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Opportunities for Collaboration: Linking Public Health and Aging Services Networks

Posted on: Friday, 30 September 2005, 06:00 CDT

By Palombo, Ruth; Alongi, Jeanne; Goldman, Allan; Greene, Rick; Et al

A way to make the most of currently fragmented and limited resources.

The alignment and coordination of policy and practice of public health and aging services networks at national, state, and local levels can help create the conditions that encourage older adults to maximize their potential for living healthy lives. As the U.S. population ages, the role of states becomes even more cruaal. Yet most states have fragmented and limited resources to address the health promotion and disease prevention needs of older adultsthe very population with the highest rates of chronic disease and disabilities. One important means for reducing this fragmentation is the promotion of collaboration and partnerships between the public health and the aging services networks.

The Association of State and Territorial Chronic Disease Program Directors (CDD) and the National Association of State Units on Aging (NASUA), with support from the Centers for Disease Control and Prevention (CDC) and the Administration on Aging (AOA), initiated the Aging States Project in spring 2001 to identify common interests and opportunities for collaboration between state health departments and state units on aging. This article presents select findings and recommendations from that project's report (CDD, 2003).

The public health and aging services networks both have a three- tiered structure with federal. state, and local agencies (Figure 1). Both networks bring a variety of resources, approaches, and partners to their efforts, including voluntary and professional organizations, academic institutions, community-based organizations, and others. The Older Americans Act (OAA), specifically Title 3-D, authorizes disease prevention and health promotion services and provides a statutory basis for the collaboration between public health and aging services. As part of OAA, the Administration on Aging is directed to consult with the Centers for Disease Control and Prevention in earning out its health promotion and disease prevention mandate. State-level coordination between the networks is not mandated in most states.

THE PUBLIC HEALTH SYSTEM

As has been noted throughout this issue, the purpose of the public health system is to promote the conditions necessary for people to live healthy lives through communitywide prevention and protection programs. To serve communities and individuals, the public health network relies on partnerships among the CDC and other federal agencies, state and local health departments, and other public and private organizations. At the federal level the Public Health Service, part of the U.S. Department of Health and Human Services (USDHSS), comprises a number of federal agencies including CDC (Lang et al., 2004). At the state level the public health network has fifty-eight health departments in states and territories. At the community level, there are more than 3,000 local public health agencies.

CDD, a national public health association, was founded in 1988 to link directors of chronic disease programs of each state and territory and provide a national forum for chronic disease prevention and control efforts. Programs of state health departments typically focus on primary or secondary prevention (risk reduction and early detection and treatment) and do not necessarily target older adults. State health departments receive funding via state appropriations and federal and nonprofit-sponsored categorical grants programs. Such disparate funding arrangements result in various organizational configurations of health promotion and chronic disease prevention programs that can pose challenges for potential partnerships.

THE AGING SERVICES NETWORK

AOA, also in USDHHS, is the lead federal agency addressing the concerns and needs of older Americans, as noted above, and administers almost all the provisions of OAA, a pivotal statute that provides for a range of services and programs for older Americans and their caregivers, emphasizing those in greatest social and economic need or at risk of losing their independence. Title 3-D provides for disease prevention and health promotion and includes services such as health screening, physical activity, injury control, and medication management among others.

Figure 1

Public Health and Aging Services Networks

State units on aging (SUAS) provide funding for OAA programs to local communities through designated area agencies on aging (AAAS). Most states have one or more AAASgovernmental, quasi-governmental, or not-forprofit entities-responsible for planning and implementing programs for their planning and service area. The aging services network includes fifty-six SUAS, 655 AAAS, 243 tribal organizations, 29,000 local community organizations, and 500,000 volunteers.

SUAS may also administer other programs, such as Medicaid waivers. Similar to state health departments (SHDS), state units on aging have a national membership organization-the National Association of State Units on Agingto support their priorities, interests, and concerns. Serving 8-9 million older adults annually, the aging services system has extensive outreach and educational capabilities. SUAS have substantial knowledge of development of service stems, program administration, service design options, and the support needs of older adultsimportant expertise that can be leveraged to encourage healthy aging.

In summary, SHDS and SUAS share a common mission of addressing the health needs of older adults. The two sets of agencies approach this population through parallel yet dirlcrcnt strategies and mechanisms. Developing an integrated system of health promotion and disease prevention services for older adults will require stronger collaboration and partnerships between these two networks.

THE AGING STATES PROJECT

Beyond structure and basic functions, little was known about the relationships between SHDs and SUAS until 2002, when the Aging States Project conducted a national needs assessment of these two networks to examine major health issues and concerns, program support needs, and the status of collaborations between the HVO(CDD, 2003). A total of 68 percent of state health departments and -s percent of state units on aging responded. The results of the needs assessment provided an overview of airrent health promotion and disease prevention efforts for older adults.

Program priorities. For both networks, chronic disease prevention and control, access to healthcare, and risk reduction were the most fixxpendy identified health issues for older adults, with cardiovascular disease identified most often a.s the major health concern. Most agencies in both groups also identified access to prescription medications and mental health as important issues. Access to prescription medication was noted by both groups to be the issue receiving most public attention. SUAS reported a higher level of involvement in programs for medication access and mental health than did SHDS. As expected, SHDS reported greater involvement with chronic disease prevention. Except for arthritis programs, SHD chronic-disease programs tended to serve few older adults. This limited reach is likely due to funding constraints, lack of collaboration between SUAS and SHDS in planning programs, and a failure to make older adults a target population.

Both SHDS and SUAS identified reduction of risk factors for prevention and management of chronic disease as top concerns. In this category, physical activity and good nutrition predominated as the means ot choice. In SHDS, physical activity and nutrition are addressed as part of health promotion and chronic disease prevention programs - Rinded through a variety of federal, state, and local resources, but older adults are often not included. In SUAS, OAA Title 3-D mandates physical activity as a focus for health promotion programs. Similarly, the higher level of SUA involvement in nutrition may reflect the OAA congregate and homedelivered nutrition program requirements. In both groups, levels of program-specific involvement appeared to be dictated by current funding opportunities.

Program support needs. SUAS and SHDS both recognized a need for more information on best practices as well as practical assistance in developing, implementing, and evaluating effective programs to improve the health of older adults. This finding was underscored by the lack of a dearly articulated science base for many programs nominated as best practices by states in the needs assessment. Both SUAS and SHDS also identified the need for assistance with effective public education materials and media efforts to address reduction of risk factors for chronic diseases.

The two networks reported different barriers to promoting health among older adults. SUAS identified individual behavior issues (e.g., lifestyle, consumer awareness, and perceptions of aging and illness) more frequently than systems issues (e.g., lack of an organized service system and Medicare restrictions). SHDS, conversely, identified systems issues more frequently. These differences may reflect the different perspectives of aging and public health - individual-focused services versus population-based programs.

In response to an open-ended question about technical assistance and training needs, n\early half of all respondents identified program planning and evaluation as an area of need. About a quarter of participants identified data and surveillance issues, and almost a third identified needs in research or best practices.

Collaboration and organization issues. Although most SUAS and SHDS collaborated with their counterpart agency, the collaboration was often limited, hindered by the lack of staff specifically assigned to health promotion for older adults. This limitation arose more frequently for SHDS, with only about a third of SHDS reporting a designated individual or unit. Lack of designated staff appeared to influence SHD internal planning for health promotion for older adults. Of the few SHDS with formal plans, all had designated individuals who may have been instrumental in plan development. Because SHDS do not typically have funding specifically dedicated to older adults, the lack of a designated individual is not surprising. As a result, opportunities for collaboration were missed. Finally, there was no clear pattern regarding which agency had lead responsibility for health promotion and disease prevention for older adults.

SUAS and SHDS identified strengths in themselves and their counterparts that could form the core of stronger partnerships. The SUAS' lead role in the highly developed aging services network was widely recognized, and skills in health programming were frequently mentioned for SHDS. Although it may appear surprising that SHDS were not widely recognized by SUAS as having expertise in prevention and control of chronic disease, this perception gap may be due to the lack of specific activities for older adults fostered by the state health departments.

The Aging States Project report does identify numerous examples of collaboration between the two types of organizations. The programs described use various approaches to SUA-SHD collaboration in areas such as management of chronic health conditions, increasing development of healthy behaviors like physical activity and consumption of fruits and vegetables, increasing access to health services, keeping individuals more socially connected, and increasing balance and strength to reduce falls. Although programs are innovative and participants appear satisfied by anecdotal reports, greater use of evidence-based programs to promote healthy aging would enhance overall effectiveness of these community-based programs by better utilizing resources, providing data that could be used to advocate for new programs, and providing new information regarding "what works" and "how to do it" (National Council on the Aging, 2004).

Another exciting area of collaboration is training on health promotion and aging to professionals in community-based health and aging programs through grants from the Health Resources and Services Administration Bureau of Health Professions Geriatric Education Center. Other potential areas for collaboration include medication management programs, nutrition programs, and end-of-life programs, such as education related to advance care planning and quality-of- life initiatives. Finally, a number of SUAS and SHDS have forged interagency agreements or memorandums of understanding to formalize and institutionalize relationships between the two agencies and make collaborative efforts explicit.

RECOMMENDATIONS

The results of the needs assessment are being used to understand the strengths and expertise of the state public health and aging networks to better align and facilitate collaboration to ensure optimal health for older adults. A strategic planning exercise bringing together public health and aging partners followed the work of the Aging States Project that elicited recommendations for action for the networks. Three main themes emerged from this process. Strategic partnerships beginning with state collaborations were a top recommendation. The use of data for action in program planning and evaluation was also a critical need. Finally, increasing capacity in the states for training and technical assistance, improved communication, and securing designated resources such as staff time was seen as an essential early step to better collaboration. The following are recommendations to promote collaboration and communication between SHDS and SUAS:

* Designate a point person for communication with the counterpart agency around health promotion and disease prevention for older adults.

* Clarify state organizational relationships related to lead roles and joint planning for healthy aging programs.

* Promote SHD and SUA collaboration in the design, implementation, and evaluation of their respective health promotion and disease prevention programs targeted to older adults.

* Include a focus on older adults in all appropriate health promotion and disease prevention initiatives directed by SHDS.

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

PROGRESS AND SUCXESS

Since the needs assessment was completed in 2002, the capacity in both networks has continued to evolve, and every state health department now has a designated contact for matters concerning healthy aging. The spectrum of the existing healthy aging capacity in these agencies ranges from a simple point of contact to a coordinating effort and to fully started programs. State units on aging have health promotion contacts and continue to develop evidence-based programs. In 2002 and 2003, AOA and CDC: provided funding through CDD and NASUA for collaborations between state units on aging and statehealth departments through the development and implementation of the health and aging grant program, with the focus on implementation of evidence-based programs in 200; (Lang et al., 2004). In 2003, AOA funded twelve threeyear community grants to increase access of older people to community-based programs for disease prevention, injury, or disability (Administration on Aging, 2004).

Recent state-level collaborations have resulted in increased reach and impact for both public health and aging services. In California, supported through the health and aging grant program, the state's health department and state unit on aging have formed a partnership to improve the capacity for developing physical activity programs at the local level. State-level leadership facilitates collaboration among AAAS, county public health departments, healthcare providers, academia, and community organizations through countywide collaborations via the state's Active Aging Community Task Force Project. Through the task force and with technical assistance from the state agencies, county agencies are building integrated, multifacctcd physical activity curricula and training into their services.

In the absence of such federal funding, states build collaboration in other ways. For example, in Georgia, the SUA and the SHD form partnerships to develop grant programs and share information. An important contribution from the SHD has been assignment of epidemiologists and chronic disease prevention coordinators to regional and county health departments to identity high-risk populations. A series of joint grant writing efforts resulted in funded projects to address a range of chronic diseases and other health problems - arthritis, osteoporosis, asthma, diabetes, suicide, older driver difficulties, and falls. Community awareness, start crosstraining, and public education feature prominently in these efforts and have helped older adults recognize the importance of adopting healthy lifestyles. The two networks have also collaborated on risk-factor surveillance and chronic-disease screening efforts. SHD contributed expertise in survey design, data collection, analysis, and information dissemination. The state unit on aging offered older adults access to screening and other health interventions.

CONCLUSION

Historically, progress toward coordinated planning and implementation has been hindered by a fragmented approach to the promorion of healthy aging, a problem magnified by inadequate resources and limited collaboration between SHDS and SUAS. By drawing on and better integrating their respective strengths and expertise, SHDS and SUAS together can significantly enhance the health status and quality of life of older Americans.

The two networks can build support for additional resources to serve older adults more effectively if they speak with one voice (CDD, 2003; Wallace and Levin, 2000). The different but complementary perspectives, cultures, and strengths of SUAS and SHDS provide a great opportunity to effectively address the needs of an increasingly diverse older population. SUAS can reach eight to nine million older adults with messages, programs, and services directed at enhancing their health. SUAS also have substantial expertise in developing statewide servicedelivery systems, designing programs responsive to the needs and preferences of older adults, and facilitating access to social and family supports, care coordination, and home- and community-based long-term care. SHDS offer expertise in the science of health promotion and disease prevention, evaluation of the effectiveness of health programs and services, surveillance and monitoring systems, community-based participatory research, and planning for evidencebased prevention programs. The findings and recommendations from the Aging States Report will continue to provide valuable information that can inform the development of future collaborations between public health and aging networks for the benefit of all.

REFERENCES

Administration on Aging (AOA), U.S. Department of Health and Human Services. 2004. Evidence-Based Disease Prevention Grants Program, http://www.aoa. gov/proffemdence/evidence.asp. Accessed Nov. 6,2004.

Association of State and Territorial Chronic Disease Program Directors (CDD). 2003. The Aging Sta\tes Project: Promoting Opportunities for Collaboration between the Public Health and Aging Services Networks. (http://www.chronk disease, org/ aging_states_project.pdf).

Lang, J., et al. 2004. "Healthy Aging: Priorities and Programs for the Centers for Disease Control and Prevention." Generations 29(2): 24-29.

National Council on the Aging (NCOA). 2004. "Using the Evidence Base to Promote Healthy Aging." Issue Brief: Evidence-Based Health Promotion Series, Center for Healthy Aging. No. 1, Winter.

Wallace, S. P., and Levin, J. R. 2000. "Patterns of Health Promotion Programs for Older Adults in Local Health Departments." American Journal of Health Promotion 15(2): 130.

Ruth Palombo, Ph.D., R.D., is former director, Office of Elder Health, Massachusetts Department of Public Health, and project director, Aging States Project, Boston, Mass; Jeanne Alongi, M.P.H., is a consultant, Association of State and Territorial Chronic Disease Program Directors, Sacramento, Calif.; Allan Goldman, M.P.H., is assistant to the director, Georgia Division of Aging Services, Atlanta, Ga.; Rick Greene, M.S. W., is an aging program specialist, Administration on Aging, Washington, D.C.; Theresa Lambert, M.Ed., is deputy director, National Association of State Units on Aging, Washington, D.C.; and Suzanne Smith, M.D., M.P.H., is special assistant for innovation, Centers for Disease Control and Prevention, Atlanta, Ga.

The authors would like to thank LyndaAnderson, acting chief, Health Care and Aging Studies, Centers for Disease Control and Prevention, for her thoughtful manuscript review and Anne-Reet Annunziata and Anne McHugh, Aging States Project consultants, far assistance with data collection, analysis, and report preparation.

Copyright American Society on Aging Summer 2005

Source: Generations

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