Healthy Aging in Action ADVANCING THE NATIONAL PREVENTION STRATEGY

NATIONAL PREVENTION, HEALTH PROMOTION, AND PUBLIC HEALTH COUNCIL

NOVEMBER 2016 Healthy Aging in Action: Advancing the National Prevention Strategy was prepared by the National Prevention, Health Promotion, and Public Health Council (National Prevention Council). The Centers for Disease Control and Prevention provides MEMBERS ongoing administrative, scientific, and technical support for Secretary Sylvia Mathews Burwell Assistant Secretary–Indian Affairs Department of Health and (Acting) Lawrence S. Roberts the operations of the National Prevention Council. Human Services Department of the Interior

Secretary Tom Vilsack Attorney General Loretta E. Lynch NATIONAL Department of Agriculture Department of Justice Acknowledgements PREVENTION, Secretary John B. King, Jr. Chief Executive Officer This report was developed with staff support from the Office of Department of Education Wendy Spencer the Surgeon General; Centers for Disease Control and Prevention, HEALTH PROMOTION, Corporation for National and Chairwoman Edith Ramirez Community Service Office of the Associate Director for Policy and Division of AND PUBLIC HEALTH Federal Trade Commission Population Health; and Department of Health and Human Secretary Ashton B. Carter Services, Administration for Community Living. The report was COUNCIL MEMBERS Secretary Anthony Foxx Department of Defense also informed by the Advisory Group on Prevention, Health Department of Transportation Promotion, and Integrative and Public Health and their Healthy Secretary Robert A. McDonald Aging working group, including members from the following CHAIR Secretary Thomas E. Perez Department of Veterans Affairs organizations: Alzheimer’s Association, American Association of Department of Labor Retired Persons, American Society on Aging, Grant Makers in Surgeon General Secretary Julián Castro Secretary Jeh Johnson Department of Housing and Aging, Hartford Foundation, National Alliance for Caregiving, Vivek Murthy National Association of Area Agencies on Aging, National Department of Homeland Security Urban Development Association of Chronic Disease Directors, and Services and U.S. Public Health Administrator Gina McCarthy Director Shaun Donovan Advocacy for GLBT Elders (SAGE). Service Environmental Protection Agency Office of Management and Budget

Director Michael Botticelli Secretary Sally Jewell FOR MORE INFORMATION ABOUT THE Office of National Drug Control Policy Department of the Interior NATIONAL PREVENTION STRATEGY GO TO: surgeongeneral.gov/priorities/prevention/strategy/ Director Cecilia Muñoz Administrator Denise Turner Roth Domestic Policy Council General Services Administration SUGGESTED CITATION: National Prevention Council. Acting Director Beth F. Cobert Healthy Aging in Action. Washington, DC: Office of Personnel Management U.S. Department of Health and Human Services, Office of the Surgeon General; 2016.

ADVANCING THE NATIONAL PREVENTION STRATEGY i MESSAGE FROM AMERICANS REACHING THE AGE of national efforts that have improved This report aligns with the four OF 65 TODAY CAN EXPECT, ON the lives of generations of older adults. strategic directions of the National THE CHAIR OF THE AVERAGE, TO LIVE AN ADDITIONAL Recognizing the contributions of these Prevention Strategy: Healthy and Safe In 2011, the year the National Prevention programs and the need to continue Community Environments, Clinical NATIONAL PREVENTION, our efforts to supportolder Americans, and Community Preventive Services, Strategy was released, the first wave of 19 years President Barack convened the sixth Empowered People, and Elimination HEALTH PROMOTION, AND the baby boomer generation celebrated White House Conference on Aging, of Health Disparities. It also PUBLIC HEALTH COUNCIL its 65th birthday. Since then, the number which brought together older adults, recommends actions that individuals of individuals over the age of 65 has As I reflect on healthy aging and caregivers, researchers, advocates, and and community leaders can take to reached 46 million and is projected to reach what that means, I am reminded leaders from across the United States address supporting older adults in 74 million by 2030. Americans reaching of Amelia Boynton, a 103-year-old to identify and recommend actions to living longer and healthier lives. woman I met just before I was sworn continue to improve the quality of life the age of 65 today can also expect, on As the U.S. Surgeon General and chair in as U.S. Surgeon General. When I of older Americans. average, to live an additional 19 years. of the National Prevention Council, I complimented Ms. Boynton on her While the federal government, states, One important outcome of the am optimistic about the opportunities many accomplishments, she told me conference was the administration’s to be gained from living longer, communities, and families significantly benefit she wasn’t finished yet. I remember announcement of the development healthier lives both for individuals from the contributions and experiences of admiring what it takes to live well to of a report to advance healthy aging and for our nation. I believe we can older Americans, there also are challenges in be 103 years old. While we all may within the National Prevention and will take action to help millions of meeting the needs of the growing population of not be destined to live that long, Strategy. The report that follows, Americans successfully navigate this what strategies can we put into Americans 65 and older. Never has there been Healthy Aging in Action: Advancing next phase of their lives, much like Ms. action, as individuals and within our such a spotlight on older adults, and we can the National Prevention Strategy Boynton did. communities, to ensure the best use this moment to redefine what it means to (HAIA), is the culmination of a review possible health outcomes as we age? experience healthy aging in the United States. of the scientific literature, as well In 2015, our country celebrated the as consultation with experts in the Vivek H. Murthy, MD, MBA U.S. Surgeon General 50th anniversaries of Medicare, fields of aging and public health Vice Admiral, U.S. Public Health Service Medicaid, and the Older Americans and the expertise from leaders U.S. Department of Health and Human Services Act, as well as the 80th anniversary across the federal government from 74 million of Social Security. These programs areas as diverse as housing, health, PEOPLE WILL BE OVER THE AGE OF 65 have proven to be shining examples employment, and transportation. BY 2030 (PROJECTED) ii 1 TABLE OF CONTENTS

NATIONAL PREVENTION, HEALTH PROMOTION, AND PUBLIC HEALTH COUNCIL MEMBERS ...... i MESSAGE FROM THE CHAIR OF THE NATIONAL PREVENTION, HEALTH PROMOTION, AND PUBLIC HEALTH COUNCIL ...... ii

INTRODUCTION ...... 4 Goals ...... 8 National Prevention Strategy ...... 9 The State of Aging in the United States ...... 10 Origins of Healthy Aging in Action ...... 13 Healthy Aging Recommendations ...... 14 HEALTHY AGING ACTIONS TO ADVANCE THE NATIONAL PREVENTION STRATEGY ...... 16 Strategic Directions of the National Prevention Strategy ...... 18 Healthy and Safe Community Environments ...... 20 Clinical and Community Preventive Services ...... 32 Empowered People ...... 45 Elimination of Health Disparities ...... 54

MOVING FORWARD ...... 62

APPENDICES ...... 66 Appendix A: Example Federal Healthy Aging Initiatives ...... 68 Appendix B: References ...... 90

2 3 Introduction

4 HEALTHY AGING IN ACTION ADVANCING THE NATIONAL PREVENTION STRATEGY 5 All sectors must he National Prevention Council, created by the Affordable TCare Act and chaired by the U.S. Surgeon General, provides be engaged in coordination and leadership among 20 executive departments Healthy Aging in Action: and agencies and aims to promote prevention and wellness. In Advancing the National planning for the 2011, the Council released the National Prevention Strategy, which Prevention Strategy (HAIA) identifies the most effective and achievable means for improving identifies specific actions opportunities health and well-being with an overarching goal of increasing the for healthy aging that are number of Americans who are healthy at every stage of life. continuing to improve health and well-being in of a growing The Strategy’s aim is to increase the length of people’s lives and ensure their lives are healthy and productive. The demographics later life. Specifically, this population of of the United States are changing, as more Americans are report highlights federal and reaching the age of 65 and can often have an additional 19 years nonfederal programs that of life.1 The U.S. Census Bureau projects that the population age advance the four Strategic older adults to 85 and over could grow from 6 million in 2014 to 20 million by Directions of the National 2060. Therefore, all sectors must be engaged in planning for the Prevention Strategy (Strategy) ensure we are opportunities of a growing population of older adults to ensure where the older adult we are not only adding years to life, but life to years. Furthermore, population is concerned: many of the strategies that promote healthy aging can ultimately Healthy and Safe Community not only adding benefit individuals across the life course. Environments, Clinical and years to life, but Today, older adults are experiencing on average better overall Community Preventive health, lower disability rates, and greater economic security than Services, Empowered People, previous generations, due in part to key federal programs such and Elimination of Health life to years as Social Security, Medicare, Medicaid, and the Older Americans Disparities. These Strategic Act. However, older adults often encounter challenges to their Directions are the foundation physical, mental, cognitive, and social health. for all prevention efforts and form the basis for a prevention-oriented society.

6 HEALTHY AGING IN ACTION 7 More specifically,Healthy Aging in Action aims to: FIGURE 1 NATIONAL The overarching goal of GOALS → SUPPORT prevention efforts to enable older the Strategy is to increase Guiding Model for PREVENTION the number of Americans This report is intended for adults to remain active, independent, and Healthy Aging a wide range of partners, involved in their community who are healthy at every including decision makers STRATEGY stage of life at the federal, state, and → HIGHLIGHT innovative and evidence- Promote health, based programs from National Prevention prevent injury, and The vision of the Strategy is working together to local government levels; Council departments and agencies and local manage chronic improve the health and quality of life for individuals, aging services providers; conditions communities that address the physical, mental, families, and communities by moving the country public health officials; from a mindset focused on sickness and disease emotional, and social well-being issues that are to one based on prevention and wellness. The and health care providers, often encountered in later life among others. The overall HEALTHY overarching goal of the Strategy is to increase the AGING number of Americans who are healthy at every stage of goal is to advance healthy → INFORM future multi-sector efforts to promote Facilitate Optimize physical, life. To achieve this vision and goal, the Strategy calls for aging (FIGURE 1), defined as and facilitate healthy aging in communities social engagement cognitive, and ongoing engagement with partners in prevention from a mental health • Promoting health, variety of disciplines, sectors, and institutions. HAIA builds preventing injury, HAIA is an effort to call attention to existing policies on this approach by focusing on multi-sector and multi- and managing chronic and programs that reflect the National Prevention disciplinary efforts to promote healthy aging. Strategy’s approach of targeting prevention and conditions SOURCE: Modified The National Prevention Council is committed to adapting wellness efforts to promote healthy aging, and from: Rowe JW, Kahn • Optimizing physical, RL. Successful Aging. approaches and recommendations in response to new offers recommendations that could further advance New York: Pantheon, 1998; and Marshal evidence, plans and reports, legislation, and partnerships. cognitive, and the Strategy for an aging society. VW, Altpeter M. HAIA aligns with the National Prevention Strategy, reflects mental health Health & Social Work 2005; 30(2):135-144. the most recent scientific evidence, and highlights innovative • Facilitating social initiatives at both the federal and local level. engagement

8 HEALTHY AGING IN ACTION ADVANCING THE NATIONAL PREVENTION STRATEGY 9 FIGURE 3

FIGURE 2 Activity of Daily Living THE STATE OF (ADL) Limitations Among Historical and projected number outnumber older men. In 2014, Non-Institutionalized % of U.S. adults aged 65 and older women accounted for 56 percent 80 AGING IN THE Medicare Beneficiaries of the population aged 65 and older and for 66 percent of the aged 65 and older, 2012 OF OLDER ADULTS HAVE AT LEAST UNITED STATES 101000 population aged 85 and older.2 ONE CHRONIC CONDITION The female to male sex ratio 88 increases with age, ranging from 33% This report focuses on older adults while 114 women for every 100 men for Aging, particularly among those over addressing critical community needs. 8080 the 65–69 age cohort to a high of All older 85, can be accompanied by declines in 74 216 women for every 100 men physical and cognitive functioning that Due to a combination of factors, including among persons aged 85 and americans negatively affect health, well-being, 60 improvements in health and longevity, the aging of the 60 older.4 Furthermore, projections (Age 65+) and independence. For example, baby boomer generation, and declining fertility rates, indicate that by 2060 the 80 percent of older adults in this older adults are a growing proportion of the U.S. 46 composition of the older age group have at least one chronic population. In 2014, 46 million adults were aged 65 population will be 55 percent non- condition (such as hypertension, 4040 years and older; by 2030, that number is expected NUMBER (IN MILLIONS) Hispanic White, 12 percent non- arthritis, heart disease, or diabetes), 2 AgeD to reach 74 million (FIGURE 2), representing 65 Hispanic Black, and 9 percent non- 25% 35% and half have two or more.5 In ≥ 2014 2030 nearly 21 percent of the total U.S. population.2 19 Hispanic Asian. Hispanics will be Ages Ages 2012, nearly one-third of Medicare 20 20 22 percent of the older population 65–74 75–84 recipients living in the community had Within this growing number of older adults, in 2060.2 Prevention efforts must a functional limitation in activities of there is a great deal of heterogeneity. 6 AgeD take into account gender, racial, daily living (ADLs), such as bathing, Prevention strategies are needed to promote 0 ≥85 ethnic, and economic health dressing, and eating (FIGURE 3).6 the health and independence of adults aged 0 59% 1900 1950 2000 2050 inequities, as well as cultural At Least 65–74, as well as adults aged 85 and older, Age 1 ADL differences in the meaning and who are at a much higher risk for functional 85+ LImitation 3 promotion of health. and cognitive impairments. Older women SOURCE: Older Americans 2012: Key Indicators of Well-Being. Washington, DC: Federal Interagency Forum on Aging-Related Statistics; 2012. http://www.cdc. gov/chronicdisease/resources/publications/aag/healthy-aging.htm SOURCE: Congressional Budget Office based on data from Medicare Current Beneficiary Survey, Access to Care files, 2010. https://www.cbo.gov/sites/default/files/113th- congress-2013-2014/reports/44363-LTC.pdf

10 HEALTHY AGING IN ACTION 11 HAIA complements other recent Psychological and social components of well-being are as important HAIA provides evidence-based efforts to promote healthy aging. For to healthy aging as physical aspects. Approximately 15 percent of actions and concrete examples that example, in 2014 the Philadelphia women 65 and older and 10 percent of men 65 and older have could be adopted and adapted by Corporation for Aging released Aging clinically relevant symptoms of depression.2 Additionally, older ORIGINS communities to promote the healthy & the National Prevention Strategy adults are at risk for social isolation. In 2015, one out of five men aging of their residents. to highlight how the work of aging and more than one out of three women 65 and older lived alone organizations, including area agencies 2 OF HEALTHY (FIGURE 4). The likelihood of living alone increases with age, and on aging, intersects with the National the proportion of older adults living alone has risen from 10 percent Prevention Strategy. In 2015, the in 1945 to 28 percent in 2014.7 AGING IN World Health Organization published White House Conference the World Report on Ageing and Health, on Aging Provides ACTION which calls for a comprehensive global FIGURE Forum for New Ideas, 4 public health approach to the aging of the population. HAIA complements Catalyzes HAIA HAIA is a response to the Living Arrangements of U.S. Adults Aged 65 this global public health approach. In demographic changes in the The White House Conference on 2016, the Association of State and and Older, 2015 population of older Americans, Aging has been held each decade Territorial Health Officials released since its inaugural meeting in 1961. as well as evidence of physical, State Strategies for Promoting On July 13, 2015, President Barack 20% Living mental, emotional, social, and Healthy Aging for All, an issue Alone Obama hosted the sixth White House financial well-being issues brief that provides an overview 36% Living with Conference on Aging, bringing together 45% often associated with aging. of strategies for creating age- Men 4% woMen nonrelatives older adults, caregivers, advocates, and It provides evidence-based friendly environments based on 6% Living with leaders from the public and private sector, relatives Healthy People 2020 and the actions and concrete examples both in person and virtually, from across National Prevention Strategy, 70% 3% Living with that could be adopted and the country. The conference provided a a Spouse along with examples from 16% adapted by communities to forum to formulate new ideas to improve states that have successfully SOURCE: U.S. Census promote the healthy aging of the health, independence, and security of Bureau, Current Population implemented programs to Survey, Annual Social and their residents. older Americans. During the conference, the Economix Supplement. promote healthy lifestyles Administration announced the development for older adults. of HAIA to support Americans in living longer, healthier lives in their communities.

12 13 We need → FACILITATE collaboration across sectors, disciplines, to create a and professions and create incentives for stakeholders HEALTHY AGING to work together to support healthy aging. culture where → EXPAND the evidence base for strategies to promote healthy aging by designing and implementing older adults RECOMMENDATIONS methodologically rigorous evaluations that include both process and outcome measures. Throughout this report and the are viewed Appendix are examples of federal → WIDELY DISSEMINATE best practices, technical and nonfederal programs that are assistance guides, and other resources that as vibrant, address barriers to healthy aging. putting the National Prevention Strategy into action in communities important, → PROMOTE the relevance of prevention across across the country. These programs the life course and recognize that the aging of demonstrate promising practices that the population is creating unique challenges and productive can be adopted or adapted by public and opportunities. and private partners to advance the members of National Prevention Strategy and → FOLLOW an aging-in-all policies create a culture where older adults approach whereby the public and private are viewed as vibrant, important, sectors consider the impact on healthy society and productive members of society. aging for all policies, programs, and Building on these existing programs, infrastructure changes. stakeholders can implement the → EMBRACE a multi-dimensional view following recommendations to of healthy aging that recognizes promote the health and engagement the importance of quality of life, of older adults in their communities: happiness, personal fulfillment, and sense of meaning along with the prevention of disease and disability.

14 HEALTHY AGING IN ACTION 15 Healthy Aging TO ADVANCE THE NATIONAL PREVENTION Actions STRATEGY

16 HEALTHY AGING IN ACTION ADVANCING THE NATIONAL PREVENTION STRATEGY 17 Increase the supply of Promote access to accessible, affordable, healthy food adaptable housing

Develop plans to address FIGURE 5 Create more walkable communities potential vulnerability to STRATEGIC DIRECTIONS OF THE natural disasters Healthy Aging Actions Improve older Protect from elder driver safety mistreatment NATIONAL PREVENTION STRATEGY to Advance the National Enhance Recruit, retain, and transportation train a multisector Prevention Strategy options and multidisciplinary HEALTHY AND workforce The National Prevention While each Strategic Direction individually guides actions to improve SAFE COMMUNITY Strategy outlines four health, together they provide a comprehensive approach to fully ENVIRONMENTS Strategic Directions as the support Americans in living longer and healthier lives. This section foundation for a prevention- of the report provides a brief overview of each of the four Strategic oriented society: Directions and recommends healthy aging actions that target each Strategic Direction to the needs of older adults (also shown in Educate professionals Increase access to to identify and preventive services FIGURE 5). These healthy aging actions were identified based on CLINICAL AND → Healthy and Safe address disparities ELIMINATION NATIONAL a review of the scientific literature and consultation with experts OF HEALTH COMMUNITY Increase access to and Community Environments Collect community PREVENTION PREVENTIVE availability of preventive in the fields of aging and public health, as well as experts from wide data to identify DISPARITIES dental services health care disparities STRATEGY SERVICES across the federal government. Each healthy aging action includes → Clinical and Community Increase access to and a rationale based on the existing evidence. In addition, Distribute information availability of behavioral Preventive Services and implement health care some healthy aging actions include a federal or local programs that community example of an initiative that is address age-related Develop falls Empowered People health issues prevention programs → putting that action into practice. EMPOWERED Train physicians and other Elimination of health care professionals on → PEOPLE age-related health issues Health Disparities Expand the availability of home- and community- based services

Provide information Support and empower Support direct about healthy options informal caregivers to care workers promote healthy aging Increase access to and use of technology to support health Combat ageism and other needs

Create opportunities for employment, education, and volunteer activities 18 19 % 4 Most Americans want to live independently and HEALTHY AND remain in their own homes OF ADULTS AGE 65 AND OLDER WERE LIVING IN AN and chosen communities INSTITUTIONALIZED SETTING as they grow older

SAFE COMMUNITY Many sectors play a part in keeping to keep older adults healthy and older adults safe and healthy in engaged in their communities. Such their homes and communities. efforts promote mobility, community The vast majority of older adults connectivity, and physical activity live in the community (FIGURE 6). among older adults by improving In 2010, only 4 percent of adults access to transportation, healthy food, ENVIRONMENTS age 65 and older were living in an affordable and accessible housing, and institutionalized setting. health care and community support services and increasing safety of Most Americans want to live Healthy and Safe Community Environments sidewalks and crosswalks. On October independently and remain in their own 6, 2015, the Institute of Medicine advance evidence-based policies and homes and chosen communities as and the Division of Behavioral and practices to create, sustain, and recognize they grow older. For older Americans Social Sciences and Education within to continue to achieve this goal, communities that promote health and the National Academies of Sciences, community environments should wellness through prevention. Engineering and Medicine convened a promote health and independence public workshop, Policy and Research while ensuring safety. Developing Needs to Maximize Independence and prevention-oriented communities Support Community Living, to explore involves policy, infrastructure, the policies and research opportunities environmental health, and social to support community living and change. Innovative initiatives are maximize independence. taking place across the country

20 HEALTHY AGING IN ACTION HEALTHY AND SAFE COMMUNITY ENVIRONMENTS 21 FIGURE 6 “As HUD Secretary, I’ve made supporting affordable and accessible communities for all Americans one of my top priorities. Percentage of U.S. HEALTHY Advance walkable One example is HUD’s Community Development Block Grant older adults living in communities (CDBG) funds, which provide approximately $34 million a year to institutionalized settings that support older improve senior centers across the nation; an additional $36 million AGING Americans’ mobility. 3% to offer public services to approximately 1 million seniors annually; The National Highway Traffic Safety and CDBG funds the rehabilitation of nearly 70,000 single family and ACTIONS Administration’s The Pedestrian 1% multi-family housing units each year, many of them occupied by low- Safety Workshop: A Focus on Older income older adults—allowing them to age in place.” Adults was developed to describe JULIÁN CASTRO how older adults, transportation All adults Develop and promote strategies to Department of Housing and Urban Development Secretary increase accessible, affordable, and and public health professionals, law Regional Forum in Cleveland, Ohio, 04/27/2015 enforcement, and other decision ages 65+ adaptable housing to allow older Americans to makers can improve pedestrian safety. live safely in their homes. Improve older Counseling Older Drivers to help health Older adults who live in walkable care providers prevent motor vehicle The Surgeon General’s Call to Action to Promote Healthy Homes communities are more likely to driver safety. crashes and injuries. Other strategies outlines steps older adults can take to protect themselves engage in physical activity than those The Federal Highway Administration 1% 2% to enhance older drivers’ safety include from disease, disability, and injury that may result from who do not,9 while those who live (FHA) developed the Handbook for 0.3% 1% increased visibility of road markings. In health hazards in their homes. Advancing Healthy Housing: A in neighborhoods without benches, Designing Roadways for the Aging Ages Ages addition, FHA’s bicycle and pedestrian Strategy for Action, developed by the federal Healthy Homes curb cuts, parks, or well-maintained Population to provide practitioners 65–74 75–84 program promotes safe, comfortable, Work Group, outlines strategies to reduce health and safety sidewalks are at a higher risk for with information that links driver and convenient walking and bicycling risks in the home and highlights the need for increased disability.10 Pedestrian-friendly design performance to highway design, for people of all ages and abilities. research to inform policies and practices that minimize 9% may be a particularly effective strategy operational, and traffic engineering adverse health outcomes for those at greatest risk, including for improving the safety of older features. In addition, FHA developed Nursing Home older Americans. At the White House Conference on Aging, 4% adults who walk to destinations or a Clinician’s Guide to Assessing and Age Residential the U.S. Department of Housing and Urban Development for exercise. 85+ Care Facility released Aging at Home: A Guide for Home Improvements to help older homeowners, families, and caregivers make OF OLDER ADULTS OF OLDER ADULTS REPORT THAT changes to their homes so that older adults can remain safe RESTRICT DRIVING THEY MISS OUT ON ACTIVITIES SOURCE: Congressional Budget Office based on % TO CERTAIN HOURS % THEY LIKE TO DO BECAUSE OF data from Medicare Current Beneficiary Survey, and independent. Basic accessibility features include no- Access to Care files, 2010. https://www.cbo.gov/ 61 OF THE DAY 21 DRIVING LIMITATIONS sites/default/files/113th-congress-2013-2014/ step entries, extra-wide doorways, and lever-style door and reports/44363-LTC.pdf faucet handles.8

22 HEALTHY AGING IN ACTION HEALTHY AND SAFE COMMUNITY ENVIRONMENTS 23 The Call to Action outlines five goals Federal agencies are also working September 2015. This is a national and related evidence-based strategies to promote the Call to Action. The campaign encouraging CEOs to Step It Up! to support walking and walkability. U.S. Regional Health Administrators recognize physical activity as an These strategies call for families partnered with America Walks to important driver of employee health. and individuals to change their own hold technical assistance webinars The Mayors’ Challenge for Safer People WALKING The Surgeon behavior and prioritize walking, and for community groups and local and Safer Streets is an initiative led by General’s Call also outline the critical role of multiple nonprofits, and the Department the U.S. Department of Transportation sectors, including transportation of the Interior (DOI) appointed a (DOT) to encourage mayors and other to Action to and community design, parks and National Coordinator to help plan elected city officials to participate in OUR WAY Promote Walking recreation, business and industry, and implement regional activities to leading a call to action and forming nonprofit, and public health, among promote the Call to Action. The CDC a local action team to advance safety and Walkable others. Middle-aged and older adults supported the development of Mall and accessibility of streets for all road Communities represent the segment of the U.S. Walking: A Program Resource Guide to users.16 Since the announcement of population that may benefit the increase walking among middle-aged the Mayors’ Challenge in January 2015, TO HEALTH most from efforts to increase walking and older adults. A group of federal there have been a total of 245 mayors’ programs in the nation. agencies is currently working together pledges in the United States. Complete to build a multi-sector coalition or Streets policies are street design Numerous organizations announced consortium, including mall managers policies that support the routine commitments to improve health and mayors across the country, to design of streets to make them safe Step It Up! The Surgeon General’s Only 36 percent of Americans through walking and walkable support mall walking as part of a city- for all pedestrians, regardless of age aged 65 years and older meet communities. America Walks and the Call to Action to Promote Walking wide approach to re-imagining and or ability, and accommodate all modes the recommendations from the Every Body Walk! Collaborative funded and Walkable Communities, using existing walkable spaces. for transport.17 As of December 2015, 2008 Physical Activity Guidelines for 10 grants up to $2,500 to community released in September 2015, 11 30 states and the District of Columbia Americans. Physical activity has groups to strengthen existing walking Since the release, 43 chief executive aims to make walking a national had adopted Complete Streets policies, a number of benefits particularly programs and support policies and officers (CEOs) signed on to the and 856 policies had been adopted at priority and disseminate relevant in later life, including reducing programs to create walkable places. CEO Pledge℠ for Physical Activity in the local and regional levels.17 evidence-based strategies to the risk of falls,12 improving balance design communities that make and stamina,13 and delaying the onset it safe and easy to walk for of cognitive decline.14 Walking is people of all ages and abilities. related to the physical environment, particularly the extent to which the FOR MORE INFORMATION surrounding neighborhood is walkable → http://www.surgeongeneral.gov/library/calls/walking-and-walkable-communities/index.html#Call%20to%20Action and includes mixed land use.15 → http://americawalks.org/surgeon-general-releases-call-to-action/

24 HEALTHY AND SAFE COMMUNITY ENVIRONMENTS 25 Percentage of U.S. older adults not meeting fruit and vegetable recommendations

78% 86% 65% MEN & WOMEN 79% MEN & WOMEN Enhance transportation options to OVER 70 WHO OVER 70 WHO Promote older adults’ meet the needs of older adults. DO NOT MEET DO NOT MEET access to healthy foods. FRUIT INTAKE VEGETABLE INTAKE Data from the National Household Travel Study RECOMMENDATIONS RECOMMENDATIONS At the White House Conference suggest that older adults use public transportation for on Aging, the U.S. Department of only 2 percent of all trips.18 Furthermore, more than Agriculture (USDA) issued a proposed 15.5 million Americans aged 65 years and older live rule to increase accessibility to critical in areas where public transportation service is limited nutrition for homebound, older or nonexistent.19 Lack of transportation access can Develop plans to Aging Program provides information, Americans and people with disabilities create a barrier for treatment and screening, with an address older adults’ tools, and resources to assist in by enabling Supplemental Nutrition estimated 3.6 million Americans missing or delaying potential vulnerability to multi-sector planning for older adults Assistance Program (SNAP) benefits to non-emergency medical care each year because of in emergencies. The Centers for be used for services that purchase and environmental hazards. transportation issues.20 Many people may not make Medicare & Medicaid Services’ (CMS) deliver food to these households. The Because of physical changes that appointments or take advantage of free health proposed Emergency Preparedness President’s fiscal year 2017 budget accompany aging, older adults may screenings such as those provided by the Affordable Rule establishes national emergency proposed nearly $850 million for be more susceptible to environmental Care Act because they cannot get a ride. Mobility preparedness requirements for Nutrition Services programs for older toxins and extreme temperature management, which coordinates multiple modes Medicare- and Medicaid-participating adults, a $14 million increase over the changes in the environment.22 of transportation from multiple public and providers and suppliers to ensure 2016 enacted level, allowing states Furthermore, because of their private providers, is one promising strategy to that they adequately plan for both to provide an estimated 205 million increased likelihood of experiencing improve community access for older adults natural and manmade disasters, meals to more than 2 million older a sensory impairment, chronic and individuals with a disability.21 Reflecting and coordinate with federal, state, Americans nationwide. The budget conditions, mobility impairment, this approach, the DOT launched the Rides to tribal, regional, and local emergency also includes a new proposal to invest and limited social and economic Wellness Initiative to increase partnerships preparedness systems. It would also in evidence-based innovations to resources, older adults are particularly between health and transportation providers ensure that these providers and help ensure that funding for Nutrition at risk for negative outcomes from and increase access to care, improve health suppliers are adequately prepared to Services programs is spent as natural disasters.23 This is especially outcomes, and reduce health care costs. meet the needs of patients, residents, efficiently as possible to maximize the true for those living in less densely clients, and participants during impact of these funds. populated, rural, and remote areas. disasters and emergency situations. CDC’s Alzheimer’s Disease and Healthy

26 HEALTHY AGING IN ACTION HEALTHY AND SAFE COMMUNITY ENVIRONMENTS 27 Events have addressed such topics The group has benefited the field of as catalyzing community gardens at aging by building awareness of aging senior centers and senior housing services in the wider community; complexes; showing urban planners facilitating cross-disciplinary learning COLLABORATING why they need to design communities and innovation around aging issues; for people of all ages; connecting stressing the competitive advantage generations through contemporary for emerging leaders from all music; presenting senior hunger issues fields to know about aging issues; to the community; and introducing strengthening the aging network ACROSS SECTORS disability and aging issues to young workforce; breaking down stereotypes technologists via a “hackathon” about working with older adults; and and more. introducing expertise from outside the GenPhilly aging network to benefit older adults. GenPhilly is an innovative, Philadelphia has the second highest proportion of older adults of large Philadelphia replicable model to engage emerging leaders from a variety U.S. cities. In 2009, PCA set out to Corporation work with organizations outside of disciplines to promote FOR MORE INFORMATION of the aging network to help them for Aging and sustain an aging-in- integrate the needs of seniors into → www.genphilly.org community agenda. their plans, policies, and programs. At that time, the agency discovered Today, it is a network of more than that many organizations throughout 500 emerging leaders from a variety the city had limited knowledge about of disciplines who are thinking about older people. Through social media, their own healthful future and the meetings, and public events, GenPhilly type of city in which they themselves has shown emerging leaders from want to age, while helping the current all fields that there is a competitive population of older adults. GenPhilly is professional advantage that results a program of Philadelphia Corporation from incorporating knowledge about for Aging (PCA), the area agency older adults into their skill set. on aging.

28 HEALTHY AGING IN ACTION HEALTHY AND SAFE COMMUNITY ENVIRONMENTS 29 Addressing the barriers to healthy aging is a complex and interventions and research in related areas like child abuse and multi-dimensional challenge domestic violence that might inform that requires the contributions % research on elder abuse; and gaps 10 Protect older adults from and opportunities in this field of of diverse stakeholders elder mistreatment. research. An estimated 10 percent of OF OLDER ADULTS At the White House Conference on older adults are the victims of elder ARE ESTIMATED TO BE Aging, CMS released a proposed mistreatment, including physical THE VICTIMS OF ELDER Recruit, retain, and to expand geriatrics education to rule to update the quality and safety abuse, emotional abuse, sexual MISTREATMENT prepare the health care workforce requirements for more than 15,000 abuse, exploitation, neglect, or train a multi-sector and to respond to the needs associated nursing homes and skilled nursing abandonment.24 Establishing accurate multi-disciplinary workforce, with advancing age. Addressing facilities to improve quality of life, estimates, however, is complicated including those outside of the the barriers to healthy aging is a enhance person-centered care and because of state variations in the health and long-term care Enhancing understanding complex and multi-dimensional services for residents in nursing definition of elder mistreatment, of the extent of elder sectors, to promote health and challenge that requires the homes, improve resident safety, and the absence of a national database, mistreatment, as well as well-being in later life. contributions of diverse bring these regulatory requirements and underreporting.25 Enhancing its risk and protective stakeholders. This requires into closer alignment with current understanding of the extent of elder As part of the White House Conference factors, is critical for training for professionals in professional standards. The National mistreatment, as well as its risk on Aging, the CDC launched a free designing and implementing different geographic areas, Institutes of Health also convened and protective factors, is critical for online course offering continuing effective prevention and from a variety of fields as a state of the science workshop designing and implementing effective education credits to physicians, nurses intervention efforts well as older adults and on elder abuse with researchers, prevention and intervention efforts. and other health professionals on their families, friends, and clinicians, and others to review making falls prevention a routine caregivers to promote the the science on understanding and part of clinical care. The Health health and well-being of preventing abuse; screening tools Resources and Services Administration older adults. to identify abuse victims; effective announced $35 million in awards to health professions training programs

30 HEALTHY AGING IN ACTION 31 BENEFITS FOR ALL CLINICAL AND This is reflected in the Affordable Care Act’s expansion and evaluation older adult of patient-centered models that remains healthy and integrate primary care with community independent services. When older adults receive preventive services from a clinician, COMMUNITY everyone benefits. The older adult can remain healthy and independent, the health care provider has a healthier health care patient, and the insurance provider provider has has a beneficiary who might be less a healthier PREVENTIVE patient likely to need more expensive acute care. Preventive services can include screenings, counseling, immunizations, chronic disease management, and insurance medications used to prevent or provider has a control disease. In order to deliver beneficiary who SERVICES appropriate preventive services, health might be less likely to need care providers must be aware of more expensive clinical preventive guidelines and the Clinical and Community Preventive acute care benefits for older adults. Older adults Services are effective in reducing must have an understanding of the death, disability, and functional benefits of preventive care, motivation decline, and can be cost-effective. to seek such care, and the ability to access services.

32 HEALTHY AGING IN ACTION CLINICAL AND COMMUNITY PREVENTIVE SERVICES 33 tooth loss and gum disease, among Americans residing in different HEALTHY geographical areas. Preventive dental services include oral health year national objectives for improving Increase access to and screenings, regular dentist checkups, the health of all Americans. In 2010, and patient counseling on behavioral AGING availability of preventive Healthy People 2020 added “older risk factors for oral disease and dental services. ACTIONS adults” as a new topic area with the conditions. These services are goal of improving the health, function, Oral health is an important but often important even if older adults do not and quality of life of older adults. One overlooked component of older adult have natural teeth and have dentures, objective for older adults is to increase health. More than 37 percent of adults to ensure gum health.28 The HRSA Increase older adults’ the proportion of that population aged 65 years and older have not had funded 420 health centers to increase access to and use of who are up to date on a core set of % a dental visit in the last 12 months.28 access to integrated oral health care clinical preventive services. clinical preventive services. Older 37 Poor oral health can affect an older services and improve health outcomes adults do not always obtain important adult’s overall health and well-being Clinical preventive services can for health center program patients. preventive services that are critical for and is often associated with several prevent or detect disease earlier The National Academies of Sciences, avoiding disease and disability. 26 In chronic diseases and conditions, such when treatment is more effective. Engineering, and Medicine report 2014, only about two out of five adults as diabetes, cardiovascular diseases, These services include screenings for Improving Access to Oral Health Care for 65 and older were up to date on all of pulmonary diseases, rheumatoid chronic conditions such as high blood Vulnerable and Underserved Populations a core set of preventive services.27 arthritis, cognitive impairment/ pressure and diabetes, immunizations provides a roadmap for the important Alzheimer’s disease, and some types for diseases such as influenza and and necessary next steps to improve of cancers (oral cavity, gastrointestinal pneumonia, and counseling about access to oral health care, reduce oral tract, bladder, liver, kidney, and health disparities, and improve the personal health behaviors such OF ADULTS AGED 65 pancreatic).28 In addition, older adults as smoking and physical activity. YEARS AND OLDER HAVE oral health of the nation’s vulnerable often do not have dental insurance The U.S. Preventive Services Task NOT HAD A DENTAL VISIT and underserved populations. IN THE LAST 12 MONTHS or adequate dental insurance, and Force provides a complete list of all IN 2014, ONLY ABOUT TWO those with the poorest oral health recommended services. Healthy OUT OF FIVE ADULTS 65 AND are economically disadvantaged People is an HHS initiative that sets 10- OLDER WERE UP TO DATE and members of racial and ethnic ON ALL OF A CORE SET OF 29 PREVENTIVE SERVICES minorities. There are also disparities in oral health outcomes, such as

34 HEALTHY AGING IN ACTION CLINICAL AND COMMUNITY PREVENTIVE SERVICES 35 Expand falls prevention among older adults is different than among younger adults, as older adults programs, including are more likely to use lethal means those that address hip fractures, hand fractures, traumatic Older adults are APPROXIMATELY (e.g., firearms) and die from their first environmental hazards brain injuries, and lacerations. Half ONE-THIRD OF Increase access to and suicide attempt, and they are less often misdiagnosed within the home and in of falls occur outdoors; such falls ADULTS AGED 65 and undertreated for availability of behavioral likely to report suicidal ideation or the community. are more likely to result in serious AND OLDER FALL seek mental health treatment prior depression because injury.34 Interventions to prevent EACH YEAR health care. In conjunction with the White to suicide.31 providers mistakenly falls must address hazards in both Medicare covers yearly screenings House Conference on Aging, the attribute symptoms to the home and the neighborhood for depression, and the Welcome to To address the growing problem of Administration for Community Living a natural reaction to environment. ACL has awarded more Medicare visit and the Annual Wellness overuse and abuse of opioid analgesics (ACL) and the National Coalition on illness or changes that than $8 million in grants to support visit require a doctor to screen for in the Part D program, the CMS Aging, organized a Falls Prevention occur with age falls prevention initiatives in domestic depression or other mental health adopted a policy in 2013 for Medicare National Resource Centers Conference 25,000 public and private nonprofit conditions. Mental health issues, such Part D plan sponsors to implement in May 2016. This meeting provided OLDER ADULTS DIED FROM entities, including state agencies, as depression or anxiety, are often enhanced drug utilization review. From an opportunity for state and FALL INJURIES IN 2013 to address the nation’s prescription community organizations, and overlooked among the older adult 2011 through 2014, there were 7,500 local agencies, community-based opioid epidemic. When prescribing tribal organizations. ACL has also population. Older adults are often fewer Medicare Part D beneficiaries organizations, and others to learn or dispensing controlled substances, funded a nonprofit organization misdiagnosed and undertreated identified as potential opioid over- about strategies to implement to serve as the first-ever ACL 32 providers should warn patients not MEDICAL COSTS ASSOCIATED for depression because providers utilizers; this is a 39 percent decrease. evidenced-based falls prevention National Falls Prevention WITH FALL-RELATED INJURIES IN to use alcohol with prescription mistakenly attribute symptoms to a In August 2016, the Surgeon General programs. Approximately one-third Resource Center 2013 WERE AN ESTIMATED medicines and they should discuss the . HUD is natural reaction to illness or changes launched the Turn the Tide Campaign of adults 65 and older fall each year, hazards of using controlled substances creating a falls prevention that occur with age.30 The rate of death making falls the leading cause of while driving. toolkit for public, non- by suicide among White men 75 and fatal and nonfatal injuries among governmental, and private older is three times the rate among older adults. In 2013, 25,500 older $34 Billion sector policy and program the general population.31 Suicide adults died from fall injuries, and managers and staff. medical costs associated with fall- related injuries were an estimated $34 billion.33 Common fall injuries include

36 HEALTHY AGING IN ACTION CLINICAL AND COMMUNITY PREVENTIVE SERVICES 37 FOR MORE INFORMATION → http://www.satellitebeachfire.com/#!mihc/ccjp

→ http://www.satellitebeachfire.com/#!fall- COMMUNITY prevention/c11m6 FALLS PREVENTION Satellite Beach, Florida PROGRAM

Satellite Beach, a small currently operates a Community potential hazardous conditions that community in Florida, has Paramedic Program and a Falls could lead to falls. This includes not been engaged in prevention Prevention Program. only factors in the environment—such as the presence of tripping hazards efforts to promote healthy The Falls Prevention Program in or the lack of handrails—but also a Satellite Beach aims to lower the aging since the 1990s, when review of medications, which were number of fall-related emergency they participated in the Brevard linked with many fall-related calls the calls by providing education, in-home County, Florida, Communities fire department received. Satellite assessments, and case management for a Lifetime initiative. Beach is using a variety of measures for older adults identified by to evaluate the effects of this program. themselves or someone else as The Communities for a Lifetime effort Data suggest that the program has being at risk. A Community Health in Satellite Beach won a 2008 EPA resulted in fewer fractured hips, Paramedic visits an older adult’s Building Healthy Communities for reduced the overall prevalence of home and works with the individual Active Aging Award. Continuing its falls, and decreased hospital 30-day and/or family members to identify focus on prevention, this community readmission rates.

38 HEALTHY AGING IN ACTION 39 Home- and community- based services are Enhance primary care associated with improved Support and protect and other allied health physical and mental health the financial security, care professionals’ training in personal safety, and health of aging-related health issues. direct care workers.

Diagnosis and treatment of health Direct care workers are workers who problems in later life are further provide home care services, such as Expand the availability of home-bound older adults. Under complicated by the development of certified nursing assistants, home home- and community- the Affordable Care Act there have geriatric syndromes, such as dizziness health aides, personal care aides, been multiple Medicaid investments 39 or delirium, which involve multiple based services. caregivers, and companions. to provide home-and community- organs, systems, and symptoms.35 Home- and community-based services Direct care workers often earn low based services and supports. The law HRSA’s Geriatrics Workforce (HCBS)—such as professional and wages, receive few if any benefits,40 improves existing tools and creates Enhancement Program serves as a family in-home personal care, adult and are at risk for job-related injuries new options and financial incentives model to improve health outcomes for day care, home health, home-delivered and other health problems.41 With for states to provide HCBS and older adults by integrating geriatrics meals, and case management—are a projected need for an additional supports. The Home- and Community- with primary care, thereby maximizing associated with improved physical 1 million in-home care workers Based Services State Plan Option enable patient and family engagement and and mental health.36,37 HCBS may by 2022,42 it is critical to address states to target home- and community- transforming the health care system. also delay or prevent nursing home these occupational hazards. The based services to particular groups of placement. Recent analyses found Department of Labor issued the Home people, to make services accessible to that as states spent more on Older Care Final Rule to extend minimum more individuals, and to ensure the Americans Act programs and Medicaid wage and overtime protections to quality of the services provided. The HCBS, the number of nursing home almost 2 million home care workers. integrating geriatrics Community First Choice State Plan residents with low ADL–care needs As of January 1, 2015, most direct with primary care Option provides increased federal decreased.38 Home-delivered meals care workers are entitled to receive maximizes patient and matching funds to states that provide were particularly effective, perhaps federal minimum wage and overtime family engagement HCBS to individuals who might be because meal drivers became pay protections. served in an institutional setting. aware of issues among isolated and

40 HEALTHY AGING IN ACTION 41 appointments that align with public of missed medical appointments transit schedules, and 2) create a bus due to transportation issues. Results GETTING PATIENTS that would provide transportation to of this research will be published and from hospital appointments for and distributed nationally and will a different neighborhood each day of inform not only the work of Rides the week. to Wellness programs, but also other local efforts to increase health DOT is also co-sponsoring with the care access for those with limited HRSA, ACL, and CMS a national survey TO SERVICES transportation options. of health centers and community Rides to centers to document the magnitude

Wellness While the health industry offers communities. DOT provided grants preventive services, patients to community organizations through Department of can face challenges in getting to two rounds of applications. In the first round, 16 finalists from local FOR MORE INFORMATION those services if they no longer Transportation communities were selected to receive → https://www2.fta.dot.gov/ drive and have limited or no $25,000 each for a planning grant ccam/about/initiatives access to transportation. based on their proposed program. During the 6-month grant period In response, DOT’s Federal Transit (June–December 2015), the 16 Administration (FTA) launched the Healthcare Access Challenge grantees Rides to Wellness initiative, which aims tested assumptions about their to increase access to care, improve proposed concepts with potential health outcomes, and reduce health users and modified their solutions care costs. to adapt to real-world situations. In March 2016, the FTA announced For example, the Worcester Regional $5.3 million in funding to support Transit Authority in Massachusetts the Rides to Wellness Demonstration engaged in planning activities to Grants. These awards build on an 1) design a web-based application to extensive planning process with help health care facilities schedule

42 43 34 million AMERICANS PROVIDE INFORMAL CARE TO AN EMPOWERED ADULT AGED 50 YEARS AND OLDER

“We need a cultural change in our view of Older adults can be empowered when aging that recognizes older they have the information, resources, adults bring experience and PEOPLE ability, supports, and motivation to make choices for themselves. When value to our communities this happens, they are able to take an that strengthen our While policies and programs can active role in improving their health society and can solve social make healthy options available, and the health of their families, problems. In other words, it’s Empowered People acknowledges friends, and communities. time to shift the conversation

that individuals need information The approximately 34 million from one that assumes an aging to make health choices. Americans who provide informal population will overwhelm us to care to an adult aged 50 years and one that recognizes older adults 43 older also need the support and as an asset to our country and information necessary to make celebrates their contributions to healthy choices for themselves improve lives for all generations.” and their care recipients. Access to easy-to-understand SYLVIA MATHEWS BURWELL information, tools for Department of Health and Human Services Secretary empowerment, and affordable White House Conference on Aging, 07/13/2015 options can support older adults and their caregivers in making healthy choices.

44 HEALTHY AGING IN ACTION EMPOWERED PEOPLE 45 Provide older adults with information about healthy options. Create opportunities While the community context can for the meaningful HEALTHY provide opportunities for healthy engagement of older adults behaviors through access to through employment, recreational facilities or farmers Increase older adults’ education, and formal and AGING markets,44 health information can access to and use of informal volunteer activities. also support older adults in engaging technology that can support Older adults who participate in paid ACTIONS in healthy behaviors. For example, their information, health, social older adults might not be aware of the employment, volunteering, informal connectivity, and other needs. benefits of regular physical activity, social assistance, or community clubs good nutrition, the risk of falls and In March 2016, The President’s and organizations typically experience related injuries, and strategies to Council of Advisors on Science and better health than do those who do manage chronic conditions.45 The Technology released a report to the not participate in such activities.46,47 National Institute on Aging’s What’s On President, Independence, Technology, Volunteering in later life is associated Older adults might not Your Plate initiative outlines smart food and Connection in Older Age. The with decreased mortality risk, be aware of the benefits choices for healthy aging. CDC’s Tips report includes four cross-cutting fewer functional limitations, better of regular physical from Former Smokers campaign profiles recommendations that span a wide mental health, and greater levels activity, good nutrition, real people, including older adults, who range of technologies and eight of life satisfaction.48,49,50 In addition, the risk of falls and are living with serious long-term health targeted recommendations concerning volunteering can foster a sense of related injuries, and effects from smoking and secondhand specific applications to improve meaning and purpose, and when older strategies to manage smoke exposure. Tips engages doctors, mobility, cognitive function, and individuals feel purpose in life, they chronic conditions nurses, dentists, pharmacists, and social engagement. Internet access, are empowered to make healthier many other health care providers so telehealth, monitoring technology, living choices.51 Furthermore, older they can encourage their smoking emergency preparedness systems, adults make valuable contributions patients to quit for good. and intentional design are some of the to their communities. technologies that will support healthy aging for all Americans.

46 HEALTHY AGING IN ACTION 47 national health education campaign than 340 partners, primarily agencies, NIA has documented growth to provide resources and, with organizations, and companies that and recognition of the Go4Life MAKING partners nationwide, help to motivate serve older adults or have physical campaign, including the older adults to engage in regular activity as part of their core missions. distribution of more than physical activity. 1.4 million copies of the exercise The campaign also partners with guide and a steady increase in Launched in 2011, the Go4Life federal agencies, including the ACL; partners, website visitors, and campaign includes an evidence- CDC and Prevention; Department of social media followers. In 2016, PHYSICAL ACTIVITY based interactive website, exercise Veterans Affairs (VA); and President’s Go4Life plans to continue partner guide (available in English and Council on Fitness, Sports & Nutrition. and community engagement, Spanish), exercise video, tip sheets, The campaign, in collaboration with create new tip sheets (including and other materials. A key strategy the White House Conference on Aging, tips on the connection between of the campaign is national outreach established September 2015 as Go4Life A WAY OF LIFE exercise and emotional well- to enlist partner organizations at Month, with more than 600 registered being), and again sponsor Go4Life the community level to help raise events taking place across the nation, Go4Life® Month in September to help shine awareness about the benefits of including A Capitol Walk with Go4Life a spotlight on the importance of The Go4Life® exercise and of chronic health conditions, such exercise and physical activity and enlist organized in Washington, DC, with the exercise and physical activity for Department as hypertension, coronary heart individuals to become more active. U.S. Surgeon General. physical activity campaign from healthy aging. of Health the National Institute on Aging disease, type 2 diabetes, and some As of January 2016, Go4Life had more cancers compared to their less fit (NIA) at the National Institutes and Human counterparts.52,53 However, only of Health offers exercises, tools, Services 36 percent of older Americans meet and tips to motivate people the recommendations from the aged 50 and older to increase 2008 Physical Activity Guidelines for Americans.11 Go4Life recognizes that their level of exercise and FOR MORE INFORMATION public understanding about the physical activity. → https://go4life.nia.nih.gov dangers of a sedentary lifestyle is not The physical, mental, and emotional enough to change behaviors. Informed benefits of physical activity have by a review of the scientific literature been well documented in scientific and input from the NIA Task Force literature; for example, those who on Exercise and Physical Activity, the are physically fit have half the risk NIA developed this comprehensive

48 49 informal caregivers.54 The National Family Caregiver Support Program, created by the Older Americans Act Amendments of 2000, provides grants to states and territories, based on Support and empower their share of the population aged 70 informal caregivers to and over, to fund a range of supports that assist family and other informal promote healthy aging for caregivers to care for their loved both caregivers and recipients ones at home for as long as possible. of care. The five types of service categories Combat ageism through In 2015, an estimated 34 million adults include 1) information to caregivers culture change efforts, in the United States served as an about available services; 2) assistance education and training, and informal caregiver to someone aged to caregivers in gaining access to the intergenerational activities. 50 or older in the prior 12 months.43 services; 3) individual counseling, Many older adults prefer to remain in organization of support groups, and Ageism can take many forms and can their home to be cared for by family caregiver training; 4) in-home respite exacerbate the social exclusion of or friends, and providing care in the during the day and overnight respite in older adults.55 Furthermore, ageism by home can help prevent more costly a long-term care facility; and 5) limited the larger society can lead to negative formal care. Informal caregivers, such supplemental services that includes self-perceptions about aging, which as family and friends, are an integral home modification, financial planning, in turn have been linked to decreased part of an older adult’s care team; and assistive devices. In addition, physiological and cognitive functioning, thus, maintaining the health and well- the White House Conference on as well as an increased mortality being of the caregiver is crucial for Aging highlighted public and private risk.56 The Reframing Aging initiative, maintaining the health and well-being employers’ efforts to develop developed by eight leading aging of the recipient of care. Approximately supports for their employees who organizations, provides an example two-thirds of older adults with are family caregivers. of the importance of shifting public disabilities receive long-term services perceptions about aging. and support at home exclusively from

50 HEALTHY AGING IN ACTION EMPOWERED PEOPLE 51 FOR MORE INFORMATION → http://www.nyc.gov/html/ dfta/downloads/pdf/press_ HEALTHY FOOD release/yellow_buses.pdf

MarketRide

MarketRide is a collaborative supermarkets and other food sources. New York City effort between New York City’s Older adults can encounter various Department Department for the Aging (DFTA) barriers to meeting their dietary needs, including a loss of appetite, and Department of Education for the Aging changes in the body’s ability to (DOE) to help older adults travel absorb and use nutrients, and drug to and from supermarkets, interactions.57 Mobility restrictions farmers markets, and other and limited financial resources can sources of nutritious food. place further constraints on older adults’ ability to access healthy food. More than 20 years ago, the Mayor’s MarketRide addresses these barriers office initiated a School Bus Program by helping senior center participants, through which DOE provides who are often low-income and may transportation to senior center live in neighborhoods with limited participants using school buses that food options, get to grocery stores. otherwise would be sitting idle during This program also aligns with the the school day. Participating senior city’s Age Friendly NYC initiative, which centers that do not have their own calls for a variety of improvements vehicle can travel to shopping centers, to the city’s social and physical museums, theaters, parks, and other infrastructure, including making it community locations. easier for older adults to find fresh fruits and vegetables. More recently, DFTA and DOE have created MarketRide, which focuses specifically on transportation to

52 53 Health disparities related to race, ethnicity, socioeconomic status, ELIMINATION gender, and sexual orientation, among others, compound health problems that can occur with age59

OF HEALTH Older adults who are a racial or adults. The more than 7 million ethnic minority or have a lower Americans aged 65 and older living socioeconomic status are more likely in a rural community can experience to experience select chronic diseases significant challenges to maintaining (FIGURE 7).60 At age 65, Whites can their health and independence62 DISPARITIES expect to live an average of 1 year compared to their urban and suburban longer than Blacks.2 Life expectancy in counterparts, including higher rates of 2014 among the Hispanic population obesity, greater risk for food insecurity, Elimination of Health Disparities aims to address the was higher than among non-Hispanic higher prevalence of chronic disease, inequities in health that adversely affect groups of people on Whites or non-Hispanic Blacks. and less access to services.63 Hispanic people who survive to age the basis of their race or ethnicity, religion, socioeconomic Furthermore, adults aged 50 years 65 can expect to live 2 years longer status, sex, age, mental health, disability, sexual orientation, and older with less than a high school than non-Hispanic Whites and 3 years gender identity, geographic location, or other characteristics education have higher rates of physical longer than non-Hispanic Blacks.61 58 limitations than their more highly- historically linked to discrimination or exclusion. Lesbian, gay, and bisexual older educated counterparts.64 In 2014, adults have higher rates of disability, people aged 65 and over who had cardiovascular disease, obesity, and not graduated from high school were depression than heterosexual older

54 HEALTHY AGING IN ACTION ELIMINATION OF HEALTH DISPARITIES 55 FOR MORE INFORMATION physician offices, and pharmacies. → http://www.voteandvax.org With initial funding from the Robert Wood Johnson Foundation, Vote & Vax launched in 2006 at 127 polling places BRINGING 69 in 14 states. In 2008, the program expanded to 331 locations in 42 states and DC. In 2012, Vote & Vax served 651 polling locations and was active in all states. The program, which has SERVICES TO THE also received support from AARP and CDC, coordinates the activities of local providers from the public (e.g., public health departments), nonprofit (e.g., visiting nurse services), and for-profit COMMUNITY sectors (e.g., pharmacies). Vote & Vax outcomes confirm that Vote & Vax polling places are effective locations for delivering flu shots to older adults Vote & Vax, a national program site for expanding vaccination and to members of racial and ethnic SPARC, Inc. of Sickness Prevention Achieved coverage. CDC recommends that minority communities. In 2012, 66 Through Regional Collaboration adults get a flu shot every year, but for example, 45 percent of those vaccination rates remain low. Less receiving flu shots at Vote & Vax clinics (SPARC, Inc.), aims to increase than half of adults aged 50–64 years, identified as African American or the number of Americans who for example, were vaccinated during Latino. About half of White recipients get flu shots by offering them the 2010–2011 winter.67 Flu vaccination and more than two-thirds of African near polling places. rates are even lower among African American and Latino recipients did American and Latino adults in this not regularly get a flu shot, indicating More than 130 million Americans age group.68 Vote & Vax may represent a helpful vote in presidential elections, a large strategy to reduce racial and ethnic proportion of whom are middle-aged Vote & Vax brings flu shots to those vaccination disparities.70 and older adults65—suggesting that who may not regularly visit traditional polling places could be an important vaccination sites, such as hospitals,

56 57 FIGURE 7 HEALTHY Collect community- Prevalence of Selected Chronic Health Conditions wide data to identify among Medicare Beneficiaries Aged 65 and Older, AGING and map health care gaps by Race/Ethnicity, 2013–2014 and high-need areas, such less likely to be vaccinated against as naturally occurring ACTIONS Distribute information both flu and pneumonia than were 0 10% 20% 30% 40% 50% 60% 70% 80% retirement communities. people who had more education and implement programs An estimated one-sixth of households (64 percent versus 72 percent for that address critical health HYPERTENSION with at least one person aged 55 the flu vaccination and 55 percent Educate professionals issues in later life such as HIV. years or older are in naturally versus 63 percent for the pneumonia to identify and address occurring retirement communities Approximately one-quarter of people vaccination). In addition, women of disparities that may be where more than half of neighboring living with HIV in the United States in any race/ethnicity are more likely than exacerbated with age. households also include someone 2012 were aged 55 years and older. men of the same age to have one or DIABETES 55 years or older.72 Community-wide Individuals 50 and older accounted for more physical limitations, and this gap Among older adults, health disparities needs assessment can examine the 18 percent of new HIV diagnoses in 64 are exacerbated by factors such as widens with increasing age. In 2014, 75 services and supports available in 2013. However, many public health 36 percent of adults 65 years of age disabilities, isolated living situations, these communities, including grocery campaigns to address HIV risk focus and older had a disability.71 limited retirement incomes, and other stores, pharmacies, medical facilities, on younger adults and teenagers, age-relevant factors. For example, ASTHMA parks and recreation areas, and and sexual health is rarely discussed Local communities have the people who are aging with a disability White public transit options. Collecting data with older adults in clinical settings, opportunity to reduce health have higher disparities of health regarding the number of older adults perhaps because of provider or Black disparities by building community risk factors like physical inactivity, partnerships that create health living alone, who are at an increased patient discomfort with the topic or Hispanic smoking, hypertension, and obesity risk for depression, physical health negative attitudes about sexuality parity; increasing access to preventive than their counterparts without STROKE 76 problems, and mortality,73,74 can also and aging. Three and a half million services; increasing the capacity of disabilities. CDC is working to address inform community planning decisions. people are chronically infected with health care and prevention workers to these disparities by funding State In 2015, 20 percent of civilian hepatitis C in the United States. Up to address disparities; and implementing Disability and Health Programs and noninstitutionalized men aged 65 and 75 percent of adults infected with the strategies that are culturally, National Centers on Health Promotion older lived alone, and 36 percent of hepatitis C are baby boomers, born linguistically, and age appropriate for for People with Disabilities across the individuals and their caregivers. civilian noninstitutionalized women during 1945–1965, and 50 percent do SOURCE: CDC, National Center for Health United States that will address the Statistics, National Health Interview Survey. lived alone.2,7 not know they are infected. needs of people with physical and intellectual disabilities, including older adults. 58 HEALTHY AGING IN ACTION ELIMINATION OF HEALTH DISPARITIES 59 For example, under the Older the nutrition services programs include Home-Delivered Nutrition Services Americans Act, AoA issues grants for 1) reducing hunger and food insecurity, provides funding for nutritious meals, NUTRITION Congregate Nutrition Services and Home- 2) promoting socialization, 3) the delivery of meals, some nutrition Administration for Delivered Nutrition Services programs promoting health and well-being, and services, opportunities for social Community Living to states, territories, and tribes. States 4) delaying adverse health conditions. engagement (which may decrease and localities augment the federal Congregate Nutrition Services provides feelings of isolation and loneliness), Health Promotion funds significantly. Meals funded funding for the provision of nutritious and in most cases an informal “safety PROGRAMS through the program must meet meals and nutrition-related services in check” for homebound frail and and Nutrition the 2015-2020 Dietary Guidelines for a variety of congregate settings, which isolated older adults. Both programs Programs Americans and the Food and Nutrition helps to keep older Americans healthy specifically target and provide services Board of the Institute of Medicine’s and may decrease or prevent the need to older adults who are in poor health SUPPORT Dietary Reference Intakes. The goals of for more costly medical interventions. and functionally impaired. Department of Health and HEALTHY AGING Human Services FOR MORE INFORMATION → http://www.aoa.gov/AoA_ programs/HPW/Nutrition_ The Administration on Aging provides funding to State Units on Services/index.aspx (AoA), part of the ACL, was Aging and federally recognized tribes. established over 50 years ago States and territories then fund area agencies on aging, which in turn fund by the Older Americans Act to direct service providers. The services support the needs of vulnerable and supports delivered through this older adults. network include nutrition services, transportation, health promotion AoA supports a sophisticated national programs, information and assistance, infrastructure to provide health and numerous caregiver supports such long-term services and support for as respite care, and a number of older adults in the communities where other services. they live. The Older Americans Act

60 61 Moving Forward

62 HEALTHY AGING IN ACTION ADVANCING THE NATIONAL PREVENTION STRATEGY 63 These examples illustrate the paradigm shift from a traditional, Many of the federal and local HAIA illustrates reactive personal health and wellness initiatives highlighted throughout approach to a more modern, this report and in Appendix A are these initiatives are tailored to the the paradigm proactive approach that emphasizes developing metrics to evaluate older adult population and its unique Healthy aging is complex prevention. The traditional approach programmatic goals. At a broader needs and characteristics. Prevention shift from a is also more individualized in nature, level, there is a need to track our and multi-faceted, and the remains vital for older adults already primarily focusing on medical care nation’s progress towards advancing diversity of the nation’s living with a condition or illness in and a patient, whereas the preventive healthy aging for all Americans. A traditional, reactive aging population creates order to mitigate impact and reduce approach is collaborative in nature useful approach may be that of opportunities at the the risk of recurrence. and involves the government, private Healthy People 2020, which uses federal, state, and local personal health and sector, health care organizations, While HAIA points to a path for various federal data sources to levels. To inform efforts communities, families, and individuals achieving the National Prevention establish a current benchmark to promote healthy aging, working together at both the Strategy’s goal of increasing the and set future goals for each wellness approach HAIA provides evidence- community- and individual-level. number of Americans who are healthy indicator of health. Continued based actions and concrete at every stage of life, in order to realize data collection at the federal to a more modern, The actions highlighted in HAIA examples from federal this overarching goal, it is important level, as well as support for also represent an important culture and nonfederal healthy to increase awareness of effective and encouragement of data change in Americans’ perceptions proactive approach aging initiatives across the strategies. Increased awareness would collection at the state and of growing older. The programs country. Many of these help maximize use of these available local levels, would improve referenced in this report and in actions, although targeted strategies and further the dialogue the ability to assess that emphasizes Appendix A, as well as the large towards older adults, could between both public and private whether the United States number of established programs not benefit all members of partners for development of other is meeting milestones mentioned, reflect an environment prevention innovative strategies for healthy aging. towards healthy aging. a community. where the health and safety of older adults is valued and promoted more than ever before. Although preventive health and wellness are important across all stages of life,

64 HEALTHY AGING IN ACTION ADVANCING THE NATIONAL PREVENTION STRATEGY 65 Appendices

66 HEALTHY AGING IN ACTION ADVANCING THE NATIONAL PREVENTION STRATEGY 67 HEALTHY AND SAFE APPENDIX A COMMUNITY ENVIRONMENTS The National Prevention Council → The program addresses at least FEDERAL provides coordination and leadership one aspect of healthy aging, CREATING, SUSTAINING, AND RECOGNIZING COMMUNITIES THAT at the federal level and identifies ways specifically: that agencies can work, individually → Promoting health, preventing PROMOTE HEALTH AND WELLNESS THROUGH PREVENTION HEALTHY AGING and together, to improve our nation’s injury, and managing chronic health. The Council helps each agency conditions INITIATIVES incorporate health considerations Building Community Resilience health and well-being of communities Additional outcomes of the Community → Optimizing physical, cognitive, into decision making, enhances to reduce the negative impacts of Health Resilience Initiative include and mental health to Address Everyday Challenges collaboration in implementing and Reduce the Impact disasters. Resilient communities the creation of a website with a prevention and health promotion → Facilitating social engagement promote individual and community community guide and toolkit. More of Disasters initiatives, and facilitates sharing physical, behavioral, and social than 250 stakeholders contributed → Local, state, and federal of best practices. This Appendix Community Health health to strengthen their capacity to these resources. The website has stakeholders, including public highlights healthy aging initiatives in Resilience Initiative to address daily, as well as extreme, community resilience resources and health officials, aging services action across the National Prevention DEPARTMENT OF challenges. A resilient community activities listed for all communities professionals, health care HOMELAND SECURITY Council departments and agencies. is socially connected and has and populations. While the guide and providers, city and county officials, The Community Health Resilience accessible health systems that are toolkit are useful for any population, The initiatives highlighted in this and older adults, can participate in Initiative of the Department of able to withstand disaster and foster they will include aging-specific Appendix were selected because they the program, benefit from technical Homeland Security (DHS) helps community recovery. resources in the future. meet the following criteria: assistance and other resources, or prepare communities to take replicate or adapt the program. The Community Health Resilience → The program promotes prevention collective action after an adverse FOR MORE INFORMATION: Initiative includes the Geriatric/Elder These initiatives are organized by event using resources that have been and aligns with at least one of the http://chri.inl.gov Disaster Resilience Group that meets → four Strategic Directions of the the National Prevention Strategy’s developed to reduce the impact of monthly via phone and through National Prevention Strategy. four Strategic Directions; however major disturbances and help protect webinars to share information many align with more than one people’s health. Older adults are the target of the from community leaders who have → Strategic Direction. program, or it has the promise of DHS’ focus on community resilience experienced and responded to being effective for older adults. involves enhancing the day-to-day natural disasters.

68 HEALTHY AGING IN ACTION 69 Promoting Cognitive Health of cognitive health with the long-term missions and planning; understanding in Aging goal of maintaining or improving the among health care partners about cognitive performance of all adults. In assessment tools and the caregiver’s The Department of Justice (DOJ) At the White House Conference on Healthy Brain Initiatives 2013, CDC released The Healthy Brain health and role in care management; provides older adults and their families Aging, DOJ’s National Institute of Equipping Older Adults DEPARTMENT OF HEALTH AND Initiative: The Public Health Road Map and understanding of cognition and with resources to educate and prevent Justice and its Elder Justice Initiative and Their Families to HUMAN SERVICES for State and National Partnerships, resources available among public abuse or exploitation of older adults. announced it will fund a multi-year Prevent and Respond HHS released an update to their 2013–2018, which outlines how state health organizations and partners. An estimated 2 to 10 percent of pilot project in 2016 to evaluate to Elder Abuse National Plan to Address Alzheimer’s and local public health agencies and older adults are the victims of elder potential means to avoid and respond Twice as many Americans fear the Disease in August 2016. The Plan their partners can promote cognitive mistreatment, including physical to elder mistreatment. In addition, on loss of mental capability as fear Resources to Prevent Elder addresses the major challenges functioning, address cognitive Abuse and Exploitation diminished physical ability. The 2015 abuse, emotional abuse, sexual August 8, 2016, DOJ published a final presented by Alzheimer’s disease impairment for individuals living in the World Alzheimer Report by Alzheimer’s DEPARTMENT OF JUSTICE abuse, exploitation, neglect, or rule expanding the ability of victim- and outlines and tracks the various community, and help meet the needs Disease International estimates that abandonment. Establishing accurate serving agencies and organizations goals and activities—from advancing of caregivers. the total worldwide cost of dementia estimates, however, is complicated across the nation to reach and scientific collaboration to improving CDC established the Healthy Brain exceeded $800 billion in 2015, because of state variations in the serve more crime victims at a time patient care—now undertaken with Research Network in 2014 to strengthen including informal care provided by definition of elder mistreatment, of substantial increases in victim- increasing collaboration within the linkages between CDC’s Prevention family and others, social care provided federal government and between the absence of a national database, assistance funding. Victims of Crime Research Centers and the public health by community care professionals, and 25 the public and private sectors. The and underreporting. Many of DOJ’s Act (VOCA) funding directed to the and aging service professionals in direct costs of medical care. Family Administration on Community Living initiatives have been in direct response states for victim assistance has more states and communities. To implement members often play a key caregiving (ACL) developed a public service to something that has happened, than quadrupled in the last two fiscal public health actions at state and local role, especially in the initial stages campaign, What is Brain Health, to prompting action or defense on behalf years. Under the final rule, programs levels, CDC is funding the “Healthy of what is typically a slow decline. spread awareness about brain health of an individual or group of individuals. that serve victims of elder abuse and Brain Initiative: Implementing Public U.S. researchers estimate that the and provide people with helpful other crimes that can affect older Health Actions Related to Cognitive annual value of informal caregiving In 2014, the Department of tips that may reduce some risks to adults, such as financial fraud, are Health, Cognitive Impairment, and for dementia in the United States Justice released the Elder Justice their brains. eligible for VOCA funding. Caregiving at the State and Local is $221 billion. Roadmap, a set of consensus policy CDC’s Healthy Brain Initiative (HBI) Levels.” Two awardees, the Alzheimer’s recommendations. The White House is an Alzheimer’s-specific segment Association and The Balm in Gilead, FOR MORE INFORMATION: FOR MORE INFORMATION: Conference on Aging built on these of CDC’s Healthy Aging Program. Inc., selected through a competitive → http://nij.gov/topics/crime/elder- → HBI: http://www.cdc.gov/aging/pdf/ recommendations to identify elder Through the HBI, CDC’s Alzheimer’s application process, began their abuse/Pages/welcome.aspx thehealthybraininitiative.pdf justice as a priority issue and further Disease and Healthy Aging Program projects in October 2015. Anticipated and the Alzheimer’s Association short-term outcomes within the next elevate this important topic. Road Map: http://www.cdc.gov/ 2 years include increased evidence for → formed a partnership in 2005 to aging/healthybrain/roadmap.htm examine how best to bring a public public health interventions; integration health perspective to the promotion of cognitive health into organizational

70 HEALTHY AGING IN ACTION 71 CLINICAL AND COMMUNITY Providing Tools to Assess At the White House Conference on prompt providers to screen for fall Risk and Prevent Falls in Aging, CDC released the STEADI risk; assess gait, strength, and balance; PREVENTIVE SERVICES Older Adults (Stopping Elderly Accidents, Deaths optimize medication; determine the & Injuries) initiative to further reduce need for follow-up; and allow clinic Fall Prevention the risk of falls. STEADI includes staff to document assessment results ENSURING THAT PREVENTION-FOCUSED HEALTH CARE DEPARTMENT OF HEALTH AND materials developed specifically for and treatment plans. HUMAN SERVICES AND COMMUNITY PREVENTION EFFORTS ARE AVAILABLE, primary care providers. These include CDC developed a Compendium of The Administration on Aging, a established clinical guidelines and INTEGRATED, AND MUTUALLY REINFORCING Effective Fall Interventions, describing program division within ACL, awarded tested interventions designed to help 41 scientifically tested and proven Evidence-Based Falls Prevention Grants health care providers integrate falls fall prevention interventions with totaling over $4.8 million—funded by screening, assessment, and referral The National Park Service’s Healthy activities and initiatives have been relevant details for organizations the 2014 Prevention and Public Health to community-based fall prevention Making Park Parks Healthy People (HPHP) program documented in national parks, with looking to implement a program. Fund—to advance implementation and programs into their daily practice. Use Part of reframes the role of parks and public half of them in collaboration with The interventions are grouped lands as a powerful health prevention health partners. Park settings provide dissemination of evidence-based falls Healthy Aging The STEADI toolkit walks health care into four categories: exercise, prevention programs and strategies strategy. This renewed focus on recreational experiences such as providers through assessing a patient’s home modification, clinical, and across the nation. These projects are Healthy Parks health is meant to generate a lifelong walking, hiking, bicycling, cross-country fall risk, educating patients, selecting multi-faceted. Healthy People designed to increase participation in impact on Americans’ lifestyle choices skiing, fishing, nature viewing, wading, interventions, and following up. It DEPARTMENT OF evidence-based community programs and their relationship with nature paddling, and swimming that promote provides a simple algorithm for falls THE INTERIOR to reduce falls and falls risk while FOR MORE INFORMATION: and the outdoors. HPHP works with personal health and well-being. screening, assessments, treatment, also increasing the sustainability of → STEADI: http://www.cdc.gov/steadi/ national, state, and local parks, as Providing access to parks for healthy and follow-up. CDC is working with such programs through innovative index.html well as business innovators, health recreational activities can address the vendors of electronic health records funding arrangements. The projects care leaders, scientists, foundations, disproportionate burden of health (EHR) to develop STEADI-based fall → Compendium of Effective Falls will specifically target adults at risk for and advocacy organizations to foster issues among older adults. http://www.cdc.gov/ prevention clinical decision support Interventions: falls, particularly older adults, including homeandrecreationalsafety/falls/ and build upon the role that parks modules, and some health care sites A pillar of HPHP is the Healthy and American Indian, Alaska Native, and compendium.html play in the physical, mental, and have already incorporated STEADI Sustainable Food Program (HSFP), Native Hawaiian elders, as well as emotional health of our society. into their EHR systems. The modules which was established in 2011. It adults with disabilities. Since HPHP’s inception, more than provides standards, guidelines, 400 park-based health promotion

72 HEALTHY AGING IN ACTION 73 CMS’s Medicare Learning Network can help providers discuss these Resources for Talking Preventive Services program aims benefits with their patients. Benefits About Coverage of to equip community providers are continuously updated pursuant to Preventive Services with resources that they can use the recommendations of the USPSTF tools, and resources for parks and disorder, diabetes, post-traumatic has established an annual National to help them talk to patients about and, for coverage of new preventive concessioners to help ensure that stress disorder, and other ailments ParkRx Day to be celebrated in April Medicare Learning Medicare-covered preventive services. services, a national coverage Network Preventive older Americans and all visitors have that have been shown to be reduced on the last day of National Park Week. Preventive health benefits comprise determination. CMS encourages Services Program healthy food options and that the through increased physical activity and A National ParkRx website (ParkRx. a broad category of services covered community leaders and public health DEPARTMENT OF National Park Service uses sustainable exposure to green space. org) provides resources, tools, HEALTH AND HUMAN by Medicare and include cancer officials to host campaigns and fairs food sourcing and service practices to and case studies to help grow the SERVICES screenings, vaccines, and tobacco that get the word out about covered The National Park Service, National reduce its environmental footprint. movement nationally. cessation counseling, among others. preventive benefits—e.g., “ask your Recreation and Park Association, and Generally, for Medicare to cover doctor about ____” or vaccination fairs ParkRx (park prescriptions) the Institute at the Golden Gate serve FOR MORE INFORMATION: a preventive service, the service at the start of the flu season. ParkRx programs are designed in as co-leaders and conveners of the must have a grade A or B from the collaboration with park managers, National ParkRx Initiative. To date, → Healthy Parks Healthy People U.S. Preventive Services Task Force health care providers and community this coalition has inventoried 32 park US Initiative: https:// FOR MORE INFORMATION: www.nps.gov/public_health/hp/ (USPSTF). More recently, independent partners that use parks, trails, and prescription programs across the → https://www.cms.gov/Outreach- hphp.htm of but related to preventive benefits, open space for the purpose of country, including 14 park prescription and-Education/Medicare-Learning- → Park Rx: www.ParkRx.org the Affordable Care Act has made the Network-MLN/MLNProducts/ improving individual and community efforts in national parks. The National annual wellness visit a covered service PreventiveServices.html health for all people, children to ParkRx Initiative partners are working for Medicare beneficiaries. seniors. Community health clinics, together to build on early successes doctors, and nonprofit organizations and lessons learned to support The Medicare Learning Network connect communities to parks through broader park and community-based gives community providers a list of a ParkRx to combat chronic disease, application of park prescriptions benefits that Medicare covers, as obesity, depression, attention deficit nationally. The National Park Service well as booklets and fact sheets that

74 HEALTHY AGING IN ACTION 75 Guidelines for Identifying Older older consume no more than one limitations might interfere with Americans at Risk for Alcohol standard drink per day or seven management of opioid therapy (for 80 and Substance Use Disorders standard drinks per week. These older adults in particular) and, if so, Clinical preventive services, including measure includes influenza and recommendations are consistent determine whether a caregiver can Gauging Older cancer screenings and immunizations pneumonia immunizations and Prescribing and Dispensing with the current evidence weighing responsibly co-manage medication Controlled Substances Adults’ Use of for flu and pneumonia, can prevent colorectal cancer screening. For the risks and beneficial health therapy. CDC has provided a DEPARTMENT OF HEALTH AND disease or help to detect disease early, women, breast cancer screening is effects of drinking.81,82 To put these Checklist for Prescribing Opioids for Screenings and HUMAN SERVICES when treatment is more effective. also included. recommendations into perspective, Chronic Pain as well as a website with Vaccinations Greater use of these services could Screening and, where appropriate, the USDA and HHS guidelines for additional tools to guide clinicians in The up-to-date measure is analogous Up-to-Date prevent thousands of deaths among brief intervention or referral to adults younger than age 65 are as implementing the recommendations. to one commonly used to report the Measure: Clinical older Americans each year.77 However, treatment by medical providers follows: up to one drink per day for In addition, clinicians should discuss Preventive Services percentage of children up to date with only about one-third of adults aged is essential for identifying older women and up to two drinks per day the importance of reassessing safer DEPARTMENT pediatric immunizations. It provides 50–64 years and less than half of those Americans at risk for alcohol and for men. One drink is defined as 12 medication use with both patients OF HEALTH AND a practical summary score that helps substance use disorders, overdose, HUMAN SERVICES aged 65 and older are up to date fluid ounces of regular beer, 5 fluid and caregivers. public health professionals and others on a selected set of recommended and death from complications. ounces of wine, or 1.5 fluid ounces of identify gaps, assess disparities, Older people with substance use screenings and immunizations. Alcohol use becomes more risky with distilled spirits.83 and gauge progress to ensure that aging, and drinking levels differ for disorders including alcohol and CDC developed a composite measure older adults receive these potentially older adults and younger adults. The Guidelines for Prescribing and prescription drug addictions can and Dispensing Controlled Substances to help close the gap in preventive life-saving services. It is a measure Substance Abuse and Mental Health should be engaged with treatment Prior to prescribing or dispensing service delivery for older Americans. of progress in meeting the Healthy Services Administration’s Center for services. Medication-assisted therapy controlled substances, providers and This composite measure, known as People 2020 national health objectives. Substance Abuse Treatment (CSAT) with FDA-approved medicines and pharmacists should check Prescription the “up-to-date measure,” assesses recommends that everyone over 60 be counseling is effective for opioid use Drug Monitoring Programs to identify the extent to which older adults FOR MORE INFORMATION: screened for alcohol and prescription disorders and alcohol addiction. are up to date on a critical set of whether an older American is receiving → https://www.healthypeople.gov/2020/ drug use and abuse annually as part of 78 controlled substances at doses or in clinical preventive services. For men topics-objectives/topic/older-adults regular health care services. FOR MORE INFORMATION: and women aged 65 and older, the combinations that might put them at https://www.cdc.gov/mmwr/ Guidelines for Alcohol Consumption risk of a drug poisoning–related injury. → volumes/65/rr/rr6501e1.htm for Older Adults The CDC guideline on opioid therapy The National Institute on Alcohol Abuse contains specific recommendations 79 and Alcoholism (NIAAA) and CSAT for those over 65.84 It also suggests recommend that people age 65 and providers consider whether cognitive

76 HEALTHY AGING IN ACTION 77 EMPOWERED PEOPLE

SUPPORTING PEOPLE IN MAKING HEALTHIER CHOICES Helping Older Adults Avoid Law Enforcement Health Scams and Other Fraud The Federal Trade Commission (FTC) enforces laws that require advertising Education about Health Care Scams to be truthful, substantiated, and FEDERAL TRADE COMMISSION not misleading. Several recent law disease and related deaths.86 An consult the Air Quality Index before health care providers to participate Air Quality and Heart Health: Elder Financial Exploitation enforcement actions focused on updated scientific statement in 2010 engaging in outdoor activities. The in the program and of patients Making the Connection As a result of the White House the deceptive marketing of health- reported even stronger evidence program also provides education to use the Air Quality Index when Conference on Aging, in March 2016 related products and services to Healthy Heart Program for the cardiovascular health to health care providers through planning outdoor activities. The EPA the Consumer Financial Protection older adults and others. These cases U.S. ENVIRONMENTAL consequences of particulate matter.87 webinars, presentations, and other plans to disseminate their message challenged false or unsupported PROTECTION AGENCY In response, in 2012 the EPA launched activities about the importance of to other groups, including public Bureau (CFPB) released an Advisory for Financial Institutions on Preventing claims that 1) brain-training programs The Healthy Heart program of the the Healthy Heart program. discussing environmental air quality health officials, hospital discharge and Responding to Elder Financial would improve cognitive function in U.S. Environmental Protection Agency with their patients. For example, planners, and physical rehabilitation Healthy Heart program activities persons with age-related memory aims to raise awareness among health EPA continues to partner with CDC’s facilities. A future goal is to evaluate Exploitation. This advisory will focus on increasing environmental care providers and the American Million Hearts® initiative, which aims their communication strategies in help financial institutions prevent, decline, dementia, and Alzheimer’s health literacy through messaging public about the link between air to prevent 1 million heart attacks terms of changing providers’ and the recognize, and report elder financial disease; 2) a “clinically proven” dietary and sharing key facts and resources pollution and cardiovascular health. and strokes by 2017; the American public’s behavior. abuse. When seniors fall victim supplement would improve memory with stakeholder groups. The Healthy Cardiovascular disease contributes to Heart Association; and the American to a scam or to theft by a trusted and prevent cognitive decline; and 3) Heart program’s website includes disabilities, high health care costs, and College of Cardiology. Healthy Heart family member, they may be too copper-infused compression garments a variety of resources, including a FOR MORE INFORMATION: poor quality of life, and it is the leading is also working with CDC, the U.S. would relieve chronic or severe pain toolkit, public service announcement, → https://www.epa.gov/air-research/ embarrassed or too frail to pursue cause of death among adults aged Forest Service, and DOI to learn more and access to the growing scientific healthy-heart-toolkit-and-research legal action or even to report that they due to arthritis, multiple sclerosis, 65 and older.85 In 2004, the American about the cardiovascular health evidence showing the link between have suffered harm. So it is crucial and fibromyalgia. In addition, the Heart Association published its first consequences of wildfires smoke particulate-matter air pollution and that others are looking out for them. agency sued telemarketers who used scientific statement concluding that among vulnerable populations and, in cardiovascular health. Financial institutions are especially false claims and coercive practices to short-term and long-term exposure particular, older adults. well-positioned to prevent such fraud. get consumers to pay for unwanted to particulate-matter air pollution The program encourages Americans, Program leaders report that they increases the risk for cardiovascular especially those who are older, to are encouraged by the willingness of

78 HEALTHY AGING IN ACTION 79 medical alert devices, and another The materials that make up the Pass FOR MORE INFORMATION: Creating Opportunities for For example, research indicates and Senior Companion programs, telemarketer whose employees posed It On campaign are just part of FTC’s → Cited cases available at that volunteering in later life fosters which are older volunteers with annual as Medicare representatives and used extensive online and print information Low-Income Older Adults to www.ftc.gov higher levels of activity, increased use incomes below 200 percent of the Contribute to the Community false claims to get access to banking in English and Spanish designed to of preventive health services, and a federal poverty level, also provide → https://www.consumer.ftc.gov/ account information. help people make informed decisions scam-alerts Senior Corps greater sense of making a positive stipends to participants. Data collected about health claims and avoid scams. impact for future generations. from grantees indicate that Senior Education about Health Care Scams CORPORATION FOR NATIONAL AND To maximize its outreach efforts, → https://www.consumer.ftc.gov/topics/ COMMUNITY SERVICE Corps volunteers are very diverse by The FTC’s bilingual Pass It On campaign FTC staff work with an informal health-fitness CNCS provides grants and technical race, ethnicity, and socioeconomic (Pásalo in Spanish), tailored to Seniors Corps, an initiative of assistance to local governments, network of about 16,000 community- status. Competitive grant opportunities people aged 65 and older, provides → https://www.consumer.ftc.gov/blog/ the Corporation for National and nonprofit organizations, heath care based organizations and national will continue to ensure the widespread spotting-elder-financial-abuse Community Service (CNCS), provides information about health care scams systems, area agencies on aging, availability of the program, such as groups that order and distribute opportunities for adults aged 55 and other frauds that affect older faith-based organizations, and the more than $3 million in funding FTC information to their members, and older to contribute to their adults. Campaign materials inform other community entities to engage for tribal communities announced clients, and constituents. In 2015, the communities through three programs: older adults in volunteering. Senior and empower readers to protect in 2015. Senior Corps volunteers FTC distributed more than 17 million the Senior Companion Program, the Companions assist with activities of themselves and resolve problems; they can also support the work of other free publications to individuals Foster Grandparent Program, and daily living and provide friendship to do not suggest, however, that readers federal initiatives, such as DOT’s Rides and organizations. the Retired and Senior Volunteer older adults at risk of nursing home are necessarily frail or vulnerable to Wellness. Program (RSVP). Recognizing the placement. Foster Grandparents because of their age. The print and The FTC encourages consumers to valuable contributions of older mentor, tutor, and care for children FOR MORE INFORMATION: video materials encourage people to help fight fraud by reporting potential volunteers to schools, nonprofits, and youth in schools, juvenile share the information with friends, scams to www.ftccomplaintassistant. and other community organizations, detention centers, and other settings. → http://www.nationalservice.gov/ especially less active friends who gov (available in English and Spanish). the Senior Corps programs were Participants in the RSVP program programs/senior-corps may not come to the library or senior In 2014, of the 2.5 million consumer launched more than 40 years ago. engage in a variety of activities and center to receive it firsthand. In 2015, complaints the FTC received, almost Substantial empirical evidence shows address a range of needs in their that volunteering not only benefits individuals, senior centers, and other 38,000 were about health products communities. The Foster Grandparent communities, but also the volunteer. community groups ordered more than and services. 3 million Pass It On publications.

80 HEALTHY AGING IN ACTION 81 The Office of Personnel Management well-being of an older adult. In state of well-being and add years of affect job performance, health, and and interventions; obesity screening Promoting a (OPM) is the federal government’s lead conjunction with the White House active living to their lives. Elements personal well-being to optimize an and counseling; and fall prevention. Healthy Workforce human resources agency. Through Conference on Aging, OPM released of these programs include agency organization’s success. EAP services Phased Retirement OPM’s initiatives, programs, and the Handbook on Workplace Flexibilities policies, educational materials and include assessments, counseling, Phased Retirement is an innovative Healthy Aging materials, the federal government and Work-Life Programs for Elder events, physical activity opportunities, and referrals for additional services Initiatives within the alternative to traditional retirement, Federal Workforce seeks to recruit and hire the best Care, which provides assistance lifestyle counseling, screenings, to employees with personal and/or in which an eligible employee receives talent; train and motivate employees and demonstrates how flexibilities assessments, and immunizations. They work-related concerns, such as stress, U.S. OFFICE OF a partial annuity and keeps accruing PERSONNEL to achieve their greatest potential; and programs available to federal address a wide range of health needs, financial issues, legal issues, family additional service credit toward their MANAGEMENT and constantly promote an inclusive employees support employees who such as tobacco cessation, nutrition, problems, office conflicts, and alcohol final annuity. The employee also work force defined by diverse are providing elder care for a family physical activity, weight management, and substance abuse. spends 20 percent of his or her time perspectives. This includes promoting member. Additionally, this handbook supports for nursing mothers, stress Federal Employees Health in mentoring activities to facilitate the and supporting healthy aging provides various tools for employees management, depression, high blood Benefits (FEHB) Program transfer of their knowledge and skills initiatives within the federal workforce. to use in preparing and planning for pressure, high cholesterol, diabetes, The FEHB program provides quality to other employees within the agency. Below is a glimpse at just a few of time off for elder caregiving. It must and vaccine-preventable diseases. health care benefits for the federal Each agency has the flexibility to the programs: be read in conjunction with agency Employee Assistance Programs (EAP) family to optimize health at every implement the mentoring component and component-specific flexibilities Alternative Work Schedules Employee Assistance Programs (EAPs) stage of life. All preventive services in a way that is best for the agency and program policies and, to the OPM developed a Handbook on can be instrumental in helping recommended with an A or B rating and employees. Through Phased extent they comport with applicable Alternative Work Schedules to provide employers, aging and older workers, by the U.S. Preventive Services Task Retirement, employees can design a law, and any applicable collective a framework for federal agencies to caregivers, and/or managers. EAPs Force, as well as immunizations smooth transition into the next phase bargaining agreements. consult in establishing alternative offer needed supports to assist recommended by the Advisory of their lives, and agencies across work schedules—such as flexible Worksite Health and Wellness experienced workers who have years Committee on Immunization Practices government can get a head start on and compressed schedules—and The leading causes of death and of valuable service left in managing (ACIP), and Women’s Health Services succession planning. to provide additional information disabilities in the United States are life concerns. Each federal executive specified in guidelines issued by the to assist agencies in administering preventable. The federal government branch agency has an EAP—a HRSA are covered with no cost share. FOR MORE INFORMATION: such programs. is committed to implementing voluntary, confidential program Services include screening for diabetes, → https://www.opm.gov/policy-data- comprehensive health and wellness that helps employees (including high blood pressure, cholesterol, oversight/worklife/health-wellness/ Elder Care programs that help employees and management) work through various osteoporosis, lung cancer, and Caregivers can be an integral part their families modify their lifestyles life challenges that may adversely depression; tobacco use counseling of maintaining the health and and move toward an optimal

82 HEALTHY AGING IN ACTION 83 ELIMINATION OF HEALTH DISPARITIES Through Community-Based Falls the Prevention and Public Health Fund, From Falls Prevention Prevention Programs, ACL/AoA ACL/AoA has been able to provide provides funding to organizations support for falls prevention programs to Brain Health— IMPROVING THE QUALITY OF LIFE FOR ALL AMERICANS implementing evidence-based falls in community settings across Programs Support prevention programs in community the country. Healthy Aging settings. Grantees are implementing programs such as A Matter of Balance, For more than a decade, ACL/AoA Americans of all ages and abilities to The Active Aging Initiative also Administration for Promoting Physical Activity Stepping On, and Tai Chi for Arthritis. has invested in organizations that Community Living Health be physically active and eat well. supports other federal efforts, are implementing Chronic Disease and Healthy Eating Among Promotion and Nutrition ACL also funds the National Falls including Step It Up! The Surgeon Self-Management Education (CDSME) Older Americans Programs Prevention Resource Center, currently The Active Aging Initiative involves General’s Call to Action to Promote housed at the National Council on programs. These evidence-based partnerships in the public and private DEPARTMENT OF HEALTH Walking and Walkable Communities, the programs provide older adults with Active Aging Initiative AND HUMAN SERVICES Aging’s Center for Healthy Aging, which sectors, including AARP, the National National Institute on Aging’s Go4Life® DEPARTMENT OF HEALTH AND works to 1) increase public education education and tools to help manage Senior Games Association, and Campaign, and the CDC’s Mall Walking: HUMAN SERVICES about the risks of falls and how to chronic conditions such as diabetes, the International Council on Active A Program Resource Guide. Finally, the prevent them; 2) support and stimulate heart disease, arthritis, HIV/AIDS, and The President’s Council on Fitness, Aging. Continuing Care Retirement Active Aging Initiative complements depression. Over its history, ACL/ Sports & Nutrition, under the Office the implementation and dissemination Communities (CCRCs) are key the work of the President’s Council’s of evidence-based community AoA has funded organizations in 47 of the Assistant Secretary for Health, collaborators at the local level. The I Can Do It, You Can Do It! program, states to coordinate and run these coordinates the Active Aging Initiative programs and strategies to reduce President’s Council is working with which facilitates and encourages falls incidence; and 3) coordinate programs. Grantees (financed by to educate, engage, and empower all the Stanford Center on Longevity in opportunities for children and adults the Prevention and Public Health Americans—including those aged 50 the national Falls Free® initiative, their efforts to disseminate the state with disabilities to engage in regular which includes the promotion of Falls Fund) are providing evidence-based and older—to lead a healthy lifestyle of science on fitness and aging and to physical activity and make healthy chronic disease self-management that includes regular physical activity Prevention Awareness Day, and the address barriers to physical activity food choices. implementation of a comprehensive education and self-management and good nutrition. The Council was among older adults. In addition to National Action Plan for reducing older support programs including The originally established by President coordinating the outreach activities FOR MORE INFORMATION: adult falls in the United States. One Diabetes Self-Management Program; Eisenhower in 1956, as the President’s of federal and nonfederal partners, in three adults 65 and older will fall Chronic Disease Self-Management Council on Youth Fitness. In recent the Active Aging Initiative engages → http://www.fitness.gov/resource- every year, which can lead to injury, Program; EnhanceWellness; HomeMeds; years, and particularly with the Council in media and other community center/research-and-reports/ hospitalization, loss of independence, and Program to Encourage Active, celebrating its 60th anniversary awareness campaigns. Rewarding Lives for Seniors (PEARLS). in 2016, the focus has evolved and even death. Through funding from to incorporate strategies to help

84 HEALTHY AGING IN ACTION 85 HUD’s Supportive Services that are selected to participate in the Coordinating Demonstration is providing 3-year demonstration will implement an Supportive Services grants to owners of HUD-assisted enhanced service coordination model senior housing to support an in the same way in all sites, guided to Help Older Adults ACL/AoA has also funded a National Institute of Neurological Disorders FOR MORE INFORMATION: enhanced service coordinator and by a training manual and resources CDSME Resource Center, housed at and Stroke at the National Institutes → Current ACL/AoA Age in Place wellness nurse to help low-income developed by HUD and its partners. the National Council on Aging’s Center of Health, and CDC’s Healthy Aging older adults age in place and avoid Selected housing developments grantees: http://www.aoa. Supportive Services for Healthy Aging. The Resource Program—are split into four modules: acl.gov/AoA_Programs/HPW/ Demonstration for nursing home placement. HUD’s will also agree to participate in a Center’s activities include 1) training Falls_Prevention/index.aspx Elderly Households Section 202 Supportive Housing multi-year randomized assignment 1. Brain health basics (e.g., and technical assistance for state and in HUD-Assisted for the Elderly program, which study to develop evidence about the resources to help professionals → Current ACL/AoA CDSME community-based organizations on Multifamily Housing provides subsidized housing to effectiveness and sustainability of this and organizations educate older grantees: http://www.aoa. implementing, scaling, and sustaining U.S. DEPARTMENT OF low-income tenants aged 62 and new model. gov/AoA_Programs/HPW/ CDSME programs; 2) serving as the adults and their families on how HOUSING AND URBAN ARRA/PPHF.aspx older, is the largest publicly funded to promote a healthy brain) DEVELOPMENT national clearinghouse of resources rental assistance program for older Although only select applicants will and best practices for CDSME → http://www.eldercare.gov/ 88 participate in the demonstration, 2. Medication management (e.g., adults. HUD has been funding programs; and 3) offering workshops service coordinators in Section 202 the resources developed as part of resources for presentations on → http://www.brainhealth.gov and presentations on CDSME to aging this project, including standardized medications and aging) buildings in which at least 25 percent and public health stakeholders. of residents are frail or at risk assessment, training manuals, and 3. Traumatic brain injury (e.g., for institutionalization. best practice guides, will be available ACL has a variety of brain health educational brochures about to all HUD-assisted properties. resources titled Brain Health as You preventing TBI) In January 2016, the department Age: You Can Make a Difference, announced a funding opportunity for FOR MORE INFORMATION: and created a national public service 4. Dementia (e.g., issue briefs on HUD-assisted developments to apply → http://www.grants. campaign called What is Brain available long-term services and for a subsidy to cover all of the costs gov/view-opportunity. Health? The brain health resources— supports for dementia) of providing a full-time enhanced html?oppId=281074 developed by the AoA, National service coordinator and half-time Institute on Aging and National Spanish versions of certain brain wellness nurse, and some of the health basics resources are available. costs of services for older residents. Applications were due in April 2016, and grant recipients will be announced by September 2016. The developments

86 HEALTHY AGING IN ACTION 87 Since 1972, the VA has been running into nursing home care settings, but supervised exercise 3–5 days a week, findings observed by the Durham Supporting Veterans the Home-Based Primary Care (HBPC) did not have the financial or social tailored to functional impairments and VA program. With funding from the program, a model that enhances the resources available for the care patient-directed goals. The primary Office of Rural Health and GEC, these as They Age health and well-being of veterans. needed to remain safely in their aim is to improve the health, physical programs are exporting Gerofit to Alternative Care Models Interdisciplinary, primary care teams own home. The program is now in function, and well-being of older partnering VA Community-Based DEPARTMENT OF consisting of a primary care physician, 45 states and territories and serves veterans. The program was originally Outpatient Clinics via video classes, VETERANS AFFAIRS nurse, social worker, mental health approximately 1,000 veterans a day established in the Durham VA in 1986. telephone follow-up, and adult day professional, rehabilitation therapist, (with a documented need for 5,000). The Geriatric Research, Education, and care exercise programming. dietitian, and pharmacist work Veterans pay on average $2,400 a Clinical Center and VA Medical Center

with patients who have long-term, month to be cared for in another in Durham, North Carolina, jointly FOR MORE INFORMATION: multiple medical and disabling health individual’s home, while VA provides support the program. The Durham → Home-Based Primary Care: conditions. Patients receive care from Home-Based Primary Care services, program documented a 5-year http://www.va.gov/geriatrics/ HBPC for approximately 3–5 years. caregiver training, and program reversal of functional trajectory and guide/longtermcare/ Evaluations of this program suggest it oversight. The home must not be 25 percent lower mortality rate over home_based_primary_care.asp can contribute to positive outcomes, caring for more than three individuals, 10 years among program participants including a 25 percent reduction including family members, at any one in comparison to nonparticipants. → Medical Foster Home: http:// in combined VA plus Medicare time. Veterans are provided any care In 2013, Gerofit began expanding to www.va.gov/geriatrics/guide/ hospitalizations, 36 percent reduction assistance they may need, including other VAs across the country with longtermcare/ in combined VA plus Medicare hospital help with activities of daily living. For support from the Office of Geriatrics medical_foster_homes.asp days, and 13 percent reduction in many veterans who need a nursing and Extended Care (GEC). Seven new combined VA plus Medicare total home level of care, MFH provides an Gerofit programs across the United → Gerofit: http://www.va.gov/ costs, after accounting for the cost of alternative that is safe, preferable to States—in Baltimore, Maryland; geriatrics/gerofit/ gerofit_Home.asp the intervention.89 many veterans, and about half the Canandaigua and Rochester, New total cost of care in a nursing home. York; Los Angeles, California; Honolulu, The VA first piloted theMedical Hawaii; Miami, Florida; and Salem, Foster Home (MFH) model in 2000 in Gerofit is a group-based exercise Virginia—are replicating clinical Little Rock, Arkansas, in response to and health promotion program for veterans who did not want to move veterans aged 65 and older that offers

88 HEALTHY AGING IN ACTION 89 19 Transportation for America. Seniors and Transit 32 Centers for Medicare & Medicaid Services. Medicare 43 National Alliance for Caregiving, AARP Public [website]. Available at http://t4america.org/maps-tools/ Part D Overutilization Monitoring System (OMS) Policy Institute. Caregiving in the U.S. 2015. seniorsmobilitycrisis2011//. Accessed September 2, Summary. 2015. Available at https://www.cms.gov/ Available at http://www.caregiving.org/wp-content/ 2016. Newsroom/MediaReleaseDatabase/Fact-sheets/2015- uploads/2015/05/2015_CaregivingintheUS_Final-Report- Fact-sheets-items/2015-11-03.html. Accessed August June-4_WEB.pdf. Accessed August 31, 2016. 20 Syed ST, Gerber BS, Sharp LK. Traveling towards 30, 2016. disease: transportation barriers to health care access. 44 Stahl T, Rutten A, Nutbeam D, Bauman A, Kannas J Community Health. 2013 Oct;38(5): 976-93. doi: 33 Centers for Disease Control and Prevention. L, Abel T, et al. The importance of the social 10.1007/s10900-013-9681-1 Important facts about falls. 2015. Available at http:// environment for physically active lifestyle: Results www.cdc.gov/homeandrecreationalsafety/falls/adultfalls. from an international study. Soc Sci Med. 2001;52:1- APPENDIX B 21 Ellis E. Mobility management. Washington, DC: AARP html. Accessed August 31, 2016. 10. Public Policy Institute; 2009. Available at http://assets. 1 National Center for Health Statistics. Health 10 Keysor JJ, Jette AM, LaValley MP, Lewis CE, aarp.org/rgcenter/ppi/liv-com/roundtable_091013_ 34 Moyer VA. Prevention of falls in community-dwelling 45 Nelson ME, Rejeski WJ, Blair SN, Duncan PW, Judge U.S. 2015, Trend Tables—Table 15. Available Torner JC, Nevitt MC, Felson DT. Community mobility.pdf. Accessed August 31, 2016. older adults: U.S. Preventive Services Task Force JO, King AC, et al. Physical activity and public health at http://www.cdc.gov/nchs/data/hus/hus15.pdf. environmental factors are associated with recommendation statement. Ann Intern Med. in older adults: Recommendation from the American REFERENCES Accessed August 31, 2016. disability in older adults with functional 22 Geller AM, Zenick H. Aging and the environment: 2012;157(3):197-204. College of Sports Medicine and the American Heart limitations: The MOST Study. J Gerontol A Biol A research framework. Environ Health Perspect. Association. Circulation. 2007;116(9):1094. 2 Federal Interagency Forum on Aging-Related Sci Med Sci. 2010;65A:393-9. 2005;113(9):1257-62. doi: 10.1289/ehp.7569. 35 Tinetti ME, Williams CS, Gill TM. Dizziness among Statistics. Older Americans 2016: Key older adults: A possible geriatric syndrome. Ann 46 Hinterlong J. Racial disparities in health among older indicators of well-being. Washington, DC: U.S. 11 Physical Activity Guidelines Advisory 23 Fernandez LS, Byard D, Lin C, Benson S, Barbera Intern Med. 2000;132(5):337-44. adults: Examining the role of productive engagement. Government Printing Office; 2016. Available Committee. Physical Activity Guidelines JA. Frail elderly as disaster victims: Emergency Health Soc Work. 2006;31:275-88. at http://www.agingstats.gov/docs/LatestReport/ Advisory Committee Report, 2008. management strategies. Prehosp Disaster Med. 36 Hadley J, Rabin D, Epstein A, Stein S, Rimes C. Post OA2016.pdf. Accessed August 31, 2016. Washington, DC: U.S. Department of Health 2002;17:67-74. hospitalization home health care use and changes in 47 Young FW, Glasgow N. Voluntary social participation and Human Services; 2008. functional status in a Medicare population. Medical and health. Res Aging. 1998;20:339-62. 3 Alzheimer’s Association. Alzheimer’s disease 24 Lachs M, Pillemer K. Elder abuse. N Engl J Med. Care. 2000;38(5):494-507. facts and figures. 2014. Available athttp:// 12 Cress ME, Buchner DM, Prohaska T, Rimmer 2015;373:1947-56. doi: 10.1056/NEJMra1404688. 48 Gottlieb BH, Gillespie AA.. Volunteerism, health, and 37 Shapiro A, Taylor M. Effects of a community-based civic engagement among older adults. Can J Aging. www.alz.org/downloads/Facts_Figures_2014.pdf. J, Brown M, Macera C, et al. Physical activity 25 National Center on Elder Abuse. Elder abuse Accessed August 31, 2016. programs and behavior counseling in older early intervention program on the subjective 2008;27(44):399-406. prevalence and incidence [fact sheet]. 2005. Available well-being, institutionalization, and mortality of low- adult populations. Med Sci Sports Exerc. at https://www.ncoa.org/public-policy-action/elder- 49 Brown SL, Nesse RM, Vinokur AD, Smith DM. 4 U.S. Bureau of the Census. American 2004;36(11):1997-2003. income elders. The Gerontologist. 2002;2(3):334-41. FactFinder [website]. Last updated 2010. justice/elder-abuse-facts/. Accessed August 31, 2016. Providing social support may be more beneficial 38 Thomas KS, Mor V. The relationship between than receiving it: Results from a prospective study of Available at http://factfinder.census.gov/ 13 Heikkinen R-L. The Role of physical activity 26 Conroy MB, Zgibor JC, Simkin-Silverman LR, Donohue faces/tableservices/jsf/pages/productview. in healthy ageing. Geneva, Switzerland: Older Americans Act Title III state expenditures mortality. Psychol Sci. 2003;14(4):320-7. JM, Albert SM, et al. Bundling preventive services for and prevalence of low-care nursing home xhtml?pid=DEC_10_DP_DPDP1&src=pt. Accessed Ageing and Health Programme, World Health community-dwelling seniors: Rationale for multi- 50 Hao Y. Productive activities and psychological well- August 31, 2016. Organization; 1998. residents. Health Serv Res. 2013;48(3):1215-26. faceted public health interventions. Primary Health doi:10.1111/1475-6773.12015. being among older adults. J Gerontol B Psychol Sci 5 Centers for Disease Control and Prevention. 14 Sofi F, Valecchi D, Bacci D, Abbate R, Gensini Care. 2015;2:203. Soc Science. 2008;63B (2):S64-S72. Healthy aging: Improving and extending GF, Casini A, et al. Physical activity and 39 Bureau of Labor Statistics, U.S. Department of Labor. 27 U.S. Department of Health and Human Services, Chart book: Occupational employment and wages— 51 Langer E. Counterclockwise: Mindful health and the quality of life among older Americans. Atlanta, risk of cognitive decline: A meta-analysis Office of Disease Prevention and Health Promotion. power of possibility. New York: Ballantine Books; GA: CDC; 2009. of prospective studies. J Intern Med. Figures 22 and 23. May 2007. Available at http://stats. Healthy People 2020. Objectives OA-2.1 and OA-2.2. bls.gov/oes/2007/may/chartbook.htm. Accessed August 2009. 2011;269(1):107-17. Washington, DC: HHS. 6 Centers for Medicare & Medicaid Services. 31, 2016. 52 Blair SN, Kampert JB, Kohl HW, Barlow CE, Macera CA, 2012 Medicare Current Beneficiary Survey Cost 15 Sallis JF, Kerr J. Physical activity and the built 28 Eke PI, Wei L, Borgnakke WS, Thornton-Evans G, 40 Lipson D, Regan C. Health insurance coverage for Paffenbarger RS, et al. Influences of cardiorespiratory and Use File. Available at https://www.cms.gov/ environment. President’s Council on Physical Zhang X, Lu H, et al. Periodontitis prevalence in adults fitness and other precursors on cardiovascular Research-Statistics-Data-and-Systems/Research/ Fitness and Sports Research Digest. 2006;7:1-8. direct care workers: Riding out the storm (Issue ≥ 65 years of age, in the USA. Periodontol. 2000, Brief No. 3). Washington, DC: Better Jobs Better Care disease and all-cause mortality in men and women. MCBS/index.html?redirect=/mcbs. Accessed 2006;72:76-95. Accessed August 31, 2016. JAMA. 1996;276(3):205-10. August 31, 2016. 16 U.S. Department of Transportation. The National Program Office; 2004. Available athttp:// Mayors’ Challenge for Safer People and 29 Centers for Disease Control and Prevention. Oral www.leadingage.org/uploadedFiles/Content/About/ 53 Grander JC, Sui X, Hébert JR, Hazlett LJ, Cai B, Lavie 7 U.S. Census Bureau. 65+ in the United States: Safer Streets. Last updated August 10, 2016. health for older Americans. Last updated July 10, Center_for_Applied_Research/Center_for_Applied_ CJ, et al. Association of cardiorespiratory fitness with 2010. Washington, DC: Government Printing Available from: https://www.transportation.gov/ 2013. Available at www.cdc.gov/oralhealth/publications/ Research_Initiatives/Direct_Care_Worker_Health_ coronary heart disease in asymptomatic men. Mayo Office; 2014. Publication No. P23-212. policy-initiatives/ped-bike-safety/join-growing-list- factsheets/adult_oral_health/adult_older.htm. Accessed Insurance_Brief.pdf. Accessed August 31, 2016. Clin Pro. 2015;90(10):1372-9. challenge-cities. Accessed August 31, 2016. August 31, 2016. 8 Joint Center for Housing Studies of Harvard 41 Hoskins AB. Occupational injuries, illnesses, and 54 Feinberg L, Reinhard S, Houser A, Choula R; AARP University. Housing America’s older adults: 17 Smart Growth America. National 30 Centers for Disease Control and Prevention. fatalities among nursing, psychiatric, and home Public Policy Institute. Valuing the invaluable: 2011 Meeting the needs of an aging population. Complete Streets Coalition. http://www. Depression is not a normal part of growing older. health aides, 1995–2004. U.S. Bureau of Labor update—The growing contributions and costs of 2014. Available at http://www.jchs.harvard. smartgrowthamerica.org/complete-streets. Last updated March 5, 2015. Available at http://www. Statistics; 2006. Available at http://www.bls.gov/ family caregiving. Available at https://assets.aarp.org/ edu/sites/jchs.harvard.edu/files/jchs-housing_ Accessed August 31, 2016. cdc.gov/aging/mentalhealth/depression.htm. Accessed opub/mlr/cwc/occupational-injuries-illnesses-and- rgcenter/ppi/ltc/i51-caregiving.pdf. Accessed August americas_older_adults_2014.pdf. Accessed August 31, 2016. fatalities-among-nursing-psychiatric-and-home-health- 31, 2016. August 31, 2016. 18 Lynott J, Figueiredo C. How the travel patterns aides-1995-2004.pdf. Accessed August 31, 2016. of older adults are changing: Highlights from 31 U.S. Department of Health and Human Services, 55 Scharf T, Phillipson C, Kingston P. Older people in 9 Berke EM, Koepsell TD, Moudon AV, the 2009 National Household Travel Survey. Office of the Surgeon General, National Action 42 Paraprofessional Healthcare Institute. Home care deprived neighbourhoods: Social exclusion and Hoskins RE, Larson EB. Association of the Washington, DC: AARP Public Policy Institute; Alliance for Suicide Prevention. 2012 National is projected to be the highest-growth occupation. quality of life in old age. Swindon, UK: ESRC Growing built environment with physical activity 2011. Strategy for Suicide Prevention: Goals and Objectives January 2015. Available at http://phinational.org/ Older Programme; 2003. and obesity in older persons. Am J Public for Action. Washington, DC: HHS; 2012. charts/home-care-projected-be-highest-growth- Hlth. 2007;97(3):486492. doi:10.2105/ occupation. Accessed August 31, 2016. AJPH.2006.085837.

90 HEALTHY AGING IN ACTION 91 56 Levy BR. Mind matters: Cognitive and physical effects 68 Lu P-J, Singleton JA, Euler GL, Williams WW, Bridges 80 DuFour M., Fuller RK. Alcohol in the elderly. Annu Rev of aging stereotypes. J Gerontol B Psychol Sci Soc CB. Seasonal influenza vaccination coverage among Med. 1995;46:123-32. Science. 2003;58(4). P203-P211. adult populations in the United States, 2005–2011. Am J Epidemiol.2013;178(9):1478–1487. 81 Klatsky AL, Armstrong MA, Friedman GD. Red wine, 57 Institute of Medicine. Food Forum: Providing healthy white wine, liquor, beer, and risk for coronary artery and safe foods as we age: Workshop summary. 69 Shenson D, Adams M. The Vote and Vax Program: disease hospitalization. Am J Cardiol. 1997;80(4):416- Washington, DC: National Academies Press; 2010. Public Health at Polling Places. J Public Health 20. Management Practice, 2008, 14(5), 476–480. 58 U.S. Department of Health and Human Services. 82 Mukamal KJ, Rimm EB. Alcohol’s effect on the risk Action Plan to Reduce Racial and Ethnic Health 70 Shenson D, Moore R.T., Benson W., & Anderson L.A. of coronary heart disease. Alcohol Res Health. Disparities: A Nation Free of Disparities in Health Polling places, pharmacies, and public health: Vote & 2001;25(4):255-61. and Health Care. 2011. Available at http://www. Vax 2012. Am J Public Health., 2008, 14(5), 476–480. minorityhealth.hhs.gov/npa/files/Plans/HHS/HHS_Plan_ Published online ahead of print April 16, 2015. doi: 83 U.S. Department of Agriculture (USDA), U.S. complete.pdf. Accessed August 31, 2016. 10.2105/AJPH. 2015.302628. Department of Health and Human Services. Nutrition and Your Health: Dietary Guidelines for Americans. 59 Smedley BD, Stith AY, Nelson AR, eds. Unequal 71 Courtney-Long EA, Carroll DD, Zhang QC, Stevens 4th ed. Home and Garden Bulletin No. 232. treatment: Confronting racial and ethnic disparities AC, Griffin-Blake S, Armour BS, et al. Prevalence Washington, DC: USDA; 1995. in healthcare. Washington, DC: National Academies of disability and disability type among adults— Press; 2002. United States, 2013. MMWR Morb Mortal Wkly Rep. 84 Dowell D, Haegerich TM, Chou R. CDC Guideline for 2015;64(29);777-83. Prescribing Opioids for Chronic Pain—United States, 60 Louie GH, Ward MM. Socioeconomic and ethnic 2016. MMWR Recomm Rep. 2016;65(No. RR-1):1-49. differences in disease burden and disparities in 72 U.S. Census Bureau. American Housing Survey for Available at http://dx.doi.org/10.15585/mmwr.rr6501e1. physical function in older adults. Am J Public Health. the United States: 2003, Current Housing Reports, Accessed August 31, 2016. 2011;101(7):1322-9. Series H150/03. Washington, DC: U.S. Government Printing Office; 2004. Available athttp://www.census. 85 Centers for Disease Control and Prevention, National 61 National Center for Health Statistics. Health, United gov/prod/2004pubs/H150-03.pdf. Accessed August 31, Center for Chronic Disease Prevention and Health States, 2014: With special feature on adults aged 2016. Promotion. The state of aging & health in America. 55-64. Hyattsville, MD: NCHS; 2015. Available at Atlanta, GA: Centers for Disease Control and http://www.cdc.gov/nchs/data/hus/hus14.pdf. Accessed 73 Golden J, Conroy RM, Bruce I, Denihan A, Greene Prevention, U.S. Department of Health and Human August 31, 2016. E, Kirby M, Lawlor BA. Loneliness, social support Services; 2013. Available at http://www.cdc.gov/aging/ networks, mood and wellbeing in community-dwelling pdf/state-aging-health-in-america-2013.pdf. Accessed 62 Grantmakers in Aging. Rural aging initiative. 2015. elderly. Int J Geriatr Psychiatry. 2009;24(7):694-700. August 31, 2016. Available at http://www.giaging.org/programs-events/ rural-aging-initiative/. Accessed August 31, 2106. 74 Patterson AC, Veenstra G. Loneliness and risk of 86 Brook RD, Franklin B, Cascio W, Hong Y, Howard mortality: A longitudinal investigation in Alameda G, Lipsett M, Tager I, et al. Air pollution and 63 Durazo, EM, Jones MR, Wallace SP, Van Arsdale J, County, California. Soc Sci Med. 2010;71(1):181-6. cardiovascular disease: A statement for healthcare Aydin M, Stewart C. The health status and unique doi:10.1016/j.socscimed.2010.03.024. professionals from the expert panel on population health challenges of rural older adults in California. and prevention science of the American Heart Los Angeles: UCLA Center for Health Policy Research; 75 Centers for Disease Control and Prevention. HIV Association. Circulation. 2014;109(21):2655-71. 2011. Available at http://healthpolicy.ucla.edu/ among people aged 50 and older [website]. Last publications/Documents/PDF/The%20Health%20 updated Sept 14, 2016. Available at http://www.cdc. 87 Brook RD, Rajagopalan S, Pope CA, Brook JR, Status%20and%20Unique%20Health%20Challenges%20 gov/hiv/group/age/olderamericans/index.html. Accessed Bhatnagar A, Diez-Roux AV, et al; American Heart of%20Rural%20Older%20Adults%20in%20California.pdf. September 20, 2016. Association Council on Epidemiology and Prevention, Accessed August 31, 2016. Council on the Kidney in Cardiovascular Disease, 76 O’Brien MA. Sexual health of older patients: and Council on Nutrition, Physical Activity and 64 Holmes J, Griner EP, Lethbridge-Cejku M, Heyman K. Attitudes and perceptions of healthcare providers. Metabolism. Particulate matter air pollution and Aging differently: Physical limitations among adults Nursing Doctoral. 2011. Paper 1. Available cardiovascular disease an update to the scientific aged 50 years and over: United States, 2001–2007. at http://fisherpub.sjfc.edu/cgi/viewcontent. statement from the American Heart Association. NCHS Data Brief No. 20. Hyattsville, MD: National cgi?article=1000&context=nursing_etd_doctoral. Circulation. 2010;121(21):2331-78. Center for Health Statistics; 2009. Accessed August 31, 2016. 88 U.S. Government Accountability Office. Elderly 65 File, T. (2013). Young adult voting: An analysis of 77 Centers for Disease Control and Prevention. Healthy housing: Federal housing programs that offer presidential elections, 1964-2012. Current Population aging: Helping older Americans achieve healthy assistance for the elderly. Report to Congressional Survey Reports, P20-572. U.S. Census Bureau, and high-quality lives—At a glance 2015. Available Requesters. Washington, DC: GAO; 2005. Publication Washington DC. at http://www.cdc.gov/chronicdisease/resources/ No. GAO-05-174. Available at http://www.gao.gov/new. publications/aag/pdf/2015/healthyaging-aag.pdf. items/d05174.pdf. Accessed August 31, 2016. 66 Centers for Disease Control and Prevention Accessed August 31, 2016. Immunization schedules for adults in easy-to-read 89 Edes T, Kinosian B, Vuckovic NH, Nichols LO, Becker formats. Last updated Feb 29, 2016. Available at 78 Blow FC, Barry KL; National Institute on Alcohol Abuse MM, & Hossain M. Better access, quality, and cost for http://www.cdc.gov/vaccines/schedules/easy-to-read/ and Alcoholism. Use and misuse of alcohol among clinically complex veterans with home‐based primary adult.html. Accessed August 31, 2016. older women. Prepared June 2003. Available at http:// care. J Am Geriatr Soc. 2014;62(10): 1954-61. pubs.niaaa.nih.gov/publications/arh26-4/308-315.htm. 67 U.S. Department of Health and Human Services, Accessed August 31, 2016. Office of Disease Prevention and Health Promotion. Healthy People 2020. Immunization and infectious 79 Blow F. Substance abuse among older adults. diseases. Last updated Sept 19, 2016. Available at Treatment Improvement Protocol (TIP) Series No. 26. https://www.healthypeople.gov/2020/topics-objectives/ Rockville, MD: U.S. Department of Health and Human topic/immunization-and-infectious-diseases. Accessed Services, Public Health Service, Substance Abuse and Sept 20, 2016. Mental Health Services Administration, Center for Substance Abuse Treatment; 1998.

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