SangNam Ahn

Successes of a National Study of the Chronic Disease Self-Management Program Meeting the Triple Aim of Health Care Reform

Background:Emerging health care reform initiatives are of growing importance amidst concerns about providing care to increasing numbers of adults with multiple chronic conditions. Evidence-based self-management strategies are recognized as central to managing a variety of chronic diseases by improving the medical, emotional, and social role management demands of chronic conditions. Objectives:To examine the effectiveness of the Chronic Disease Self-Management Program (CDSMP) among a national sample of participants organized around the Triple Aim goals of better health, better health care, and better value in terms of reduced health care utilization. Research Design:Utilizing data collected from small-group CDSMP workshops, baseline, 6-month, and 12-month assessments were examined using 3 types of mixed-effects models to provide unbiased estimates of intervention effects. Subjects:Data were analyzed from 1170 community-dwelling CDSMP participants. Measures:Triple Aim–related outcome measures: better health (eg, self-reported health, pain, fatigue, depression), better health care (eg, patient-physician communication, medication compliance, confidence completing medical forms), and better value [eg, reductions in emergency room (ER) visits and hospitalizations in the past 6 mo]. Results:Significant improvements for all better health and better health care outcome measures were observed from baseline to 12-month follow-up. The odds of ER visits significantly reduced from baseline to 12-month follow-up, whereas significant reductions in hospitalization were only observed from baseline to 6-month follow-up. Conclusions:This National Study of CDSMP (National Study) demonstrates the successful translation of CDSMP into widespread practice and its potential for helping the nation achieve the triple aims of health care reform.

National study of chronic disease self-management: six-month outcome findings.

Objective: To investigate how the Chronic Disease Self-Management Program (CDSMP) changes health outcomes, lifestyle behaviors, and health care service utilization over a 6 month period. Method: The participants were 1,170 adults enrolled in the National Study of CDSMP in 2010-2012 (M age = 65.4 years). Six-month assessments were available for 903 participants. Linear mixed models and generalized linear mixed models were used to assess the changes between baseline and 6-month assessment for primary and secondary outcomes among CDSMP participants. Results: Social/role activities limitations, depression, and communication with physicians improved significantly from baseline to 6-month follow-up. Study participants reported significant improvements in more physical activity and less emergency room (ER) visits and hospitalization during that period. Discussion: Nationally, CDSMP not only improves health outcomes and lifestyle behaviors but also decreases costly ER visits and hospitalization. Geriatricians and other primary care providers should be encouraged to refer patients with chronic conditions to such self-management programs.

Self-reported physical and mental health of older adults: The roles of caregiving and resources

OBJECTIVES This study examined factors associated with self-reported physical and mental health, focusing on caregiving status and the availability of social supports and financial resources. METHODS Two bivariate analyses were performed to examine the sociodemographic characteristics as well as perceived health outcomes among caregiving and non-caregiving participants. Two-equation probit models were used to determine independent predictors of self-reported physical and mental health, using data from 1071 community-based adults (≥ 60 years). An additional bivariate analysis was conducted to investigate the characteristics of caregivers who reported better physical health. RESULTS Approximately 17% (n=183) of respondents reported being caregivers, and those in caregiving roles tended to be ethnic minorities, married, and have telephone communication with family or friends on a daily basis. Better physical and mental health outcomes were common for caregivers and non-caregivers who reported having more resources (e.g., higher income, better preparedness for future financial need, higher satisfaction with transportation and housing, and no limitation of usual daily activities). However, sociodemographic and social support factors were not significantly associated with physical and mental health among caregivers, unlike their non-caregiver counterparts. In the probit model, caregivers were more likely to be physically healthy compared to non-caregivers (Coefficient=0.34; p-value=0.031). Compared with healthy non-caregivers (n=631), healthy caregivers (n=141) tended to be ethnic minorities, married, and have telephone communication with family or friends on a daily basis. CONCLUSIONS Findings suggest that preparing resources and maintaining strong social support systems may foster health status among older family caregivers.

The Utility of Rural and Underserved Designations in Geospatial Assessments of Distance Traveled to Healthcare Services: Implications for Public Health Research and Practice

Health disparities research in rural populations is based on several common taxonomies identified by geography and population density. However, little is known about the implications of different rurality definitions on public health outcomes. To help illuminate the meaning of different rural designations often used in research, service delivery, or policy reports, this study will (1) review the different definitions of rurality and their purposes; (2) identify the overlap of various rural designations in an eight-county Brazos Valley region in Central Texas; (3) describe participant characteristic profiles based on distances traveled to obtain healthcare services; and (4) examine common profile characteristics associated with each designation. Data were analyzed from a random sample from 1,958 Texas adults participating in a community assessment. K-means cluster analysis was used to identify natural groupings of individuals based on distance traveled to obtain three healthcare services: medical care, dental care, and prescription medication pick-up. Significant variation in cluster representation and resident characteristics was observed by rural designation. Given widely used taxonomies for designating areas as rural (or provider shortage) in health-related research, this study highlights differences that could influence research results and subsequent program and policy development based on rural designation.

Correlates of volunteering among aging Texans: the roles of health indicators, spirituality, and social engagement.

OBJECTIVES This study aimed to identify participant characteristics associated with volunteering among older adults. METHODS Based on data from the 2008 Aging Texas Well (ATW) Indicators Survey, we examined the degree to which demographic factors, health status, spiritual participation, and community involvement are associated with volunteering among adults aged 60 years or older (n = 525). RESULTS Rates of volunteering varied by race/ethnicity: non-Hispanic Whites (56.4%), African Americans (51.1%), and Hispanics (43.2%). Bivariate analyses showed that non-Hispanic White older adults were more likely to participate in formal volunteering activities, while their African American and Hispanic counterparts tended to participate in informal volunteering activities. Logistic regression analyses revealed that volunteering was less observed among Hispanics (OR = 0.48, 95% CI 0.29-0.78). Volunteering was more observed among those who reported providing informal care (OR=1.93, 95% CI 1.14-3.28), having very good or excellent mental health (OR = 1.90 and 2.07, 95% CI 1.09-3.32 and 1.20-3.55, respectively), having weekly or daily spiritual participation (OR = 2.15 and 2.35, 95% CI 1.28-3.63 and 1.29-4.28, respectively), perceiving community involvement very important (OR = 2.37, 95% CI 1.55-3.62), and being very satisfied with the community interaction (OR = 1.81, 95% CI 1.15-2.85). CONCLUSIONS Given the positive associations of mental health, spirituality, and social engagement with volunteering among older adults, system-level efforts to increase the sense of community among older adults and recognize their roles as volunteers will be helpful in recruiting and retaining older volunteers.

Older Adults’ Participation in a Community-Based Falls Prevention Exercise Program: Relationships Between the EASY Tool, Program Attendance, and Health Outcomes

PURPOSE OF THE STUDY The Exercise Assessment Screening for You (EASY) tool was developed to encourage older adults at every functional level to be more physically active. The purposes of this study were to examine characteristics of older adults who participated in an evidence-based falls prevention program by their entry to EASY tool scores, associations between EASY tool responses and class completion, and influences of EASY scores and items on improvements in days limited from usual activity and unhealthy physical health days. METHODS AND DESIGN The program consisted of eight sessions conducted statewide by trained lay leaders in Texas. Assessments were collected at the beginning of session 1 and conclusion of session 8. Data included responses of 2,235 older adults. Logistic regression analyses were performed to assess the influence of individual EASY items and cumulative scores on health outcomes from baseline to postintervention. RESULTS Neither the composite EASY scores nor the individual items significantly influenced program attendance. Higher cumulative EASY scores and individual items were associated with improvements in both health outcomes. IMPLICATIONS The EASY tool enabled seniors with major health problems to enroll in falls prevention classes, without the additional burden of requiring medical consent for participation.

Correlates of chronic disease and patient-provider discussions among middle-aged and older adult males: Implications for successful aging and sexuality.

Objective: Effective erectile dysfunction (ED) treatments and cardiovascular disease (CVD) and diabetes risk assessments are available, but require patient–provider communication. The present study explored this issue using 2010 National Social Life, Health and Aging Project data for males age 57 years and older (n = 1011).Methods: Multinomial logistic regression was performed to compare factors associated with being without CVD/diabetes (39.9%), being diagnosed with CVD only (43.1%), and having comorbid CVD/diabetes (CVD 17.0%). Logistic regression compared factors associated with having ever discussed sexual issues with physicians.Results: CVD-only participants were more likely to be ≥75 years (p = 0.004) and smoke (p = 0.019); CVD&D participants were more likely to report activity limitations (p < 0.001) and less likely to have sex within the previous year (p = 0.014). Compared to CVD-only, men with CVD&D were more likely to be minorities, obese, have daily activity limitations, and report erectile difficulties (all p < 0.05). Males discussing sexual issues with physicians were more likely to report higher education [OR = 1.68, p = 0.001], have sex in previous year [OR = 1.73, p = 0.006], and have erectile difficulties [OR = 2.26, p < 0.001].Discussion: Increased patient and provider awareness and communication are needed to lifestyle behaviors, promote self-care practices, and improve health care utilization among male patients affected by chronic disease and ED.

National Dissemination of Multiple Evidence-Based Disease Prevention Programs: Reach to Vulnerable Older Adults

Older adults, who are racial/ethnic minorities, report multiple chronic conditions, reside in medically underserved rural areas, or have low incomes carry a high burden of chronic illness but traditionally lack access to disease prevention programs. The Chronic Disease Self-Management Program (CDSMP), A Matter of Balance/Volunteer Lay Leader (AMOB/VLL), and EnhanceFitness (EF) are widely disseminated evidence-based programs (EBP), but the extent to which they are simultaneously delivered in communities to reach vulnerable populations has not been documented. We conducted cross-sectional analyses of three EBP disseminated within 27 states throughout the United States (US) (2006–2009) as part of the Administration on Aging (AoA) Evidence-Based Disease and Disability Prevention Initiative, which received co-funding from the Atlantic Philanthropies. This study measures the extent to which CDSMP, AMOB/VLL, and EF reached vulnerable older adults. It also examines characteristics of communities offering one of these programs relative to those simultaneously offering two or all three programs. Minority/ethnic participants represented 38% for CDSMP, 26% for AMOB/VLL, and 43% for EF. Rural participation was 18% for CDSMP, 17% for AMOB/VLL, and 25% for EF. Those with comorbidities included 63.2% for CDSMP, 58.7% for AMOB/VLL, and 63.6% for EF while approximately one-quarter of participants had incomes under

National dissemination of chronic disease self-management education programs: an incremental examination of delivery characteristics.

15,000 for all programs. Rural areas and health professional shortage areas (HPSA) tended to deliver fewer EBP relative to urban areas and non-HPSA. These EBP attract diverse older adult participants. Findings highlight the capability of communities to serve potentially vulnerable older adults by offering multiple EBP. Because each program addresses unique issues facing this older population, further research is needed to better understand how communities can introduce, embed, and sustain multiple EBP to ensure widespread access and utilization, especially to traditionally underserved subgroups.

The Reach of Chronic-Disease Self-Management Education Programs to Rural Populations

With a near 20-year developmental history as an evidence-based program, the suite of Chronic Disease Self-Management Education (CDSME) programs were selected in 2010 for grand-scale dissemination in a federally supported initiative to improve the health of older Americans. The primary charge of this national effort was to establish a sustainable program delivery system for empowering American adults with one or more chronic conditions to better manage their health. The current study focused on a series of dissemination and implementation science research questions to: (1) examine the geographic distribution of participation in this initiative across the Unites States; (2) describe workshop characteristics engaged to reach program participants in various settings; and (3) describe personal characteristics of the first 100,000 participants. Each subsequent entering cohort was descriptively examined to indicate whether there was constancy or change in delivery sites and populations reached over time. Findings show a strengthening of the workshop delivery infrastructure in that it took 9.4 months to reach the first 25,000 participants in 853 counties compared to 5.4 months to reach the last 25,000 participants in 1,109 counties. The workshop delivery characteristics and participant characteristics remained relatively consistent across increments of 25,000 participants reached, although general trends were observed for some variables. For example, after reaching the first 25,000 participants, subsequent groups of 25,000 participants were reached more quickly. Additionally, workshops were increasingly delivered in ZIP Codes with higher percentages of families residing below the federal poverty line. As more participants were reached, more participants with chronic conditions were enrolled. This national translational study illustrates the rapid expansion of CDSME programs throughout the United States and capability to reach diverse populations in a variety of settings.