthy aging and can be incorporated into community practice. Researchers affiliated with the center have expertise in developing interventions to reduce chronic disability in seniors. They design a core project by working with an advisory board from the community in which the project will be conducted. The core research project must be consistent with the center s theme (more information about the UW PRC can be found at ROLE OF THE COMMUNITY ADVISORY BOARD (CAB) The HPRC has stated one of its values as the creation and sustenance of meaningful and effective collaboration with community partners. The HPRC has a community advisory board (CAB) that is composed of individuals representing both traditional public health departments at the state and local levels as well as individuals from local senior-serving agencies. This structure is consistent with the recommendations from the CDC Conference on Public Health and Aging. 1 The CAB is responsible for developing the overall mission and vision for the HPRC and overseeing the evaluation of HPRC activities. A key part of the HPRC mission is to translate research into community practice; an important CAB function is to assist in this translation process. CAB members provide input on program design when new research projects are being formulated, focusing in particular on whether the program addresses a significant community need and can be sustained if results are positive. When a research project is completed and findings are positive, CAB members can assist in implementing the program in their own agencies. CAB members are recruited to fulfill this dual role of helping design and implement programs that can be realistically incorporated into ongoing community practice. Because CAB members are either representatives of population-based agencies that serve seniors or individuals who work on an ongoing basis with seniors, they are well positioned to provide input regarding client needs and program design. The current CAB includes representatives of seven organizations that provide social and health services to significant numbers of seniors: Aging and Disability Services; Asian Counseling and Referral Services; Good Samaritan Community Healthcare, a comprehensive health care delivery system located in Puyallup, Washington, a community southeast of Seattle; SeaMar Community Care Center, an Hispanic oriented health care organization; Senior Services of Seattle/ King County (SSSKC), a large nonprofit agency that provides services to support the independence of elders in the Seattle/King County area; Spokane Regional Health District; and the Washington State Department of Health s Office of Health Promotion. Other CAB members include a member of the Seattle Mayor s Council on African American Elders and the associate director of the University of Washington s Northwest Geriatric Education Center, an academic center producing geriatric-focused educational opportunities for health care providers and administrators in Washington, Wyoming, Idaho, Alaska, and Montana. TRIALS CONDUCTED THROUGH THE PARTNERSHIP This article describes three interventions designed for community elders that have been tested in randomized trials conducted by the HPRC in partnership with community organizations: 1. An exercise intervention (Lifetime Fitness Program, or LFP, tested in a study known as the Disability Prevention Trial)

3 216 FAMILY &COMMUNITY HEALTH/JULY SEPTEMBER A multicomponent health promotion intervention (Health Enhancement Program, or HEP) 3. A depression treatment intervention (Program to Encourage Active, Rewarding Lives for Seniors, or PEARLS) The major findings from each trial and the roles of each partner involved are described, and lessons, as they relate to using results to inform new research and broader dissemination, are discussed. Disability prevention trial The disability prevention trial 2 tested a senior center-based intervention that involved a nurse assessment visit and follow-up interventions targeting risk factors for disability (eg, exercise habits, alcohol and tobacco use, inadequate nutrition) and falls with a structured exercise program as the central component. The trial was conducted at the Northshore Senior Center, located in Bothell, Washington, in partnership with that organization and with Group Health Cooperative of Puget Sound (GHC), a health maintenance organization based in Seattle. Northshore Senior Center provided the physical site for the intervention and a community base from which subjects for the trial could be recruited. GHC and HPRC investigators worked with Northshore Senior Center to design the intervention, and investigators from GHC and the HPRC carried out data analyses. The purpose of the trial was to evaluate the feasibility and efficacy of delivering a disability-prevention intervention in a community setting and was built on prior work conducted at GHC that had shown that a risk factor-reduction intervention could decrease the incidence of functional decline and falls. 3 One hundred subjects were recruited from the neighborhood surrounding the senior center and completed 6 months of followup. The intervention tested in the trial was well received by participants, with 85% retention at 6 months of follow up and excellent (> 90%) adherence to the exercise classes. Significant improvements in scores on SF-36 subscales and fewer depressive symptoms were observed for the intervention group. 2 Subsequently, the exercise component was formalized into a program now known as the Lifetime Fitness Program (LFP) and then offered as a health benefit to GHC Medicare enrollees (see below). As LFP was replicated, and the replication grew, SSSKC assumed responsibility for program dissemination. The current program is jointly owned and managed by GHC and SSSKC; the HPRC continues to work closely with these entities to provide technical and evaluative support. Data from GHC enrollees who have participated in the LFP show that total health care costs to the organization for those who attended LFP an average of 1 time weekly, adjusted for comorbidity and pre-exposure cost and utilization levels, was 79% of that of controls matched on age and gender (Ackerman R., unpublished data). Health enhancement program efficacy trial The Health Enhancement Program (HEP) is a multicomponent health promotion intervention based on the Buchner/Wagner model of disability, 4 wherein predictors of disability can be modified to reduce susceptibility to functional decline. It was specifically designed to assess a strengthened role for nursing, a more formalized approach to enhancing participants self-management skills for managing chronic conditions (eg, diabetes, arthritis, and hypertension) than had been tested in the Disability Prevention trial, and to take advantage of some of the extra social supports available in a senior center by creating a cadre of peer mentors who would be available to help participants meet their health care goals. The initial intervention involved a geriatric nurse practitioner (GNP) and social worker working in a community senior center. The GNP met with each participant to gather health and disability risk factor information during a baseline assessment and develop a health action plan, tailored to the participant s

4 Promoting Health and Preventing Disability in Older Adults 217 goals and preferences. Disability risk factors screened for included inadequate control and/or self-management of chronic conditions, use of unnecessary psychoactive medications, physical inactivity, depression, and social isolation. The GNP encouraged all intervention participants to enroll in any or all of three core offerings: the LFP from the Disability Prevention Trial 2 ; chronic disease self-management classes 5 ; pairing with a trained volunteer senior (health mentor) for peer support. 6 Participants with depressive symptoms were referred to a HEP social worker for assessment and brief counseling or support group sessions. The GNP encouraged intervention participants who chose not to participate in LFP to follow an exercise program at home or with another group. The GNP reported to primary care providers, details of their patient s participation and acute situations when encountered. After the initial meeting with each intervention participant, the GNP monitored progress toward health goals through follow-up visits and telephone calls. This intervention was tested in a randomized trial 7 at Northshore Senior Center in the mid-1990s. The trial was carried out in partnership with GHC and Pacificare, another large health care organization in the Pacific Northwest, and Northshore Senior Center. The program team enrolled 201 older adults over the age of 70 who had at least one chronic condition; 188 completed one year of trial participation. GHC and Pacificare provided access to populations of community dwelling older adults with health issues; Northshore provided the physical site for the intervention, organized and administered the LFP and the chronic disease self-management classes, and recruited and trained a cadre of mentors. Investigators from GHC and the HPRC worked with Northshore to design the intervention and were responsible for data analyses. Evergreen Healthcare, a hospital in the area, partnered with the Northshore Senior Center to help recruit Pacificare physicians who were practicing as part of the Evergreen Physicians Group, one of Evergreen s hospital-based practices, The efficacy trial of HEP showed that the intervention resulted in less functional decline and fewer hospitalizations when compared to a control group that received a tour of the senior center. and the patients of those physicians. Evergreen Healthcare also provided funding that partially supported the GNP s salary. The efficacy trial of HEP showed that the intervention resulted in less functional decline and fewer hospitalizations when compared to a control group that received a tour of the senior center. Psychoactive medication use was reduced, social activity increased, and higher levels of physical activity were observed. 7 An analysis of those who served as mentors indicated that physical function improved and that fewer mentors reported fair or poor health. Health enhancement program effectiveness study Following the completion of the randomized trial, HEP was disseminated to senior centers in western Washington, with funding provided by the local Area Agency on Aging, several local hospitals, and the Seattle/King County Health Department. SSSKC assumed responsibility for the local dissemination from Northshore Senior Center in In the process of dissemination, several notable modifications occurred, including a shift away from management by a nurse practitioner with formal geriatric training to registered nurse management and a decrease in the amount of interaction with primary care. The HPRC conducted an evaluation in to determine whether the effects of one year of program participation on risk factors for functional decline, health and functional status, and health care use that were observed in the randomized trial persisted when the program was carried out under real world conditions rather than as part of a research investigation. The program is currently being nationally

5 218 FAMILY &COMMUNITY HEALTH/JULY SEPTEMBER 2003 disseminated by SSSKC with a grant from the Robert Wood Johnson Foundation; the HPRC is conducting an evaluation of data from the national dissemination. The effectiveness evaluation of HEP indicated that there were improvements in disability risk factors. Participants in the intervention experienced a highly significant reduction in their level of depressive symptoms and improvement in their level of physical activity and exercise readiness. In addition, there was a significant improvement in selfperceived health over the year of program participation. Functional status and use of inpatient services remained stable. 8 Program to Encourage Active Rewarding Lives for Seniors (PEARLS) In the HEP efficacy trial, it was noted that there was little impact on depressive symptoms in the subset of participants having significant depressive symptoms. This observation led to the HPRC s current core project, Program to Encourage Active Rewarding Lives for Seniors (PEARLS). The PEARLS project is testing an intervention to reduce minor depression and its resultant disability among economically disadvantaged older adults. Depression afflicts 10% to 20% of individuals aged 65 and older. This rate is even higher among adults who are socially isolated, have low incomes, and concomitant health problems. Depression can have a severe, adverse impact on the health, quality of life, independence, and longevity of older adults. The study is examining the effect of an innovative treatment approach, designed by mental health professionals, that involves problemsolving therapy combined with planning physical, social, and other pleasurable activities. Three community agencies that provide social support to older adults are partnering with the HPRC to help design the intervention, recruit older adults, and carry out the counseling intervention: Aging and Disability Services, Senior Services of Seattle/King County, and the department of Public Health of Seattle/King County. Social workers at each of the agencies ask clients to complete a brief survey to determine if symptoms of depression are present. Those with symptoms are asked to participate in the study. Those who are eligible and willing are randomized to either the intervention or the control group. Control participants receive referral and communication with their physician and the agency social worker. The primary outcome is depressive symptom burden, which is assessed at 6 and 12 months by HPRC researchers. Those randomized to the control group are offered the intervention after their 12-month interview. Although data on the main outcome of interest are not yet available for PEARLS, analyses of baseline data indicate that better problem-solving ability, as measured by a fiveitem problem-solving inventory measure, 9 is associated with significantly higher functional and emotional quality of life as measured by the Functional Assessment of Cancer Therapy general measure (FACT-G), 10 controlling for age, gender, depressive symptoms, living situation, bed days, and frailty level. 11 DISCUSSION Characteristics of effective partnerships Reflection on the characteristics of an effective partnership by the researchers and community partners involved has led to the following assessment. HEP and LFP are used as examples to illustrate each characteristic. First, each party must have a shared vision of what they are trying to accomplish and a commitment to achieving similar goals. For example, the shared vision for both HEP and LFP is that it be a service that is fundable as an insurance benefit, either by Medicare health maintenance organizations, fee-for-service Medicare, or as an employer-sponsored retirement benefit. The partners current work is directed toward that goal. Second, the parties should have complementary expertise and resources. Each party should be indispensable to the other. In the current phase of HEP, which is a national dissemination, the HPRC is providing scientific expertise and evaluation support as well as

6 Promoting Health and Preventing Disability in Older Adults 219 guidance on quality monitoring and improvement for the program. Concurrently, SSSKC supervises operations and staff at each site where HEP is in existence, and has a first-hand working knowledge of issues around operations, including marketing and recruitment of new participants into HEP and status of commitments from current funders. In the case of LFP, which is also being disseminated throughout the United States, the HPRC s current role is analogous to its current role in HEP, while SSSKC oversees initial training of new LFP instructors and data collection for quality monitoring at all sites where LFP is offered. Together, the HPRC, GHC, and SSSKC sponsor two meetings annually for LFP trainers, where the trainers can acquire continuing education as well as information related to program modifications that are driven by data being collected as part of the program s dissemination. Third, each party must be willing to contribute real time and effort on whatever projects are pursued; this will frequently mean that individuals work independently outside of meeting times and bring their work products back to the group for discussion. Fourth, a regularly scheduled time to meet and review progress and barriers to progress is needed. For example, the HEP partnership between HPRC and SSSKC meets once every other month for 2 hours, while the LFP partnership meets quarterly. Topics discussed typically include program implementation issues, strategies and materials for marketing the particular program, and data being collected as part of the program s dissemination. A structured agenda is followed for each meeting, and as actionable items are identified, they are assigned to someone to carry out. Fifth, spending time getting to know each other personally enhances the working relationships in such a partnership. Getting to know each other may happen naturally around discovery of shared interests, but can also be fostered. For example, key partners are routinely invited by the HPRC to attend a professional meeting and then opportunities to interact are created, over a meal, at a poster session, or during a meeting-hosted reception. Finally, as in all human relationships, listening, receptivity, flexibility, and respect foster a successful partnership. Iterative process of idea generation, study development, evaluation, and quality monitoring Figure 1 illustrates our perspective on the steps involved in the work of the academic community partnership. An idea leads to a Figure 1. Iterative process of intervention development: From idea to quality improvement.

7 220 FAMILY &COMMUNITY HEALTH/JULY SEPTEMBER 2003 study design and resource garnering, which is followed by an efficacy study. If results are favorable, dissemination and an effectiveness analysis occur next. Finally, a system for ongoing quality monitoring is established when an intervention becomes an established program. The figure in its most global sense illustrates the cyclical and iterative nature of the process, as well as the feedback loops involved. CONCLUSION This research illustrates that academic community partnerships can work together to develop, test, disseminate, and institutionalize programs that can improve the health of our elders. We believe that such partnerships are an essential component of a national strategy to promote health and prevent disability among older adults. REFERENCES 1. Hickey T, Speers MA, Prohaska TR. Public health and aging. Baltimore: Johns Hopkins University Press; Wallace JI, Buchner DM, Grothaus L, et al. Implementation and effectiveness of a community-based health promotion program for older adults. J Gerontol Med Sci 1998;53A(4):M Wagner EH, LaCroix AZ, Grothaus L, et al. Preventing disability and falls in older adults: a population-based randomized trial. Am J Public Health 1994;84(11): Buchner DM, Wagner EH. Preventing frail health. Clin Geriatr Med. 1992;8(1): Lorig KR, Sobel DS, Stewart AL, et al. Evidence suggesting that a chronic disease self-management program can improve health status while reducing hospitalization: a randomized trial. Med Care. 1999;37(1): Davis C, Leveille S, Favaro S, LoGerfo M. Benefits to volunteers in a community-based health promotion and chronic illness self-management program for the elderly. J Gerontol Nurs. 1998;24(10): Leveille SG, Wagner EH, Davis C, et al. Preventing disability and managing chronic illness in frail older adults: a randomized trial of a community-based partnership with primary care. J Am Geriatr Soc. 1998;46(10): Phelan EA, Williams B, Leveille S, Snyder S, Wagner EH, LoGerfo JP. Outcomes of a community-based dissemination of the Health Enhancement Program. J Am Geriatr Soc. 2002;50(9): Maydeu-Olivares A, D Zurilla TJ. A factor analytic study of the Social Problem Solving Inventory: An integration of theory and data. Cognit Ther Res. 1996;20(2): Cella DF, Tulsky DS, Gray G, et al. The Functional Assessment of Cancer Therapy scale: development and validation of the general measure. J Clin Oncol. 1993;11(3): Kulzer J, Williams B, Ciechanowski P, Schwartz S, Wagner E. Does problem-solving ability predict quality of life among older adults with late life depression? [abstract, Centers for Disease Control and Prevention s (CDC) 18th National Conference on Chronic Disease Prevention and Control Web site]. Available at: conf17/index.htm (click on List of Submitted Abstracts link). Accessed on February 19, 2003.