Why Learn Policies Related to Health Promotion for Older Adults?

1. Five Federal Policies and Funding Related to Health Promotion and Disease Prevention for Older Adults

2. Why Learn Policies Related to Health Promotion for Older Adults? Background • Social work agencies may partner with public health agencies when trying to help older adults manager their own care and/or coordinate care within various health-related programs. • Social workers in aging-related programs or aging services agencies will have older adults who are Medicare and/or Medicaid beneficiaries and are eligible for prevention and health promotion services. Under certain circumstances, it is possible that social work agencies can be reimbursed providing these services. http://www.aoa.acl.gov/AoA_Programs/HPW/Title_IIID/Index.aspx

3. Why Learn Policies Related to Health Promotion for Older Adults (continued)? • Social work agencies serving older adult clients often work across agency boundaries with other health care organizations such as federally qualified health care centers that may wish to contract for health promotion services for older adults in order to meet mandated outreach goals. • Hence, social workers managing agencies that serve older adults, or contracting with agencies that serve older adults need to be aware of a range of policies and funding mechanisms to support services. http://www.aoa.acl.gov/AoA_Programs/HPW/Title_IIID/Index.aspx

4. 1. Healthy People 2020: Older Adults

5. Healthy People 2020: Background • Healthy People is a set of goals and objectives with 10-year targets designed to guide national health promotion and disease prevention efforts to improve the health of all people in the United States. • Developed under the leadership of the Federal Interagency Workgroup (FIW), the Healthy People 2020 framework is the product of an exhaustive collaborative process among the U.S. Department of Health and Human Services (HHS) and other federal agencies, public stakeholders, and the advisory committee. http://www.healthypeople.gov/2020/topics-objectives/topic/older-adults

6. Healthy People 2020: Background • Healthy People reflects the idea that setting objectives and providing science-based benchmarks to track and monitor progress can motivate and focus action. • Healthy People 2020 represents the fourth generation of this initiative, building on a foundation of three decades of work. • State and Local Public Health Departments implement programs and policies to address these objectives. http://www.healthypeople.gov/2020/topics-objectives/topic/older-adults

7. Healthy People 2020: What’s New for 2020? • Healthy People 2020 includes a small set of high-priority health issues called Leading Health Indicators (LHIs) that represent significant threats to the public’s health. • Selected from the Healthy People 2020 objectives, the 26 LHIs, organized under 12 topic areas, address determinants of health that promote quality of life, healthy behaviors, and healthy development across all life stages. • This is the first time that Older Adult health is addressed as its own area. • The LHIs provide a way to assess the health of the Nation for key areas, facilitate collaboration across diverse sectors, and motivate action at the national, state, and local levels. http://www.healthypeople.gov/2020/topics-objectives/topic/older-adults

8. Healthy People 2020: 3 Overarching Goals • Eliminate preventable disease, disability, injury, and premature death. • Achieve health equity, eliminate disparities, and improve the health of all groups. • Create social and physical environments that promote good health for all; and promote healthy development and healthy behaviors across every stage of the life cycle. http://www.healthypeople.gov/2020/topics-objectives/topic/older-adults

9. Healthy People 2020: Understanding the Health of Older Adults • The Healthy People 2020 objectives about older adults are designed to promote healthy outcomes for this population. Many factors affect the health, function, and quality of life of older adults. • Individual Behavioral Determinants of Health in Older Adults • Behaviors such as participation in physical activity, self-management of chronic diseases, or use of preventive health services can improve health outcomes. • Social Environment Determinants of Health in Older Adults • Housing and transportation services affect the ability of older adults to access care. People from minority populations tend to be in poorer health and use health care less often than people from nonminority populations. • Health Services-Related Determinants of Health in Older Adults • The quality of the health and social services available to older adults and their caregivers affects their ability to manage chronic conditions and long-term care needs effectively. http://www.healthypeople.gov/2020/topics-objectives/topic/older-adults

10. Healthy People 2020: Emerging Issues in the Health of Older Adults • Emerging issues for improving the health of older adults include efforts to: • Coordinate care. • Help older adults manage their own care. • Establish quality measures. • Identify minimum levels of training for people who care for older adults. • Research and analyze appropriate training to equip providers with the tools they need to meet the needs of older adults. • There is growing recognition that data sources are limited for certain subpopulations of older adults, including the aging lesbian, gay, bisexual, and transgender populations. Research for these groups will inform future health and policy initiatives. http://www.healthypeople.gov/2020/topics-objectives/topic/older-adults

11. Specific Objectives for Older Adults: Arrayed Under Prevention and Long Term Services and Supports Prevention: • Increase the proportion of older adults who use the Welcome to Medicare benefit • Increase the proportion of older adults who are up to date on a core set of clinical preventive services • Increase the proportion of older adults with one or more chronic health conditions who report confidence in managing their conditions • Increase the proportion of older adults who receive Diabetes Self-Management Benefits • Reduce the proportion of older adults who have moderate to severe functional limitations • Increase the proportion of the health care workforce with geriatric certification • Increase the proportion of older adults with reduced physical or cognitive function who engage in light, moderate, or vigorous leisure-time physical activities http://www.healthypeople.gov/2020/topics-objectives/topic/older-adults

12. Specific Objectives for Older Adults: Arrayed Under Prevention and Long Term Services and Supports Long-Term Services and Supports: • Reduce the proportion of noninstitutionalized older adults with disabilities who have an unmet need for long-term services and supports. • Reduce the proportion of unpaid caregivers of older adults who report an unmet need for caregiver support services • Reduce the rate of pressure ulcer-related hospitalizations among older adults • Reduce the rate of emergency department (ED) visits due to falls among older adults • Increase the number of States, the District of Columbia, and Tribes that collect and make publicly available information on the characteristics of victims, perpetrators, and cases of elder abuse, neglect, and exploitation http://www.healthypeople.gov/2020/topics-objectives/topic/older-adults

13. 2. Title IIID of the Older Americans Act Disease (Prevention and Health Promotion Services)

14. Purpose of the AoA IIID Program • Was established in 1987. It provides grants to States and Territories based on their share of the population aged 60 and over for programs that support healthy lifestyles and promote healthy behaviors. • For the past decade, the aging network has been moving toward only implementing disease prevention and health promotion (DPHP) programs that are evidence-based. Evidence-based programs are now required. The Federal FY-2012 Congressional appropriations law included, for the first time, an evidence-based requirement. In response to that new requirement, AoA developed an evidence-based definition to support the transition. http://www.aoa.acl.gov/AoA_Programs/HPW/Title_IIID/Index.aspx

15. Purpose of the AoA IIID Program (continued) • Evidence-based disease prevention and health promotion programs reduce the need for more costly medical interventions. Priority is given to serving elders living in medically underserved areas of the State or who are of greatest economic need. • Title IIID evidence-based Disease Prevention and Health Promotion (DPHP) programs help to attract young older adults through innovative fitness programs, health technology, and healthy aging programs. http://www.aoa.acl.gov/AoA_Programs/HPW/Title_IIID/Index.aspx

16. AoA IIID Program Expected or Required Partnerships • Partnerships extend the reach of DPHP programs, and can include: community health centers, mental health centers, state and local government agencies, centers for independent living, public health departments, state and local non-profit organizations, hospitals, universities and community colleges, jails and prisons, schools of dental hygiene, transportation and mobility management programs, and faith-based organizations. http://www.aoa.acl.gov/AoA_Programs/HPW/Title_IIID/Index.aspx

17. AoA IIID Program Expected or Required Partnerships (continued) • Often grant federal initiatives require partnership with the state public health department and either the state aging agency of the department of public health can be the lead agency for a grant application. • Senior centers and congregate meal sites are key partners for implementation and gaining consumer feedback for DPHP programs.

18. AoA 3 Tiers of Criteria for Evidence-Based Programs(Valid Until October 1, 2016) • This is a graduated or tiered set of criteria for defining “evidence-based”. • In order to meet the Minimal criteria, the program must meet the bullets listed under the Minimal tier. In order to meet the Intermediate criteria, the program must also meet the Minimal tier. In order to meet the Highest-level criteria, the program must also meet both the Intermediate and Minimal tiers. • While these tiers of evidence will no longer be applied by AoA, it is important to have a general understanding of the criteria for weighing the level of the evidence of a program. http://www.aoa.acl.gov/AoA_Programs/HPW/Title_IIID/Index.aspx#current

19. 3 Tiers of Evidence: Minimal Level Criteria • Demonstrated through evaluation to be effective for improving the health and well-being or reducing disease, disability and/or injury among older adults; and • Ready for translation, implementation and/or broad dissemination by community-based organizations using appropriately credentialed practitioners. http://www.aoa.acl.gov/AoA_Programs/HPW/Title_IIID/Index.aspx#current

20. 3 Tiers of Evidence: Intermediate Level Criteria • Demonstrated through evaluation to be effective for improving the health and wellbeing or reducing disease, disability and/or injury among older adults; and • Ready for translation, implementation and/or broad dissemination by community-based organizations using appropriately credentialed practitioners. • Published in a peer-review journal; and • Proven effective with older adult population, using some form of a control condition (e.g. pre-post study, case control design, etc.); and • Some basis in translation for implementation by community level organization. http://www.aoa.acl.gov/AoA_Programs/HPW/Title_IIID/Index.aspx#current

21. 3 Tiers of Evidence: Highest Level Criteria • Demonstrated through evaluation to be effective for improving the health and well-being or reducing disease, disability and/or injury among older adults; and • Ready for translation, implementation and/or broad dissemination by community-based organizations using appropriately credentialed practitioners. • Published in a peer-review journal; and • Proven effective with older adult population, using some form of a control condition (e.g. pre-post study, case control design, etc.); and • Some basis in translation for implementation by community level organization. • Proven effective with older adult population, using Experimental or Quasi-Experimental Design;* and • Fully translated in one or more community site(s); and • Includes developed dissemination products that are available to the public. http://www.aoa.acl.gov/AoA_Programs/HPW/Title_IIID/Index.aspx#current

22. AoA IIID Requirements for Evidence-based Health Promotion Programs: Single Tier Beginning October 1, 2016, Title IIID funds will only be able to be used on health promotion programs that meet the Highest-level criteria that includes: • Demonstrates through evaluation to be effective for improving the health and well-being or reducing disease, disability and/or injury among older adults; and • Proven effective with older adult population, using Experimental or Quasi-Experimental Design;* and • Research results published in a peer-review journal; and • Fully translated in one or more community site(s); and • Includes developed dissemination products that are available to the public. http://www.aoa.acl.gov/AoA_Programs/HPW/Title_IIID/Index.aspx

23. 3. The Patient Protection and Affordable Care Act and its Provisions for Health Promotion and Disease Prevention

24. Patient Protection and Affordable Care Act (HR 3590) • On March 23, 2010, President Obama signed comprehensive health reform, the Patient Protection and Affordable Care Act (PPACA), into law. • The PPACA is made up of the following: • Affordable Health Care for America Act • The Patient Protection Act • Health care related sections of the Health Care and Education Reconciliation Act and the Student Aid and Fiscal Responsibility Act. • Also includes amendments to other laws like the Food, Drug and Cosmetics Act and the Health and Public Services Act. Adapted: http://obamacarefacts.com/affordablecareact-summary/

25. ACA Triple Aims • The Affordable Care Act places emphasis on achieving the Triple Aims of: • Better health • Better health care, and • Better value. • These aims are salient given concern about the provision of adequate and affordable care for older adults with multiple chronic conditions (73% of this population).

26. Patient Protection and Affordable Care Act (HR 3590) • Key federal provisions are intended to: • Expand access to insurance, • Increase consumer protections, • Emphasize prevention and wellness, • Improve quality and system performance, • Expand the health workforce, • and curb rising health care costs. Adapted: http://www.ncsl.org/portals/1/documents/health/hraca.pdf/

27. Titles of the PPACA • The ACA addresses the following topics in detail – each topic is a title, which contains sections of provisions that reform our health care system: • Title I Quality, affordable health care for all Americans • Title II The role of public programs • Title III Improving the quality and efficiency of health care • Title IV Preventing chronic disease and improving public health • Title V Health care workforce Adapted: http://obamacarefacts.com/affordablecareact-summary/

28. Titles of the PPACA (continued) • Title VI Transparency and program integrity • Title VII Improving access to innovative medical therapies • Title VIII Community living assistance services and supports • Title IX Revenue provisions • Title X Reauthorization of the Indian Health Care Improvement Act

29. Title IV Preventing Chronic Disease and Improving Public Health • This Title is intended to promote prevention, wellness, and the public health and provides an unprecedented funding commitment to these areas.  • It directs the creation of a national prevention and health promotion strategy that incorporates the most effective and achievable methods to improve the health status of Americans and reduce the incidence of preventable illness and disability in the United States. • It focuses on the delivery of preventive clinical services and evidence-based health promotion programs. • It relies on the innovation of small businesses and state and local governments to find the best ways to improve wellness in the workplace and in communities.  • The Act empowers families by giving them tools to find the best science-based nutrition information, and it makes prevention and screenings a priority by waiving co-payments for America’s older adults on Medicare. http://obamacarefacts.com/affordablecareact-summary/

30. ACA: Selected Preventive and Public Health Provisions re: MEDICAID • Incentives for Prevention of Chronic Diseases in Medicaid (Sec. 4108) • Directs the Secretary to award grants to states to carry out initiatives to provide incentives to Medicaid beneficiaries who successfully participate in a healthy lifestyles program and demonstrate changes in health risk and outcomes. • The program shall be comprehensive, evidence-based, widely available, and easily accessible... designed to address the needs of Medicaid beneficiaries to achieve: ceasing the use of tobacco; controlling or reducing weight; lowering cholesterol; lowering blood pressure; avoiding the onset of diabetes or improving management of diabetes. Adapted: http://healthyamericans.org/assets/files/Summary.pdf

31. ACA: Selected Preventive and Public Health Provisions re: MEDICAID • Community Transformation Grants (Sec. 4201) – Authorizes CDC to award competitive grants to state and local governmental agencies and community-based organizations for the implementation, evaluation, and dissemination of evidence-based community preventive health activities in order to reduce chronic disease rates, prevent the development of secondary conditions, address health disparities, and develop a stronger evidence-base of effective prevention programming. • Activities may focus on …programs to support active living and …chronic disease priorities; implementing worksite wellness; … reducing disparities; and addressing special population needs. Adapted: http://healthyamericans.org/assets/files/Summary.pdf

32. ACA: Selected Preventive and Public Health Provisions re: MEDICARE • Healthy Aging, Living Well; Evaluation of Community-Based Prevention; and Wellness Programs for Medicare Beneficiaries (Sec. 4202) – • Awards competitive grants to health departments and Indian tribes to…provide public health community interventions…for individuals who are between 55-64 years old. • Grantees must design a strategy to improve the health status of this population through community based public health interventions. • Intervention activities may include efforts to improve nutrition, increase physical activity, reduce tobacco use and substance abuse, improve mental health, and promote healthy lifestyles among the target population Adapted: http://healthyamericans.org/assets/files/Summary.pdf

33. ACA: Selected Preventive and Public Health Provisions re: MEDICARE • Healthy Aging, Living Well; Evaluation of Community-Based Prevention; and Wellness Programs for MEDICARE Beneficiaries (Sec. 4202) – • Includes an evaluation of community-based prevention and wellness programs and develops a plan for promoting healthy lifestyles and chronic disease self-management for Medicare beneficiaries. • The evaluation shall include programs sponsored by the Administration on Aging that are evidence-based and have demonstrated potential to help Medicare beneficiaries reduce their risk of disease, disability, and injury by making healthy lifestyle choices. Adapted: http://healthyamericans.org/assets/files/Summary.pdf

34. ACA: Selected Preventive and Public Health Provisions • Prevention and Public Health Fund (Sec. 4002) - • Establishes a fund…to provide for an expanded and sustained national investment in prevention and public health programs. • The Fund will support programs authorized by the Public Health Service Act, for prevention, wellness and public health activities, including prevention research and health screenings and initiatives. Adapted: http://healthyamericans.org/assets/files/Summary.pdf

35. Prevention and Public Health Fund Fiscal year 2015: Funding for Chronic Disease and Falls Prevention • Chronic Disease Self-Management - $8 million • To continue funding a resource center and award new competitive grants to help older adults and adults with disabilities from underserved areas and populations to cope with their chronic conditions by providing access to evidence-based chronic disease self-management programs, and also to assist state grantees in developing sustainability plans to continue providing these programs after the grant period ends. • Falls Prevention - $5 million • To award competitive grants to implement and disseminate evidence-based community programs that have been proven to reduce the incidence of falls for older adults and adults with disabilities, and to continue funding a resource center to promote the importance of falls prevention strategies and provide public education about the risks of falls and ways to prevent them. Adapted http://www.hhs.gov/open/prevention/index.html

36. Administration on Aging, Chronic Disease Self-Management and the Prevention and Public Health Fund (PPHF) • Background: • Chronic Disease Self-Management Education (CDSME) programs provide older adults and adults with disabilities with education and tools to help them better manage chronic conditions such as diabetes, heart disease, arthritis, HIV/AIDS, and depression. • Current: • AoA’s most recent grant program, the Empowering Older Adults and Adults with Disabilities through CDSME Programs, began in September 2012 and is funded by PPHF. • The PPHF CDSME cooperative agreements are designed to achieve two major goals: • Goal 1: Significantly increase the number of older and/or disabled adults who complete evidence-based CDSME programs to maintain or improve their health status. • Goal 2: Strengthen and expand integrated, sustainable service systems within states to provide evidence-based CDSME programs. Adapted: http://www.aoa.acl.gov/AoA_Programs/HPW/ARRA/PPHF.aspx

37. National Study of the Chronic Disease Self-Management Program (CDSMP) Addressing ACA Triple Aims First study to explicitly document the potential of the CDSMP to facilitate the Triple Aim goals. Study participants reported significant improvements for better health, better health care, and better value.

38. Additional Readings • Howard K. Koh, M.D., M.P.H., and Kathleen G. Sebelius, M.P.A. Promoting Prevention through the Affordable Care Act N Engl J Med 2010; 363:1296-1299. September 30, 2010 doi: 10.1056/NEJMp1008560. Available at: http://www.nejm.org/doi/full/10.1056/NEJMp1008560 • Ory, Marcia G. PhD, MPH*; Ahn, SangNam PhD, MPSA*,†; Jiang, Luohua PhD‡; Smith, Matthew Lee PhD, MPH, CHES*,§; Ritter, Philip L. PhD∥; Whitelaw, Nancy PhD¶; Lorig, Kate DrPH∥. Successes of a National Study of the Chronic Disease Self-Management Program: Meeting the Triple Aim of Health Care Reform. Medical Care: November 2013 - Volume 51 - Issue 11 - p 992–998. doi: 10.1097/MLR.0b013e3182a95dd1

39. 4. DHHS Federally Qualified Health Center Advanced Primary Care Practice (FQHC APCP) Demonstration Project

40. Federally Qualified Health Centers (FQHCs) and the Affordable Care Act • The passage of the ACA in March 2010 resulted in provisions that increased federal funding to Federally Qualified Health Centers (FQHCs) to help them meet the anticipated health care demand of millions of Americans who will gain health care coverage as result of the health reform law. • One of the goals is to register people into the Medicaid system, or private insurance so they can be assigned, or choose, a primary care physician (PCP). • In theory, having a PCP gives the system one point of contact for medical care which can lower over-utilization, lower ER visits, and increase health outcomes. Adapted: https://www.ncoa.org/resources/how-to-work-with-a-federally-qualified-health-center/

41. What is a Federally Qualified Health Center (FQHC)? • FQHCs are defined asa reimbursement designation from the Bureau of Primary Health Care and the Centers for Medicare and Medicaid Services of the U.S. Department of Health and Human Services.  • FQHCs are community-based organizations that provide comprehensive primary care and preventive care, including health, oral, and mental health/substance abuse services  • FQHCs must be a nonprofit, tax-exempt corporation or public agency. The organization must have an independent governing board of directors. There are specific criteria for board participation including the fact that at least 51% (simple majority) of the board members must be consumers that the health center serves and represent the population being served by the health center. Adapted: https://www.ncoa.org/resources/how-to-work-with-a-federally-qualified-health-center/

42. What is a Federally Qualified Health Center (FQHC)? • They must be located in a designated Medically Underserved Area (MUA) or provide services to a Medically Underserved Population (MUP). • According to HRSA, four variables are taken into the designation as a MAU/MUP: • ratio of primary medical care physicians in the area, • infant mortality rate, • percentage of the population with incomes below the poverty level, • and percentage of the population age 65 or over.

43. FQHCs as Patient Centered Medical Homes (PCMH) • In June 2011, the Department of Health and Human Services announced the Federally Qualified Health Center Advanced Primary Care Practice (FQHC APCP) demonstration project. • This demonstration project is conducted under the ACA and establishes the Center for Medicare and Medicaid Innovation (Innovation Center). • The CMS and Innovation Center in partnership with HRSA is operating the demonstration. This initiative was designed to evaluate the impact of the advanced primary care practice (APCP) model, also referred to as the Patient Centered Medical Home (PCMH) on improving health, quality of care and lowering the cost of care provided to Medicare beneficiaries. Adapted: https://www.ncoa.org/resources/how-to-work-with-a-federally-qualified-health-center/

44. What is a Patient Centered Medical Home (PCMH)? • The Patient Centered Medical Home (PCMH) is a primary care, team-based approach to meeting a patient’s health care needs. PCMH views the person as a whole being at the center of their own health. Specifically, the PCMH is an approach to the delivery of primary care that is: • Patient-centered: A partnership among practitioners, patients, and their families ensures that decisions respect patients’ wants, needs, and preferences, and that patients have the education and support they need to make decisions and participate in their own care. • Comprehensive: A team of care providers is wholly accountable for a patient’s physical and mental health care needs, including prevention and wellness, acute care, and chronic care. info taken from: Patient Centered Primary Care Collaborative website: https://www.pcpcc.org/about/medical-home

45. What is a Patient Centered Medical Home (continued)? • Coordinated: Care is organized across all elements of the broader health care system, including specialty care, hospitals, home health care, community services and supports. • Accessible: Patients are able to access services with shorter waiting times, "after hours" care, 24/7 electronic or telephone access, and strong communication through health IT innovations. • Committed to quality and safety: Clinicians and staff enhance quality improvement to ensure that patients and families make informed decisions about their health.

46. When are FQHCs interested in talking with social workers in community-based agencies that serve older adults? • The link is the PCMH. • Standard 4: Care Management and Support is the most difficult for CHCs to meet. • FQHC providers have productivity expectations that they must meet. • If they do not see an acceptable number of patients each year, they could be cited by HRSA and continual infractions could result in a mandatory change in scope or reduction in grant award. Adapted: https://www.ncoa.org/resources/how-to-work-with-a-federally-qualified-health-center/

47. When are FQHCs interested in talking with social workers in community-based agencies that serve older adults? • It is to the benefit of any FQHC to work with organizations that can help them meet their patient productivity goals each year. • A community-based organization can help the FQHC by • increasing the number of Medicare beneficiaries served • being a new source of patient referrals, recurring patients, referrals for other services, etc. • Helping to meet the requirement for self-management education and referrals to community resources

48. The Connection of PCMH and the Chronic Disease Self-management Education (CDSME)Programs • CDSME provides an opportunity for clinics to improve clinical outcomes by increasing the self-management skills of patients. Once involved in a CDSME workshop, providers and patients can work together to set measurable, achievable goals that result in improved health.  • Clinics that partner with community-based organizations to provide CDSMP workshops see real benefits to the practice, including:  • Reinforcement and feedback, • Documentation of patient self-management in PCMH terms, • Documented shifts in patient interaction, • Attainment of required quality measures, and • Activated and engaged clients who report increased confidence levels for managing their chronic conditions. Adapted: https://www.ncoa.org/resources/how-to-work-with-a-federally-qualified-health-center/

49. 5. The Centers for Medicare and Medicaid Health and Behavior and Assessment & Intervention (HBAI) Services Coverage of Chronic Disease Self-Management Education

50. Health and Behavior Assessment & Intervention (HBAI): Purpose • The Centers for Medicare and Medicaid HBAI is an established intervention designed to: • Enable the consumer to overcome the perceived barriers to self-management of his/her chronic disease(s) by: • Identifying and addressing the psychological, behavioral, emotional, cognitive, and social factors important to the treatment and management of physical health problems • The HBAI is not psychiatric or mental health treatment. https://www.socialworkers.org/advocacy/issues/health_behavior_assessment_intervention.asp