Preventing Disability Through Community-Based Health ... - CiteSeerX

SYSTEMS & MODELS OF GERIATRIC CARE

Preventing Disability Through Community-Based Health Coaching Stephen K. Holland, MD,* Jay Greenberg, ScD,† Lynette Tidwell, RN, BSN,‡ and Robert Newcomer, PhD§

The California Public Employees Retirement System (CalPERS) Health Matters program is a randomized controlled trial of a community-based health coaching program operating in Sacramento, California, since January 2001. It is modeled after the Health Enhancement Program and Senior Wellness Program of Seattle, Washington. Like the Health Enhancement Program, this program incorporates a menu of disability-prevention strategies, with health coaching, patient education on the self-management of chronic illness, and fitness forming the program’s core. Unlike the Health Enhancement Program, the Health Matters program focuses as much attention on linking participants to existing community, health plan, and selfdirected programming as it does encouraging them to participate in programming developed especially for the project. All participants and controls continue to receive their usual medical care from their managed care providers. Eligibility criteria for the program include having one or more qualifying chronic health conditions, being aged 65 and older, being a member of a participating health plan, and being accepted into CalPERS’ Long Term Care Insurance Program. Baseline exclusions include being cognitively impaired or qualifying for long-term care insurance benefits due to deficiencies in two or more activities of daily living. The project has been successful in its enrollment strategy. It has also been successful in recruiting participants into project-sponsored, community-based, and self-directed disability-prevention programming. This is particularly true for programming related to diet, exercise, and various aspects of disease management. J Am Geriatr Soc 51:265–269, 2003. Key words: aged; disability prevention; health coaching; managed care

From the *Long Term Care Group, Inc., Natick, Massachusetts; †National Council on Aging, Washington, DC; ‡Eskaton, Sacramento, California; and §Department of Social and Behavioral Sciences, University of California at San Francisco, San Francisco, California. Funded by the California HealthCare Foundation under Grant 99–3072. This project was conducted under the auspices of the University of California, San Francisco Institutional Review Board, number H945–18391–02. Address correspondence to Stephen K. Holland, MD, Medical Director and Senior Vice President, Long Term Care Group, Inc., 5 Commonwealth Road, Natick, MA 01760. E-mail: [email protected]

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n 1999, the California Public Employees Retirement System (CalPERS), the Long Term Care Group (an independent corporation administering the CalPERS Long Term Care Insurance Program), and the three major Medicare health plans available to CalPERS members in the Sacramento Area (Kaiser, Health Net, and PacifiCare) collaborated to develop and test a community-based disabilityprevention program for their members. This program, known as CalPERS Health Matters (CHM), is a communitybased randomized trial supported by a $1 million grant from the California HealthCare Foundation. The core component of the program is the nurse health coaching team that assists participants with the development and implementation of health action plans. Supporting activities include a chronic-disease self-management program, fitness classes, and linkages to other relevant programming. Eskaton, a Sacramento-based senior services agency, is responsible for implementing the community-based intervention. The University of California at San Francisco (UCSF) is responsible for the evaluation of the trial. Informed consent was obtained in accordance with UCSF Institutional Review Board protocols. CHM is a test of scale and an extension and expansion of a community-based chronic-illness self-management and disability-prevention program originally known as the Health Enhancement Project (HEP) and now called the Senior Wellness Program. The University of Washington and Group Health Cooperative of Puget Sound initially developed the HEP. Results of the HEP randomized trial1 show statistically significant differences in hospitalization rates and hospital days in treatment and control groups. Additionally, treatment cases took fewer or no psychoactive medications (38%). Similar chronic-disease self-management interventions have shown comparable effects on hospital use.2–5 CHM differs from the HEP in several ways. Although both programs require participants to have one or more chronic health conditions, their physicians referred HEP participants to the program because of precarious health status, whereas CHM participants referred themselves after receiving a recruitment letter from CalPERS. In addition, the CHM program’s health coaches are registered nurses and not nurse practitioners. CHM uses a combination of senior center and community center sites that are

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not necessarily senior centers, whereas the HEP was conducted only at full-service senior centers that provide a comprehensive array of activities and programming for seniors, including classes, congregate meals, outreach services, and a variety of social activities. CHM programming also includes helping participants find community-based and health plan programming resources to achieve their stated goals and provides project-sponsored programs. Furthermore, CHM programming encourages self-directed activities aimed at disability prevention and quality-of-life improvement, whereas the HEP’s programming emphasized enhancing and providing senior center programming. CHM project staff developed comprehensive lists of communitybased and participating health plan–sponsored classes and programs that relate to exercise and fitness, health education and promotion, diet, and disease management for participants. PROGRAM ELIGIBILITY AND RECRUITMENT Participant recruitment, which extended from January through July 2001, involved a two-stage process. The first stage offered the program to a probability sample of CalPERS members who also participate in the CalPERS Long Term Care Insurance Program. Eligibility rules required that CalPERS members live in an area served by a participating senior or community center, have one or more qualifying chronic health conditions (e.g., arthritis, hypertension, diabetes mellitus, cardiovascular disease, pulmonary disease), be healthy enough to be considered a reasonable long-term care insurance risk, be aged 65 and older, and be a member of Kaiser’s, Health Net’s, or PacificCare’s senior managed care program. Baseline exclusions included being cognitively impaired as measured by the Mini-Mental State Examination,6 as defined by a score of 24 or less, or qualifying for long-term care benefits due to deficiencies in two or more activities of daily living (ADLs).7 These criteria are similar to those used in the HEP. Drawn from information in their long-term care insurance files, approximately 1,700 of the 2,700 age- and insurance-coverage-eligible CalPERS members in the target area had at least one chronic condition. Recruitment of study participants began by mailing prospects an introduction letter from CalPERS. Those agreeing to participate after the initial mailing or after a follow-up call were scheduled for an in-person interview at one of the participating senior centers. Of the 1,650 individuals invited to participate, 500 agreed (30%) to participate by completing an extensive health questionnaire and an in-person assessment of instrumental activities of daily living, functional abilities, ADLs, and cognition. Only one individual was excluded from the study because of their score on the cognitive screening test, and no one was excluded for ADL dependencies. The participants were then randomly assigned to the participant or the control group. During the study, participants received usual care from their primary care physician and coverage for health services under their regular health maintenance organization (HMO) benefit contracts. To avoid inappropriate enrollment in fitness classes, primary care physicians received copies of participants’ health action plans and a notice regarding their desire to attend a fitness class. Physicians

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were asked to notify patients within 2 weeks to discourage inappropriate participation in CHM’s fitness classes. HEALTH MATTERS PROGRAM DESIGN The program incorporates a menu of disability-prevention strategies, with health coaching, patient education on selfmanagement of chronic illness, and fitness forming the program’s core. HEALTH COACHING TEAMS The health coaching team consists of bachelor’s degree– trained nurse health coaches (NHCs), master’s degree– trained social workers, and a consulting geriatrician. The NHC is the participant’s consistent link to all CHM programming and services. The NHCs perform health assessments and work with participants to develop and update their Health Action Plans (described below). In addition to identifying group health education activities that may be beneficial for the enrollee, the NHC (and the program social worker) is available to provide one-to-one services such as health education, counseling, medication management coaching, and continued motivation and support through monitoring adherence to the plan and progress over time. After the initial face-to-face assessment, most ongoing communication is accomplished by telephone or e-mail. Participants can arrange an in-person meeting with their NHC at any time during the program and are strongly encouraged to meet face-to-face with their NHC for their 6-month reassessment. The NHC is also responsible for sending the Health Action Plan to each participant’s primary care physician and obtaining input on the appropriateness of the exercise program if selected by the participant. However, the emphasis of the program is teaching the participants how to approach their physician with questions about management of their condition whenever possible. The NHC is responsible for periodic follow-up assessments and monitoring, particularly monitoring the participant’s adherence to the Health Action Plan and any new health issues. Staffing ratios are patterned after the HEP, with one registered nurse responsible for 160 to 175 program participants. A social worker is available to participants if issues of loneliness, isolation, low self-esteem, or other situational mood-related issues are identified in the initial assessment or by the NHC. The social worker provides brief counseling for mood-related issues, conducts didactic and support groups, and provides information on other available community resources (e.g., interest groups, social activities, or volunteer activities). Referrals to the social worker are based on CHM’s intervention protocols and can be prompted by issues of social isolation, alcohol, depression, anxiety, weight loss, short-term memory loss, or lack of access to community resources. A staffing ratio of 0.5 full time equivalent (FTE) social worker per 1.0 FTE nurse health coach is budgeted for the program. Two consulting geriatricians act as the “coach’s coach” and are available for consultation with CHM’s nurse health coaches and social worker. The geriatricians assist with interpreting medical and psychiatric aspects of health action planning, educating the health coaching team about various medical conditions and guiding any interaction that may be indicated with primary or specialty physicians. They also provide twice monthly “The Doctor Is

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In” classes for CHM participants, addressing identified health concerns such as osteoporosis, balance and fall prevention, medication and supplements, and making the most of medical appointments. The consulting geriatricians are contracted to provide approximately 3 to 5 hours of consultation and classes per month but do not provide medical care to program participants. THE HEALTH ACTION PLAN The Health Action Plan is designed to be each participant’s blueprint for health empowerment by encouraging them to take charge of managing their chronic conditions by obtaining relevant health education and adopting a healthier lifestyle. The goal is to enable participants to feel empowered and motivated to change, rather than having professionals doing it for them. Unlike a care plan, the Health Action Plan provides a contract wherein both the participant and NHC take responsibility for the next steps. After a thorough health assessment, areas where healthrelated behavior change could benefit the participant are identified. The Health Action Plan incorporates fitness and health education goals, identifies classes and other activities the participant can join, and highlights programs and services to which the nurse will provide referrals. These programs cover such areas as fitness, nutrition, mood or self-esteem, social connectedness, alcohol and drug use, use of medications, stress reduction, and need for supportive services to compensate for functional limitations. Specific protocols determine use of various health education activities and referrals to other programs. For example, a history of smoking will prompt a discussion of tobacco cessation, whereas a low score on the Geriatric Depression Scale will prompt a referral to CHM’s social worker. These protocols provide assurance that the success of the program can easily be replicated in other settings and with other staff. Protocols developed for the HEP were used as a starting point for the program and were modified to reflect CHM’s programming and programming available in the community and in participating health plans and medical groups. SPECIAL CENTER-BASED PROGRAMMING CHM helps link program participants to existing health education programs offered by participating health plans and medical groups. CHM also offers similar healthrelated classes on a number of topics at participating community centers and two programs that focus on managing chronic health conditions: Lifetime Fitness Program The University of Washington and Senior Services of Seattle/ King County developed this exercise program as a means of providing strength, endurance, and flexibility training to seniors. These classes are offered to all Health Matters program participants three times a week at each participating local site. Certified fitness instructors teach classes, which include strength training with wrist and ankle weights and aerobic, balance, stretching, endurance, and flexibility training, doing so in a safe way modified to the needs of persons with chronic conditions. The program is specifically designed to be safe and effective for seniors with a wide range of physical abilities.

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Self-Management of Chronic Conditions Classes Self-Management of Chronic Conditions is a six-session course developed by Lorig et al. at Stanford University 2,8 that was offered to all CHM participants. It is designed to teach seniors how to cope better with a broad range of chronic health conditions. It has proven effective in giving participants a greater sense of control over their lives, helping them grasp the realities of living with a chronic condition, and teaching them how to cope with pain, depression, lifestyle changes, and medication issues. Teams of two leaders teach each class, and at least one of the leaders is a layperson who also has a chronic condition. The course fosters patient self-advocacy and assists participants in making health behavior changes by practicing problem solving and goal-setting techniques. Course content includes nutrition, communication skills, relaxation techniques, coping with fatigue, coping with pain, learning to work with healthcare providers, and planning for the future. COMMUNITY CENTERS Community center site selection was based on where CalPERS enrollees reside. Although CHM’s ideal was to use full-service senior centers, many CalPERS enrollees live in areas where there are no senior centers; only one of the three participating CHM sites is a full-service senior center. To address the lack of senior programming at the community center sites, CHM offered weekly wellnessrelated classes at each community center in addition to Lifetime Fitness classes three times per week. Information on additional senior-specific activities and programs at other senior centers, such as meal programs, travel groups, and yoga, is provided to participants as needed. ALTERNATIVE PROGRAMMING VENUES In addition to the special programming developed for the project, CHM participants are encouraged to engage in disability-prevention activities and programming in the community. These include activities offered by health plans, self-directed activities that can be done at home (e.g., walking programs, dieting, socializing), and activities in community centers. To facilitate awareness and use of these other resources, project staff catalogued and offered participants relevant community-based programming and health plan offerings. PRELIMINARY ANALYSIS OF PROGRAMMING AND VENUE USE As discussed above, a major goal of the health coaching component of the program is to help the participant develop a health action plan and to act on the plan in tangible ways such as exercising, changing dietary habits, learning about their medications and more about their medical conditions and how to manage them, learning how to talk to their doctor, and engaging in other activities designed to improve their quality of life. Tables 1 and 2 and Figure 1 present a summary of the use of various programs and venues by program participants during the first 10 months of the project. Because of staggered enrollment, these data represent 10 months of program participation for the first enrollees and 5 months of program participation for the last enrollees.

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Table 1. Number of Participants Using Programming by Venue (N 254)

Venue

Enrollees Using Venue n (%)

Health Matters programming Self-directed at home Community programming Health plan programming One or more venues

137 (54) 200 (79) 116 (46) 33 (13) 245 (96)

Preliminary data show that 96% of CHM’s participants have engaged in one or more activities at one or more venues (Table 1). Seventy-nine percent of participants have used home-based self-directed activities, whereas 54% of participants have used programming developed especially for CHM. Forty-six percent of participants have used various community-sponsored programming cataloged and offered by CHM staff. The least-used activity has been health plan–sponsored programming (13%). An analysis of multiple-venue use revealed that a majority of the participants (68%) are involved in activities associated with more than one venue. Table 2 summarizes program use by type and venue. Self-directed lifestyle changes and activities related to diet and exercise at home have been most popular among the enrollees (71%), whereas 43% of participants have joined CHM’s Lifetime Fitness classes. No participants who chose diet or exercise as part of their Health Action Plans selected a program offered by their health plan. Perhaps people who were already engaged in activities sponsored by their health plans were less likely to agree to participate in the CHM study. Early reports from participants in the Lifetime Fitness classes underscore the effectiveness of participation in this program. Frequent interactions with the NHCs, social workers, geriatricians, and other healthcare professionals appear to increase participants’ resolve to accomplish identified health action plans. To encourage participation in classes, a monthly newsletter with a calendar of activities was sent to each participant. In addition, participants were sent fliers for CHM classes at the community or se-

Figure 1. CalPERS Health Matters Program. Two hundred forty-five of 254 participants (96%) participated in one or more program venues.

nior center closest to them. To encourage maximum participation in the Lifetime Fitness exercise program, efforts were made to bring the classes closer to the participants. Three sites in addition to participating senior and community centers are being used (two churches and one senior housing complex); the addition of these extended sites has increased participation in the classes. As the yearlong program draws to a close, each participant and control receives a health questionnaire and an inperson reassessment of activities and function, and utilization data from the 12 months before enrollment and during the study period will be collected from their health plans and from the CalPERS Long Term Care Insurance Program. The exit questionnaire and in-person assessment are similar to those administered at the onset of the program. GENERALIZABILITY AND DISSEMINATION PLANS Studies of projects from which the CalPERS Health Matters program was adapted have found nurse coaching, exercise, and other community resource use to be promising in disability prevention in chronically ill older populations.9–12 CHM was implemented as a randomized, controlled, experimental trial focused on individuals regardless of their health plan or health insurance options. If the

Table 2. Program Usage by Type and Venue (N 254) Venue, n (%)

Activity

Health Matters

Self-Directed at Home

Community Resources

Health Plan

Lifestyle (diet or exercise) Wellness/disease management Professional consultation Social activities and lifelong learning One or more activities used in venue

110 (43) 78 (31) 23 (9) N/A 137 (54)

180 (71) 66 (26) N/A N/A 200 (79)

65 (26) 0 (0) N/A 90 (35) 116 (46)

0 (0) 20 (8) 13 (5) N/A 33 (13)

Note: Percentages are number of participants that engage in that activity in that venue divided by total number of participants (254). Participants often engage in activities in more than one venue. Therefore, rows and columns sum to more than 100%, and totals are not shown because they have little meaning. N/A not available.

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program is successful in improving health outcomes or reducing healthcare use, it should find support for dissemination and replication from funding sources in addition to health plans. These sources may include employers and other entities responsible for healthcare insurance payments, disease management firms, and even Medicare Part B. More immediately, continuation of CHM after the grant period centers on an agreement with CalPERS and participating health plans that they will seriously explore the feasibility of making this program an integral part of the CalPERS Long Term Care Insurance Program. Their willingness to explore these opportunities will depend on the effect and success of the project as measured by positive changes in healthcare and long-term-care insurance use and improvement in the health status of participants. CalPERS is also committed to working with its other Medicare risk contractors and disease management firms should a positive effect on healthcare and long-term care insurance use be demonstrated. Business models developed by the investigators project that this program could be delivered in the community for approximately $40 per participant per month. Perhaps a combination of plan sponsorship and participant copayment could effectively support the continuation and expansion of this program. Surveys are planned to determine participants’ willingness to pay a portion of the ongoing cost of the CalPERS Health Matters program. ACKNOWLEDGMENTS The authors would like to acknowledge the assistance and support of the members of the planning and development team, including Tom Fischer, Chief of Self-Funded Programs, and Daniel Schroepfer, Chief, Long Term Care Program, both from the California Public Employees Retirement System; Eskaton; Kaiser Foundation Health Plan, Health Net, and PacifiCare. Each of the health plans has endorsed the project and agreed to facilitate the involve-

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ment of their larger medical groups and will provide utilization data on hospitalizations and emergency room visits for the study’s evaluation. The authors would also like to acknowledge the assistance and support of our Consulting Geriatricians, Dr. Cheryl Phillips of Sutter Medical Group and Dr Michael GuntherMaher, Permanente Medical Group Inc., and the excellent assistance of Ms. Susan Snyder of Senior Services of Seattle/King County and Ms. Joelyn Malone early on in the planning and implementation stages of this program. REFERENCES 1. Leveille SG, Wagner EH, Davis C et al. Preventing disability and managing chronic illness in frail older adults: A randomized trial of a community-based partnership with primary care. J Am Geriatr Soc 1998;46:1191–1198. 2. Lorig K, Sobel DS, Stewart AL et al. Evidence suggesting that a chronic disease self-management program can improve health status while reducing hospitalization: A randomized trial. Med Care 1999;37:5–14. 3. Wagner EH, Grothaus LC, Hecht JA et al. Factors associated with participation in a senior health promotion program. Gerontologist 1991;31:598–602. 4. Buchner DM, Beresford SA, Larson EB et al. Effects of physical activity on health status in older adults: II. Interventional studies. Annu Rev Public Health 1992;13:469–488. 5. Fiatarone MA, Marks EC, Ryan CN et al. High intensity strength training in nonagenarians. Effects on skeletal muscle. JAMA 1990;263:3029–3034. 6. Folstein M, Folstein S, McHugh P. Mini-mental state. A practical method for grading the cognitive state of patients for the clinician. J Psychiatr Res 1975; 12:189–198. 7. Katz S, Ford A, Moskowitz R et al. Studies of illness in the aged: The index of ADL, a standardized measure of biological and psychosocial functioning. JAMA 1963;185:94–101. 8. Lorig K, Stewart A, Ritter P et al. Outcome Measures for Health Education and Other Health Care Interventions. Thousand Oaks, CA: Sage Publications, 1996. 9. Hawley D, Wolfe F. Sensitivity to change of the health assessment questionnaire (HAQ) and other clinical and health status measures in rheumatoid arthritis. Arthritis Care Res 1992;5:130–136. 10. Wagner E, LaCroix A, Grothaus L et al. Responsiveness of health status measures to change among the aged. J Am Geriatr Soc 1993;41:241–248. 11. Maly R, Frank J, Marshall G et al. Perceived efficacy in patient–physician interactions (PEPPI). Validation of an instrument in older persons. J Am Geriatr Soc 1998;46:889–894. 12. Reuben DB, Frank JC, Hirsch SH et al. A randomized clinical trial of outpatient comprehensive geriatric assessment coupled with an intervention to increase adherence to recommendations. J Am Geriatr Soc 1999;47:269–276.