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HUFH UH
202 260 7837 P.01/08
HEALTH CARE
FINANCING ADMINISTRATION
ADDRESSEE:
Chus Jennings
FROM: Bonne Washington
OFFICE OF THE ADMINISTRATOR
200 INDEPENDENCE AVE., S.W.
Dan Mendelson
ROOM 314G
Mark Miller
WASHINGTON, DC 20201
PHONE: 202-690-6726
PHONE:
FAX : 202-690-6262
TOTAL PAGES:
ADDRESSEE'S FAX MACHINE NUMBER:
DATE:
$
REMARKS:
Draft OPD letter to Sen Rockefeller
+ others for your nevrew. Please
let me know today if you have
Comments.
DEPARTMENT OF HEALTH & HUMAN SERVICES
Health Care Financing Administration
Deputy Administrator
Washington, D.C. 20201
The Honorable John D. Rockefeller
United States Senate
Washington, D.C. 20510
Dear Senator Rockefeller:
Thank you for your letter to the Administrator concerning the proposed Medicare hospital
outpatient prospective payment system. I am responding on her behalf, and I regret the
delay in this response.
I am aware of the many concerns raised about the potential impact that this proposed system
would have on hospitals. The estimated 5.7 percent overall reduction in payments to
hospitals that would result from implementation of this new system is sizable. You advise
that this reduction is an unintended decrease in payments to hospitals which "represents a
misinterpretation of Congressional intent" that you believe can be resolved administratively.
I want to assure you that the Health Care Financing Administration is committed to ensuring
that our payment policies are based upon an accurate reading of the law. In view of your
concerns and similar ones raised by others, I have asked the Office of General Counsel to
closely review the Balanced Budget Act provisions pertaining to the hospital outpatient
prospective payment system and to advise us of areas where we may have some flexibility.
Please be assured that this task will be completed in time to give full consideration to any
such flexibility before the promulgation of the final rule.
I appreciate your bringing this matter to my attention and your interest in assuring
appropriate payments to hospitals for outpatient services delivered to Medicare
beneficiaries. My staff and I look forward to working together on this issue with you and
the other Congressional Members who co-signed your letter.
A similar letter is being sent the other Members who co-signed your letter.
Sincerely,
Michael M. Hash
Deputy Administrator
202
260
7837
P.03/08
WASHINGTON, DC 20519 JUN 28 AN 11: 23
June 18, 1999
Nancy-Ann Min DeParle
Administrator
Health Care Financing Administration
200 Independence Avenue, S.W.
Room 314G
Washington, D.C.
Dear Madame Administrator:
We are concerned about the Department's Notice of Proposed Rulemaking (NPRM)
for the implementation of the outpatient prospective payment system (PPS) enacted in the 1997
Balanced Budget Agreement (BBA).
With the encouragement of Congress, HCFA, seniors' representatives and providers
cooperatively developed the outpatient PPS policy. The new policy was designed to address a
longstanding flaw in outpatient payment policy and to gradually rationalize Medicare's outpatient
copayments, without imposing unmanageable outpatient payment cuts on hospitals. This policy
change was accomplished in the Balanced Budget Act, which contained a $7.2 billion outpatient
payment reduction. No additional payment reductions were contemplated, analyzed or scored.
We strongly support the outpatient PPS approach. However, HCFA's proposed rule
contains an additional, unintended 5.7 percent "across the board" reduction in payments to hospital
outpatient departments. This $850 million per year reduction represents a misinterpretation of
Congressional intent and threatens the integrity of a broadly supported compromise. Total outpatient
hospital payments were to be budget neutral to a clearly identified new baseline in the law. No
additional reduction was contemplated.
Congress clearly intended that these changes to outpatient copayments be achieved on
a budget-neutral basis - the identical language that originally passed the House and the Senate clearly
precluded any payment reduction for this policy. While a minor technical drafting change in the
Conference agreement resulted in confusion over the outpatient payment formula, we believe the
Department has the flexibility under the statute to implement Congress' clear intent.
We urge that HCFA not implement an outpatient PPS rule which is inconsistent with
Congressional intent.
Day Rahyclle
Malloch Hany Tom Hartin
Sincerely,
--more--
202
200
7837
P.04/08
Hnited States Senates/DCCM
WASHINGTON, DC 20510
1999 JUN 28 All 11: 23
June 18, 1999
Nancy-Ann Min DeParle
Administrator
Health Care Financing Administration
200 Independence Avenue, S.W.
Room 314G
Washington, D.C.
Dear Madame Administrator:
We are concerned about the Department's Notice of Proposed Rulemaking (NPRM)
for the implementation of the outpatient prospective payment system (PPS) enacted in the 1997
Balanced Budget Agreement (BBA).
With the encouragement of Congress, HCFA, seniors' representatives and providers
cooperatively developed the outpatient PPS policy. The new policy was designed to address a
longstanding flaw in outpatient payment policy and to gradually rationalize Medicare's outpatient
copayments, without imposing unmanageable outpatient payment cuts on hospitals. This policy
change was accomplished in the Balanced Budget Act, which contained a $7.2 billion outpatient
payment reduction. No additional payment reductions were contemplated, analyzed or scored.
We strongly support the outpatient PPS approach. However, HCFA's proposed rule
contains an additional, unintended 5.7 percent "across the board" reduction in payments to hospital
outpatient departments. This $850 million per year reduction represents a misinterpretation of
Congressional intent and threatens the integrity of a broadly supported compromise. Total outpatient
hospital payments were to be budget neutral to a clearly identified new baseline in the law. No
additional reduction was contemplated.
Congress clearly intended that these changes to outpatient copayments be achieved on
a budget-neutral basis - the identical language that originally passed the House and the Senate clearly
precluded any payment reduction for this policy. While a minor technical drafting change in the
Conference agreement resulted in confusion over the outpatient payment formula, we believe the
Department has the flexibility under the statute to implement Congress' clear intent.
We urge that HCFA not implement an outpatient PPS rule which is inconsistent with
Congressional intent.
Sincerely,
Dan Rahyelle
Malloch Tom Hark
--more--
HUFH UH
202 260 7837 P.05/08
HCFA Letter
June 18, 1999
Page 2
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202 200 7837 P.06/08
HCFA Letter
June 18, 1999
Page 3
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202 260 7837 P.07/08
HCFA Letter
June 18, 1999
Page 4
Cluis Dr.Sol
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May L Larburd
Wayne alland
Serson Collins
Charles Schine Chuck Grassley
Max Baucus
Chuck (Robb Ped
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Mike Crpo Patent Leahy
202 200 7837 P.08/08
HCFA Letter
June 18, 1999
Page 5
10 11 mly Jammy
Jack Road
John Breacht Strom Thurmond
Richard
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TOTAL P.08
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DATE: 9-14
HUMAN SERVICES USA
U.S. DEPARTMENT OF
&
HEALTH & HUMAN SERVICES
HEALTH
ROOM 416G, HUMPHREY BUILDING
200 INDEPENDENCE AVENUE, SW
of
WASHINGTON, D.C. 20201
DEPARTMENT
PHONE: (202) 690-7627
FAX: (202) 690-7380
OFFICE OF THE ASSISTANT SECRETARY FOR LEGISLATION
ROOM 416-G HUMPHREY BUILDING
TO:
Chin Jennings
RICHARD J. TARPLIN
OFFICE:
[]] KEVIN BURKE
ROOM:
[] HAZEL FARMER
PHONE:
[]
ROSE CLEMENT LUSI
FAX:
454-5557
[] ALICE ARTIS
TOTAL PAGES
(INCLUDING COVER):
M
[ ]
FRANKIE MELTON
REMARKS: Edits on big problems only, please
Thanks for The help,
Rich
10AM
FROM
P.2
Questions and Answers for Senate DPC Luncheon
Q.
Senate Democrats are concerned that the Administration doesn't share our sense of
urgency about the BBA provider give backs. Why aren't you doing more to help deal
with this problem?
A.
Let me assure you that the President and I, as well as John Podesta, Jack Lew and others,
realize how important and urgent this issue is for you.
We have acknowledged publicly that there were unintended consequences from the BBA
that need to be addressed, and the President's plan includes $7.5 billion over 10 years to
help address problems with beneficiary access to quality care. We are also taking several
administrative actions on our own to help hospitals, home health agencies, and other
providers to adjust to the changes.
We have been working very hard over the summer with provider groups, GAO, CBO and
others to collect data and monitor access to services. While we have better information in
some areas than others, we have been able to identify provider services that need
attention. For example, we know that we will need to address the $1500 caps on
outpatient rehabilitation therapy and the nursing home payments for high acuity patients.
The bottom line is this. We will be prepared to engage in detailed work on specific
legislative proposals in the context of discussions with Congress that will take place this
fall.
Q.
Would you support restoring more than $7.5 billion in Balanced Budget Act Medicare
cuts?
A.
We continue to review the latest information to determine the appropriate level of relief
for health care providers. While we have yet to reach any conclusions that justify going
beyond the $7.5 billion in the President's plan, we would seriously consider an increase if
we were convinced that amount was insufficient to deal with problems affecting
beneficiary access to quality services. However, such provisions must have specified and
workable offsets and cannot undermine the integrity of the Medicare trust fund. We also
have to keep in mind that additional funds for providers are funds that are not available
for other important priorities that we share.
Q.
Would you support BBA relief outside of the context of broader Medicare Reform?
A.
The President has laid out a detailed plan that makes Medicare more efficient and
competitive, extends the life of the trust fund, modernizes its benefits, and funds relief
YYYY AM
FROM
P.3
from excessive BBA provider cuts. There is no question that we believe the Congress
should pass legislation this year that reflects all of these priorities. We also believe that
focusing on broad-based reforms rather than narrow pieces of policy reinforces the
public's perception that Democrats are committed to guaranteeing Medicare's future.
If, however, there is no chance for passing broader reforms and it becomes clear that the
BBA is undermining access to care for beneficiaries, we would consider the possibility of
stand-alone legislation. However, this is not our preference - and we do not think that it
should be the preference of Democrats. Medicare's challenges are bigger than the BBA
and we have an historic opportunity to address them.
Q.
If the Labor/HHS/Education allocation is so far short of the President's budget, how do
you expect this to get resolved this fall?
A.
We are very disappointed that the Republicans have dug such a deep hole for themselves,
but we believe we can have a bill at the end that preserves the priorities that we share
with you. Jack Lew can speak better to the details, but I do know that we have not even
begun to explore many of the offsets included in the President's budget.
Many of these offsets are outside my purview. But one that I know a lot about is tobacco.
We could raise significant funds through an excise tax or the kind of youth smoking
penalty that Senator Harkin is working on. This would not only fund important priorities,
but by raising the price of cigarettes it would be great public health policy too. We will
continue to work closely with you to explore the full range of options for funding the
Labor/HHS programs at an acceptable level.
BILL THOMAS, CALIFORNIA, CHAIRMAN
BILL ARCHER, TEXAS, CHAIRMAN
SUBCOMMITTEE ON HEALTH
COMMITTEE ON WAYS AND MEANS
NANCY L JOHNSON, CONNECTICUT
JIM McCRERY, LOUISIANA
AL. SINGLETON, CHIEF OF STAFF
PHILIP M. CRANE, ILLINOIS
SAM JOHNSON, TEXAS
COMMITTEE ON WAYS AND MEANS
ANN-MARIE LYNCH, SUBCOMMITTEE STAFF DIRECTOR
DAVE CAMP. MICHIGAN
JIM RAMSTAD, MINNESOTA
JANICE MAYS, MINORITY CHIEF COUNSEL
PHILIP S. ENGLISH, PENNSYLVANIA
U.S. HOUSE OF REPRESENTATIVES
BILL VAUGHAN, SUBCOMMITTEE MINORITY
FORTNEY PETE STARK, CALIFORNIA
GERALD D. KLECZKA, WISCONSIN
WASHINGTON, DC 20515
JOHN LEWIS, GEORGIA
JIM McDERMOTT, WASHINGTON
KAREN L. THURMAN, FLORIDA
SUBCOMMITTEE ON HEALTH
Ex OFFICIO
BILL ARCHER, TEXAS
CHARLES B. RANGEL, NEW YORK
April 29, 1999
Mr. Christopher Jennings
Domestic Policy Council
The White House
Washington, DC 20500
Dear Chris,
In a recent Senate Finance Committee hearing on the context and evolution of
Medicare, several Senators - both Republican and Democrat - expressed interest in the
testimony of Dr. Wennberg of Dartmouth University. As you know, Dr. Wennberg's work
shows that health care demand is generated by supply, and that spending is determined by
utilization in a given area. Dr. Wennberg asserts that by changing practice patterns, we can
curb Medicare spending without jeopardizing health outcomes and quality.
For the past several months, I have been working on a comprehensive package of
incremental changes for Medicare. Many of these ideas are based on Dr. Wennberg's
findings in the 1998 Dartmouth Atlas. I am writing to ask that you consider incorporating
some of my ideas into the President's Medicare reform proposal. Not only will these
suggestions help establish bipartisan support for the President's bill, they may also enable
us to achieve our goal of a modernized Medicare program without having to adopt more
radical reforms. Incremental steps are a more feasible, and more desirable way to ensure
the Medicare guarantee of accessible, high quality health care.
Democrats agree that Medicare needs to be improved. But overhauling the program
is unnecessary when alternative solutions, such as these, are available. Granting Medicare
more flexibility to negotiate prices and conduct demonstration projects will make the
program more equitable, effective, and efficient. These changes may also result in
substantial program savings.
Attached is a list of ideas to consider. I would appreciate hearing your thoughts.
Please let me know if you need any additional information or clarification.
The Pete Stark
Sincerely,
Member of Congress
MEDICARE MODERNIZATION PROVISIONS
Part of a plan to improve the equity, effectiveness, and efficiency
of Medicare for all Americans
Traditional Medicare fee-for-service can and should be improved. Granting greater
flexibility for purchasing and demonstration projects to Medicare will enable the
program to change and improve over time. When combined with appropriate
patient and provider incentives, these tools will not only improve the quality of
health services, but will also result in significant savings for Medicare. The
following ideas are drawn heavily from suggestions made by Dr. John Wennberg of
Dartmouth University and the National Academy of Social Insurance:
Purchasing and Payment Initiatives
Global payments (HR 1392: Centers of Excellence)
Sustainable growth rate (SGR) and anti-gaming provisions to correct for
program inflation
Adjust physician RBRVS SGR by region, state, or MSA
Selective contracting
Competitive bidding
A single payment system for post-acute care hospital services
Outpatient payment reform to ensure services in most appropriate setting
Reduced capital payments in areas of excess bed supply
DSH "carve-out" and adjustments for VA/DOD beneficiaries
Expanded inherent reasonableness authority
Contractor reform
Health Outcomes and Quality Improvements
Shared decision making between patients and providers (HR 1544: "Patient
Empowerment Act")
Case management, bundling, and post-acute care services (rural bill
introduced 4/29)
Normative practice guidelines and incentives
Expanded preventive health services and patient reminder mechanisms
Improved end-of-life care
DRAFT Stark Medicare Modernization Proposal
The following is a compilation of work begun in previous
Congresses, and elaborations on recommendations by the
National Academy of Social Insurance and Dr. John
Wennberg of Dartmouth University. This comprehensive
package is currently being drafted by Legislative
Council. Several items have already been introduced,
either as free-standing bills, or as sections in other
legislation.
Title: Medicare Modernization
Chapter 1. Purchasing and Payment Initiatives (Give
Medicare Preferred Provider Authority)
Subchapter A. Centers of Excellence
(Introduced 106th: HR 1392)
An administration proposal, passed by
House in BBA, but failed in Conference.
Expand on this proposal by giving the
Secretary authority to waive Part A
hospital deductible to patients who use
a Center of Excellence. In other words,
for certain expensive, complicated
procedures and coordinated chronic care
treatment, Medicare starts acting like
a PPO.
Subchapter B. Authority to selectively contract (see
NASI Recommendations)
Subchapter C. Normative Practice Information
By 1/1/05 the Secretary shall profile
practice patterns of providers (both
individuals, institutions, and
1
Medicare+Choice organizations) and shall
provide information to the provider and
the public on how their pattern of
practice compares to others in the
Nation, State, and locally. [This policy
is an elaboration of unused authority
currently in 1842 (G) (3) (L) ]
After 2010, the Secretary may adjust
payments to providers to encourage
movement away from deviations of under-
service and over-service compared to
generally accepted practices (e.g., if a
hospital discharges more than one
standard deviation earlier, or later,
for a particular DRG, its payment rate
shall be reduced)
Subchapter D. Treatment Notification
(Introduced 106th: HR 1544)
Demonstration project: In areas where
there is wide variation of practice
without variation in outcome, the
Secretary shall furnish videotapes to
providers outlining treatment options,
including discussions of recent
scientific opinions. The physician is
expected to show the videotape to
patients with designated diseases or
injuries before the patient elects a
course of treatment. Compensation will
be provided to participating
physicians. Such information shall be
reviewed and approved by the AHCPR (This
is the Dartmouth Atlas education
proposal)
2
Chapter 2. Sustainable Growth Rate (SGR) and Anti-
Gaming Authority
Subchapter A. Give the Secretary the authority to
recommend to Congress, in the event of
unexplained increases in intensity of
services, utilization, unbundling, etc.
which is causing an unusual growth in
costs in a service (e.g., the recent GAO
report describing the growth of
expensive tests for ESRD patients
outside the ESRD composite rate), a SGR
system similar to that used in the RB-
RVS doctor payment system for any Part A
or B service. The SGR may be set
nationally, by region, State or MSA.
Implementation is contingent on
Congressional enactment.
Subchapter B. The Secretary may adjust total payments
to a hospital (or hospital chain) if she
determines that on a case-severity
adjusted basis, the hospital or chain is
costing Medicare more than similar types
of cases in public and not-for-profit
hospitals (the Columbia/HCA loophole
closing amendment)
Subchapter C. The Secretary may adjust Physician RBRVS
SGR by region, State, or MSA (MedPAC
recommendation).
Chapter 3. Expansion of Competitive Bidding
The Medicare+Choice and DME Competitive
Bidding demonstration in the BBA sections
4011 and 4319 should be presumed to work and
save money, made permanent and extended
nationwide after 2004, and administered
3
through local intermediaries and carriers,
and consortia of contractors (i.e., a
combined A&B contractor may request bids for
a bundled A&B service)
The Secretary shall have authority to enter
into competitive bids for other medical
services with extra weight given to
providers for demonstrated quality.
Examples of bidding expansion would include
organ transplant centers (in the area
whether there are more than one)
lithotripsy services, diagnostic imaging,
non-emergency ambulance services, etc.
Chapter 4. Case Managers, Bundling, and Post-Acute Care
Services
Subchapter A. Provide a case manager for post-acute
hospital care.
(Introduced 106th: HR 746)
The Secretary shall demonstrate (and if
she finds cost savings, implement)
methods of case management, bundling of
services, chronic care, end-of-life
care, and post-acute care case
management. [Drafting note: Build on BBA
sec. 4016, re: Medicare Coordinated Care
Demonstration Project and HR 4591 -
105th].
Subchapter B. If the Secretary estimates that
treatment in a non-hospital or non-
institutional setting can provide
quality care and outcomes, she may waive
requirements which discourage or prevent
treatment in such setting (e.g., SNF 3-
day hospitalization rule, co-pays,
4
deductibles, etc. )
Subchapter C. Development of a single payment system
for post-acute care hospital services.
As soon as possible, but no later than
2010, the Secretary shall develop and
implement a single, unified payment
system for post-acute care hospital
services. (Currently, we are developing
5 or 6 PPS systems all using somewhat
different payment, risk adjuster, and
other criteria. There is great fear
that we are setting ourselves up for
being gamed by providers who will bounce
patients from setting to setting to
maximize payments. A single system is
essential- but the research of how to
get there is weak. This would indicate
our long-term goal.)
Subchapter D. Case Management in Rural Areas
(Introduced 106th: HR 1646)
Since managed care plans are unlikely to
ever develop or operate in rural and
frontier areas, give the Secretary
authority to pay an extra monthly amount
to primary care providers who undertake
case management' functions for rural
Medicare residents (if the Secretary
determines that such payments will
produce savings and improve quality of
care).
5
Subchapter E. Outpatient Payment reform
(Draft received: to be introduced)
The Secretary may pay the lower of
hospital outpatient or ambulatory
surgical center rates, if she determines
it will save Medicare and beneficiaries
money. She can apply this provision by
region, state of MSA.
Subchapter F. Preventive Health Care Expansion
(Draft received: to be introduced)
Give the Secretary authority to provide
a service when she determines that,
based on evidence, and on consultation
with the Office of the Chief Actuary and
the Congressional Budget Office, that
the provision of the service will save
Medicare resources in the long-run by
delaying the onset of a more expensive
disease (e.g., dietetic services may in
some cases delay the onset of kidney
dialysis), detecting the disease at a
more treatable and less expensive stage,
or offering a service which will save
the cost of treatment in a more costly
setting [e.g., more adequate coverage of
adult day care services (HR 4403 -
105th) may avoid more costly
institutionalization].
Chapter 6. More Efficient Use of Capital
Reductions in Capital Payments in Cases of
Excess Bed Supply (in some States, hospitals
are half empty)
6
The Secretary may, for years after 2004,
reduce PPS and TEFRA capital payments by up
to 25% in a region, state, county, or MSA
that she determines has a higher number of
beds per 1000 than the national average, and
the hospital occupancy is below national
average.
She shall make exceptions in cases of
capital needed to downsize, for a merger
which reduces excess capacity, respond
to closure of another facility or to
meet needs of an under-served
population.
Chapter 7. Improve payments to Medicare+Choice Plans
and increase consumer protections
(Draft received: to be introduced)
by counting Medicare costs of VA & DoD
services (McDermott Amendment to VA
Subvention bill and included in HR 491 -
106th)
by 'carving out' DSH payments from M+C
payments and pay directly to hospitals
when a M+C plan uses a DSH hospital (HR
2701 - 105th/Rangel)
Chapter 8. Expanded Inherent Reasonableness/"Most- -
Favored-Nation" concept
(Draft received: to be introduced)
BBA's Inherent Reasonableness authority is
expanded to allow any amount of adjustment
that the Secretary finds is appropriate to
eliminate overpayments (i.e., adjustment is
not limited to 15% per year)
7
Similar to the authority used by CalPERS,
the Secretary shall have the authority to
request the Most-Favored-Rate (making
appropriate adjustments for any extra costs
associated with dealing with Medicare) in
cases where Medicare is the volume buyer in
the market and other efforts at achieving a
market price are not available (i.e., a sole
or dominant provider in an area does not
respond to competitive bidding)
Title II:
Medicare Administration
Chapter 1. New Provider Fees
(On Hold)
HCFA shall set fees for granting a new
provider number to anyone seeking to
bill Medicare (Administration user fee
proposals for FY 99) to finance
provider background check.
Starting in 2003, HCFA shall impose an
administrative fee on anyone still
submitting paper claims (Administration
user fee proposals for FY 99).
Chapter 2. Compliance plan
Providers must have a Compliance Plan in
Operation [Anti-fraud provision: insert HR
2543], in exchange for which HCFA will offer
paperwork reduction proposals [to be
developed].
8
Chapter 3. Contractor Reform
(To be introduced w/in Early Access Bill)
The Administration proposal to give HCFA
more authority and flexibility to contract
with intermediaries and carriers. HR 4186.
Chapter 4. Medicare Secondary Payer
(Introduced w/in Fraud and Abuse Bill)
Ensure better data match between employers
and Medicare [CBO: +$400 million/5 Insert
HR 2632 section].
K:\Work\Wp\Legislation\Medicare Mods pub draft.wpd
MAY 27 '99 15:16 FR
TO 94565557
P.01/23
UNITED * STATES * *
*
ES
SENATE
Bob Graham
Florida
FAX TRANSMITTAL SHEET
TO: Devora Adder
PHONE:
FROM:
PHONE:
MaH Basry
DATE:
TIME:
5/27/99
NUMBER OF PAGES (including cover):
524 Hart Senate Office
45(2 trensmissions)
Building, Washington
D.C. 20510
COMMENTS:
Per our connosation.
PLEASE DELIVER THE FOLLOWING PAGES TO THE PARTY LISTED ABOVE.
If there is a problem in transmission, please call (202) 224-3041
MAY 27 '99 15:16 FR
TO 94565557
P.02/23
O:\JGS\JGS99.137
DISCUSSION DRAFT
S.L.C.
106TH CONGRESS
1ST SESSION
S.
IN THE SENATE OF THE UNITED STATES
Mr. GRAHAM introduced the following bill; which was read twice and referred
to the Committee on
A BILL
To promote general and applied research for health pro-
motion and disease prevention among the elderly, to
amend title XVIII of the Social Security Act to add
preventive benefits, and for other purposes.
1
Be it enacted by the Senate and House of Representa-
2 tives of the United States of America in Congress assembled,
3 SECTION 1. SHORT TITLE; TABLE OF CONTENTS.
4
(a) SHORT TITLE.-This Act may be cited as the
5 "Healthy Seniors Promotion Act of 1999".
6
(b) TABLE OF CONTENTS.-The table of contents is
7 as follows:
Sec. 1. Short title; table of contents.
Sec. 2. Finding
Sec. 3. Definitions.
MAY 27 '99 15:16 FR
TO 94565557
P.03/23
0:\JGS\JGS99.137
DISCUSSION DRAFT
S.L.C.
2
TITLE I-HEALTHY SENIORS PROMOTION PROGRAM
Sec. 101. Healthy seniors promotion program.
Sec. 102. Sense of Congress regarding the response of HCFA to preventive
health issues.
Sec. 103. Sense of Congress regarding the efforts of HCFA to study health
promotion and disease prevention for medicare beneficiaries.
Sec. 104. Sense of Congress regarding the establishment of a medicare health
promotion and disease prevention clearinghouse.
TITLE II-MEDICARE COVERAGE OF PREVENTIVE SERVICES
Sec. 201. Medicare coverage of counseling for cessation of tobacco use.
Sec. 202. Medicare coverage of screening for hypertension.
Sec. 203. Medicare coverage of counseling for hormone replacement therapy.
Sec. 204. Medicare coverage of screening for glaucoma.
Sec. 205. National falls prevention education and awareness campaign.
Sec. 206. Program integrity.
TITLE III-LIMITED PREVENTION-RELATED OUTPATIENT
PRESCRIPTION DRUG BENEFIT
Sec. 301. Medicare coverage of outpatient prescription drugs.
Sec. 302. Selection of entities to provide outpatient drug benefit.
Sec. 303. Access of low-income beneficiaries to covered outpatient drugs.
Sec. 304. Allocation of Federal proceeds from global tobacco settlement to en-
hance covered outpatient drug benefit.
Sec. 305. Medicare drug benefit study.
Sec. 306. Effective date.
TITLE IV-STUDIES AND REPORTS ADVANCING ORIGINAL
RESEARCH IN PREVENTION AND THE ELDERLY
Sec. 401. MedPAC biannual report.
Sec. 402. National Institute on Aging study and report.
Sec. 403. Institute of Medicine 5-year medicare prevention benefit study and
report.
Sec. 404. Fast-track consideration of preventive benefit legislation
1 SEC. 2. FINDING.
2
Congress finds that despite significant advancements
3 in general research for health promotion and disease pre-
4 vention among the elderly, there has been a failure in
5 translating that research into practical intervention.
6 SEC. 3. DEFINITIONS.
7
As used in this Act:
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3
1
(1) MEDICARE BENEFICIARY-The term "med-
2
icare beneficiary" means any individual who is enti-
3
tled to benefits under part A or enrolled under part
4
B of the medicare program, including any individual
5
enrolled in a Medicare + Choice plan offered by a
6
Medicare + Choice organization under part C of such
7
program.
8
(2) MEDICARE PROGRAM.-The term "medicare
9
program" means the health care program under title
10
XVIII of the Social Security Act (42 U.S.C. 1395 et
11
seq.).
12
(3) SECRETARY.-The term "Secretary" means
13
the Secretary of Health and Human Services.
14
TITLE I-HEALTHY SENIORS
15
PROMOTION PROGRAM
16 SEC. 101. HEALTHY SENIORS PROMOTION PROGRAM.
17
(a) DEFINITIONS.-As used in this section:
18
(1) ELIGIBLE ENTITY.-The term "eligible en-
19
tity" means an entity that the Working Group deter-
20
mines has demonstrated expertise in research re-
21
garding health promotion and disease prevention
22
among the elderly.
23
(2) WORKING GROUP.-The term "Working
24
Group" means the Healthy Seniors Working Group
25
established under subsection (d).
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1
(b) PROGRAM AUTHORIZED.-The Secretary, subject
2 to the general policies and criteria established by the
3 Working Group and in accordance with the provisions of
4 this Act, is authorized to make grants to eligible entities
5 to pay for the costs of the activities described in subsection
6 (c).
7
(c) USE OF FUNDS.-An eligible entity may use pay-
8 ments received under this section in any fiscal year to
9 study-
10
(1) the effectiveness of using different types of
11
providers of care who are not physicians and the use
12
of alternative settings (including community based
13
senior centers) for the implementation of a success-
14
ful health promotion and disease prevention strat-
15
egy, including implications regarding the payment of
16
such providers;
17
(2) the most effective means of educating medi-
18
care beneficiaries and providers of services regarding
19
the importance of health promotion and disease pre-
20
vention among the elderly and identification of in-
21
centives that would increase the use of new and ex-
22
isting preventive services by medicare beneficiaries;
23
and
24
(3) other topics designated by the Secretary.
25
(d) HEALTHY SENIORS WORKING GROUP.-
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1
(1) ESTABLISHMENT-There is established
2
within the Department of Health and Human Serv-
3
ices a Healthy Seniors Working Group.
4
(2) COMPOSITION.-Subject to paragraph (3),
5
the Working Group established pursuant to sub-
6
section (b) shall be composed of 5 members as fol-
7
lows:
8
(A) The Administrator of the Health Care
9
Financing Administration.
10
(B) The Director of the Centers for Dis-
11
ease Control and Prevention.
12
(C) The Administrator of the Agency for
13
Health Care Policy and Research.
14
(D) The Assistant Secretary for Aging.
15
(E) The Director of the National Institute
16
on Aging.
17
(3) ALTERNATIVE MEMBERSHIP.-
18
(A) APPOINTMENT.-The members of the
19
Working Group described in paragraph (2) may
20
appoint an individual who is an officer or em-
21
ployee of the Federal Government to serve as a
22
member of the Working Group instead of the
23
member described in such subparagraph.
24
(B) DEADLINE.-If a member described in
25
subparagraph (A) elects to appoint an individ-
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6
1
ual under such subparagraph, such individual
2
shall be appointed not later than December 31,
3
1999.
4
(4) GENERAL POLICIES AND CRITERIA.-The
5
Working Group shall establish general policies and
6
criteria with respect to the functions of the Sec-
7
retary under this section including-
8
(A) priorities for the approval of applica-
9
tions;
10
(B) procedures for developing, monitoring,
11
and evaluating research efforts conducted under
12
this section; and
13
(C) such other matters as are rec-
14
ommended by the Working Group and approved
15
by the Secretary.
16
(5) CHAIRPERSON.-The Chairperson of the
17
Working Group shall be the The Administrator of
18
the Agency for Health Care Policy and Research.
19
(6) QUORUM.-A majority of the members of
20
the Working Group shall constitute a quorum, but
21
a lesser number of members may hold hearings.
22
(7) MEETINGS.-The Working Group shall
23
meet at the call of the Chairperson, except that-
24
(A) it shall meet not less than 4 times each
25
year; and
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1
(B) it shall meet whenever a majority of
2
the appointed members request a meeting in
3
writing.
4
(8) COMPENSATION OF MEMBERS.-Each mem-
5
ber of the Working Group shall be an officer or em-
6
ployee of the Federal Government and shall serve
7
without compensation in addition to that received for
8
their service as an officer or employee of the Federal
9
Government.
10
(d) APPLICATION.-
11
(1) IN GENERAL.-Each eligible entity which
12
desires to receive a grant under this section shall
13
submit an application to the Secretary, at such time,
14
in such manner, and accompanied by such additional
15
information as the Secretary may reasonably re-
16
quire.
17
(2) CONTENTS.-Each application submitted
18
pursuant to paragraph (1) shall--
19
(A) describe the activities for which assist-
20
ance under this section is sought;
21
(B) describe how the research effort pro-
22
posed to be conducted will reflect the medical,
23
behavioral, and social aspects of care for the el-
24
derly, including cost-effectiveness and quality of
25
life impacts stemming from any initiative;
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1
(C) provide evidence that the eligible entity
2
meets the general policies established by the
3
Working Group pursuant to subsection (d) (4);
4
(D) provide assurances that the eligible en-
5
tity will take such steps as may be available to
6
it to continue the activities for which the eligi-
7
ble entity is making application after the period
8
for which assistance is sought; and
9
(E) provide such additional assurances as
10
the Secretary determines to be essential to en-
11
sure compliance with the requirements of this
12
Act.
13
(3) JOINT APPLICATION.-A consortium of eli-
14
gible entities may file a joint application under the
15
provisions of paragraph (1) of this subsection.
16
(f) APPROVAL OF APPLICATION.-The Secretary
17 shall approve applications in accordance with the general
18 policies established by the Working Group under sub-
19 section (d).
20
(g) PAYMENTS.-The Secretary shall pay to each eli-
21 gible entity having an application approved under sub-
22 section (f) the cost of the activities described in the appli-
23 cation.
24
(g) EVALUATION AND REPORT.-
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1
(1) EVALUATION.-The Secretary shall conduct
2
an annual evaluation of grants made under this sec-
3
tion to determine—
4
(A) the results of the overall applied re-
5
search conducted under this Act;
6
(B) the extent to which research assisted
7
under this section has improved or expanded
8
the general research for health promotion and
9
disease prevention among the elderly and identi-
10
fied practical interventions based upon such re-
11
search;
12
(C) a list of specific recommendations
13
based upon research conducted under this sec-
14
tion which show promise as practical interven-
15
tions for health promotion and disease preven-
16
tion among the elderly;
17
(D) whether or not as a result of the ap-
18
plied research effort certain health promotion
19
and disease prevention benefits or education ef-
20
forts should be added to the medicare program,
21
including discussions of quality of life and cost-
22
effectiveness for each proposed addition;
23
(E) the utility of, potential for, and issues
24
surrounding health risk appraisals sponsored
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1
under the medicare program and targeted fol-
2
low up; and
3
(F) how best to increase utilization of ex-
4
isting and recommended health promotion and
5
disease prevention services, including an edu-
6
cation and public awareness component discus-
7
sion of financial incentives for providers of serv-
8
ices and medicare beneficiaries to improve utili-
9
zation and other administrative means of in-
10
creasing utilization.
11
(2) REPORT.-Not later than December 31,
12
2002, the Secretary shall submit a report to Con-
13
gress based on the annual studies made under para-
14
graph (1), which shall contain a detailed statement
15
of the findings and conclusions of the Working
16
Group together with its recommendations for such
17
legislation and administrative actions as it considers
18
appropriate.
19
(h) AUTHORIZATION OF APPROPRIATIONS.-There
20 are authorized to be appropriated $25,000,000 for fiscal
21 years 1999, 2000, 2001, and 2002 to carry out the provi-
22 sions of this section.
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1 SEC. 102. SENSE OF CONGRESS REGARDING THE RESPONSE
2
OF HCFA TO PREVENTIVE HEALTH ISSUES.
3
It is the sense of Congress that in administering the
4 medicare program the Secretary should ensure that the
5 Administrator of the Health Care Financing Administra-
6 tion encourages the inclusion of preventive measures as
7 part of all treatments described in such program.
8 SEC. 103. SENSE OF CONGRESS REGARDING THE EFFORTS
9
OF HCFA TO STUDY HEALTH PROMOTION
10
AND DISEASE PREVENTION FOR MEDICARE
11
BENEFICIARIES.
12
It is the sense of Congress that the Secretary should
13 ensure that the Administrator of the Health Care Financ-
14 ing Administration expands the study of the most promis-
15 ing behavioral modification of risk factors associated with
16 health promotion and disease prevention for all medicare
17 beneficiaries.
18 SEC. 104. SENSE OF CONGRESS REGARDING THE ESTAB-
19
LISHMENT OF A MEDICARE HEALTH PRO-
20
MOTION AND DISEASE PREVENTION CLEAR-
21
INGHOUSE.
22
It is the sense of Congress that the National Library
23 of Medicine should collect information regarding innova-
24 tive and successful health promotion and disease preven-
25 tion interventions from both published and unpublished
26 sources, establish a clearinghouse targeting all medicare
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1 beneficiaries in a variety of settings for the consolidation
2 and coordination of all such information, and make the
3 clearinghouse available to the public and accessible
4 through the Internet.
5 TITLE II-MEDICARE COVERAGE
6
OF PREVENTIVE SERVICES
7 SEC. 201. MEDICARE COVERAGE OF COUNSELING FOR CES-
8
SATION OF TOBACCO USE.
9
(a) COVERAGE.-Section 1861(s)(2) of the Social Se-
10 curity Act (42 U.S.C. 1395x(s)(2)) is amended-
11
(1) in subparagraph (S), by striking "and" at
12
the end;
13
(2) in subparagraph (T), by striking the period
14
at the end and inserting "; and"; and
15
(3) by adding at the end the following:
16
"(U) counseling for cessation of tobacco use (as
17
defined in subsection (uu)).".
18
(b) SERVICES DESCRIBED.-Section 1861 of such
19 Act (42 U.S.C. 1395x) is amended by adding at the end
20 the following:
21
"Counseling for Cessation of Tobacco Use
22
"(uu) The term 'counseling for cessation of tobacco
23 use' means diagnostic, therapy, and counseling services for
24 cessation of tobacco use which are furnished by or under
25 the supervision of a physician or other health care profes-
57840
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1 sional who is legally authorized to furnish such services
2 under State law (or the State regulatory mechanism pro-
3 vided by State law) of the State in which the services are
4 furnished, as would otherwise be covered if furnished by
5 a physician or as an incident to a physician's professional
6 service.".
7
(c) PAYMENT.-Section 1833(a)(1) of such Act (42
8 U.S.C. 13951(a)(1)) is amended-
9
(1) by striking "and (S)" and inserting "(S)";
10
and
11
(2) by striking the semicolon at the end and in-
12
serting the following: ", and (T) with respect to
13
counseling for cessation of tobacco use (as defined in
14
section 1861(uu)), the amount paid shall be 100
15
percent of the lesser of the actual charge for the
16
services or the amount determined by a fee schedule
17
established by the Secretary for the purposes of this
18
subparagraph;".
19
(d) EFFECTIVE DATE.-The amendments made by
20 this section shall apply to services furnished on or after
21 December 31, 2001.
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1 SEC. 202. MEDICARE COVERAGE OF SCREENING FOR HY-
2
PERTENSION.
3
(a) COVERAGE.-Section 1861(s)(2) of the Social Se-
4 curity Act (42 U.S.C. 1395x(s)(2)) (as amended by sec-
5 tion 201(a)) is amended-
6
(1) in subparagraph (T), by striking "and" at
7
the end;
8
(2) in subparagraph (U), by striking the period
9
at the end and inserting "; and"; and
10
(3) by adding at the end the following:
11
"(V) screening for hypertension (as defined in
12
subsection (vv))
13
(b) SERVICES DESCRIBED.-Section 1861 of such
14 Act (42 U.S.C. 1395x) (as amended by section 201(b))
15 is amended by adding at the end the following:
16
"Screening for Hypertension
17
"(vv) The term 'screening for hypertension' means di-
18 agnostic services for hypertension which are furnished by
19 or under the supervision of a physician or other health
20 care professional who is legally authorized to furnish such
21 services under State law (or the State regulatory mecha-
22 nism provided by State law) of the State in which the serv-
23 ices are furnished, as would otherwise be covered if fur-
24 nished by a physician or as an incident to a physician's
25 professional service.".
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1
(c) PAYMENT.-Section 1833(a)(1) of such Act (42
2 U.S.C. 13951(a)(1)) (as amended by section 201(c)) is
3 amended-
4
(1) by striking "and (T)" and inserting "(T)";
5
and
6
(2) by striking the semicolon at the end and in-
7
serting the following: ", and (U) with respect to
8
screening for hypertension (as defined in section
9
1861(vv)), the amount paid shall be 100 percent of
10
the lesser of the actual charge for the services or the
11
amount determined by a fee schedule established by
12
the Secretary for the purposes of this subpara-
13
graph;".
14
(d) EFFECTIVE DATE.-The amendments made by
15 this section shall apply to services furnished on or after
16 December 31, 2001.
17 SEC. 203. MEDICARE COVERAGE OF COUNSELING FOR HOR-
18
MONE REPLACEMENT THERAPY.
19
(a) COVERAGE.-Section 1861(s)(2) of the Social Se-
20 curity Act (42 U.S.C. 1395x(s)(2)) (as amended by sec-
21 tion 202(a)) is amended—
22
(1) in subparagraph (U), by striking "and" at
23
the end;
24
(2) in subparagraph (V), by striking the period
25
at the end and inserting "; and"; and
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1
(3) by adding at the end the following:
2
"(W) counseling for hormone replacement ther-
3
apy (as defined in subsection (ww))
4
(b) SERVICES DESCRIBED.-Section 1861 of such
5 Act (42 U.S.C. 1395x) (as amended by section 202(b))
6 is amended by adding at the end the following:
7
"Counseling for Hormone Replacement Therapy
8
"(ww) The term 'counseling for hormone replacement
9 therapy' means diagnostic, therapy, and counseling serv-
10 ices for hormone replacement which are furnished by or
11 under the supervision of a physician or other health care
12 professional who is legally authorized to furnish such serv-
13 ices under State law (or the State regulatory mechanism
14 provided by State law) of the State in which the services
15 are furnished, as would otherwise be covered if furnished
16 by a physician or as an incident to a physician's profes-
17 sional service."
18
(c) PAYMENT-Section 1833(a)(1) of such Act (42
19 U.S.C. 1395](a)(1)) (as amended by section 201(c)) is
20 amended-
21
(1) by striking "and (U)" and inserting "(U)";
22
and
23
(2) by striking the semicolon at the end and in-
24
serting the following: ", and (V) with respect to
25
counseling for hormone replacement therapy (as de-
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1
"Screening for Glaucoma
2
"(xx) The term 'screening for glaucoma' means diag-
3 nostic services for early detection of glaucoma which are
4 furnished by or under the supervision of a physician or
5 other health care professional who is legally authorized to
6 furnish such services under State law (or the State regu-
7 latory mechanism provided by State law) of the State in
8 which the services are furnished, as would otherwise be
9 covered if furnished by a physician or as an incident to
10 a physician's professional service."
11
(c) PAYMENT.-Section 1833(a)(1) of such Act (42
12 U.S.C. 1395l(a)(1)) (as amended by section 201(c)) is
13 amended-
14
(1) by striking "and (V)" and inserting "(V)";
15
and
16
(2) by striking the semicolon at the end and in-
17
serting the following: ", and (W) with respect to
18
screening for glaucoma (as defined in section
19
1861(xx)), the amount paid shall be 100 percent of
20
the lesser of the actual charge for the services or the
21
amount determined by a fee schedule established by
22
the Secretary for the purposes of this subpara-
23
graph;".
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1
(d) EFFECTIVE DATE.-The amendments made by
2 this section shall apply to services furnished on or after
3 December 31, 2001.
4 SEC. 205. NATIONAL FALLS PREVENTION EDUCATION AND
5
AWARENESS CAMPAIGN.
6
The Secretary, in consultation with the Director of
7 the Centers for Disease Control and Prevention, shall con-
8 duct a national falls prevention and awareness campaign
9 to reduce fall-related injuries among medicare bene-
10 ficiaries.
11 SEC. 206. PROGRAM INTEGRITY.
12
The Secretary, in consultation with the Inspector
13 General of the Department of Health and Human Serv-
14 ices, shall integrate the benefits described in sections 201,
15 202, 203, and 204 with existing program integrity meas-
16 ures.
17 TITLE III-LIMITED PREVEN-
18
TION-RELATED OUTPATIENT
19
PRESCRIPTION DRUG BENE-
20
FIT
21 SEC. 301. MEDICARE COVERAGE OF OUTPATIENT PRE-
22
SCRIPTION DRUGS.
23
(a) COVERAGE.-Section 1861(s)(2) of the Social Se-
24 curity Act (42 U.S.C. 1395x(s)(2)) (as amended by sec-
25 tion 204(a)) is amended—
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1
(1) in subparagraph (W), by striking "and" at
2
the end;
3
(2) by striking the period at the end of sub-
4
paragraph (X) and inserting "; and"; and
5
(3) by adding at the end the following:
6
"(Y) covered outpatient drugs (as defined in
7
section 1849(h)(1)) pursuant to the procedures es-
8
tablished under such section;".
9
(b) PAYMENT.-Section 1833(a)(1) of such Act (42
10 U.S.C. 13951(a)(1)) (as amended by section 204(c)) is
11 amended—
12
(1) by striking "and (W)" and inserting "(W)";
13
and
14
(2) by striking the semicolon at the end and in-
15
serting the following: and (X) with respect to cov-
16
ered outpatient drugs (as defined in section
17
1849(h)(1)), the amounts paid shall be the amounts
18
established by the Secretary pursuant to such sec-
19
tion;".
20 SEC. 302. SELECTION OF ENTITIES TO PROVIDE OUT-
21
PATIENT DRUG BENEFIT.
22
Part B of title XVIII of the Social Security Act (42
23 U.S.C. 1395j et seq.) is amended by adding at the end
24 the following:
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1 "SEC. 1849. SELECTION OF ENTITIES TO PROVIDE OUT-
2
PATIENT DRUG BENEFIT.
3
"(a) ESTABLISHMENT OF BIDDING PROCESS.-
4
"(1) IN GENERAL.-The Secretary shall estab-
5
lish procedures under which the Secretary accepts
6
bids from eligible entities and awards contracts to
7
such entities in order to provide covered outpatient
8
drugs to eligible beneficiaries in an area. Such con-
9
tracts may be awarded based on shared risk, capita-
10
tion, or performance.
11
"(2) AREA.-
12
"(A) REGIONAL BASIS.-The contract en-
13
tered into between the Secretary and an eligible
14
entity shall require the eligible entity to provide
15
covered outpatient drugs on a regional basis.
16
"(B) DETERMINATION.-In determining
17
coverage areas under this section, the Secretary
18
shall take into account the number of eligible
19
beneficiaries in an area in order to encourage
20
participation by eligible entities.
21
"(3) SUBMISSION OF BIDS.-Each eligible en-
22
tity desiring to provide covered outpatient drugs
23
under this section shall submit a bid to the Sec-
24
retary at such time, in such manner, and accom-
25
panied by such information as the Secretary may
26
reasonably require. Such bids shall include the
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1
amount the eligible entity will charge eligible bene-
2
ficiaries under subsection (e)(2) for covered out-
3
patient drugs under the contract.
4
"(4) ACCESS.-The Secretary shall ensure
5
that-
6
"(A) an eligible entity complies with the
7
access requirements described in subsection
8
(f)(4); and
9
"(B) an eligible entity makes available to
10
each beneficiary covered under the contract the
11
full scope of benefits required under paragraph
12
(5).
13
"(5) SCOPE OF BENEFITS.-The Secretary shall
14
ensure that all covered outpatient drugs that are
15
reasonable and necessary to prevent or slow the de-
16
terioration of, and improve or maintain, the health
17
of eligible beneficiaries are offered under a contract
18
entered into under this section.
19
"(6) NUMBER OF CONTRACTS.-The Secretary
20
shall, consistent with the requirements of this sec-
21
tion and the goal of containing medicare program
22
costs, award at least 2 contracts in an area, unless
23
only 1 bidding entity meets the minimum standards
24
specified under this section and by the Secretary.
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1
"(7) DURATION OF CONTRACTS.-Each con-
2
tract under this section shall be for a term of at
3
least 2 years but not more than 5 years, as deter-
4
mined by the Secretary.
5
"(b) ENROLLMENT.-
6
"(1) IN GENERAL.-The Secretary shall estab-
7
lish a process through which an eligible beneficiary
8
shall make an election to enroll with any eligible en-
9
tity that has been awarded a contract under this sec-
10
tion and serves the geographic area in which the
11
beneficiary resides. In establishing such process, the
12
Secretary shall use rules similar to the rules for en-
13
rollment and disenrollment with a Medicare+Choice
14
plan under section 1851.
15
"(2) REQUIREMENT OF ENROLLMENT.-An eli-
16
gible beneficiary not enrolled in a Medicare + Choice
17
plan under part C must enroll with an eligible entity
18
under this section in order to be eligible to receive
19
covered outpatient drugs under this title.
20
"(3) ENROLLMENT IN ABSENCE OF ELECTION
21
BY ELIGIBLE BENEFICIARY.-In the case of an eligi-
22
ble beneficiary that fails to make an election pursu-
23
ant to paragraph (1), the Secretary shall provide,
24
pursuant to procedures developed by the Secretary,
25
for the enrollment of such beneficiary with an eligi-
** TOTAL PAGE. 23
**
From: RelaisFax To:
Date: 4/30/99 Time: 15:05:09
Page 2 of 19
Physical Activity Interventions Targeting Older Adults,
A Critical Review and Recommendations
Abby C. King, PhD, W. Jack Rejeski, PhD, David M. Buchner, MD, MPH
Background:
Although many of the chronic conditions plaguing older populations are preventable
through appropriate lifestyle interventions such as regular physical activity, persons in this
age group represent the most sedentary segment of the adult population. The purpose of
the current paper was to provide a critical selected review of the scientific literature
focusing on interventions to promote physical activity among older adults.
Methods:
Comprehensive computerized searches of the recent English language literature aimed at
physical activity intervention in adults aged 50 years and older. supplemented with visual
scans of several journal on aging, were undertaken. Articles were considered to be relevant
for the current review if they were community-based, employed a randomized design or a
quasi-experimental design with an appropriate comparison group, and included informa-
tion on intervention participation rates, pre- and post-intervention physical activity levels,
and/or pre/post changes in relevant physical performance measures.
Results:
Twenty-nine studies were identified that fit the stated criteria. Among the strengths of the
studies reviewed were reasonable physical activity participation rates and relatively long
study durations. Among the weaknesses of the literature reviewed were the relative lack of
specific behavioral or program-based strategies aimed at promoting physical activity
participation, as well as the dearth of studies aimed at replication, generalizability of
interventions to important subgroups, implementation, and cost-effectiveness evaluation.
Conclusions:
Recommendations for future scientific endeavors targeting older adults are discussed.]
Medical Subject Headings (MeSH): review, physical fitness, exercise, adult aged+,
intervention studies, leisure activities (recreation) (Am] Prev Med 1998;15(4):316-333) ©
1998 American Journal of Preventive Medicine
P
eople over age 65 constitute one of the fastest-
can begin to become evident as early as the fifth decade
growing population segments among industrial-
of life,⁸ arguing for preventive approaches begun in the
ized nations. 1.2 They additionally carry by far the
middle years, as well as earlier, as a means of promoting
greatest proportion of chronic disease burden, disabil-
health and limiting disability in the later years of life.3
ity, and health care utilization, 3-5 much of it prevent-
Although regular physical activity has been demon-
able. 3,6 For example, approximately 88% of those over
strated to be critical for the promotion of health and
age 65 have at least one chronic health condition, and
function as people age," persons over 50 years of age
large numbers of older adults suffer from impaired
represent the most sedentary segment of the adult
functioning and well-being. Notably, loss of function
population. 10 This is particularly the case for persons
aged 75 and above. 10
Division of Epidemiology Department of Health Research and Policy]
The vast majority of physical activity intervention
and the Stanford Center for Research in Disease Prevention, Depart-
studies undertaken to date have focused on younger
ment of Medicine, Stanford University School of Medicine
Palo Alto, California 94304-1583; Department of Health and Sports
adult populations. 11 The purpose of the current paper
[USA]
Science, Wake Forest University (Rejeski) Winston-Salem. North
is to provide a critical review of the scientific literature
Carolina 27109-7234; Departments of Health Services and Medicine,
focusing on interventions to promote physical activity
University of Washington (Buchner), Seattle, Washington 98103; and
Northwest Health Services Research and Development Field Pro-
among older adults. Consonant with the recent World
grain, Seattle VA Medical Center (Buchner). Seattle, Washington
Health Organization guidelines for promoting physical
98103.
activity and fitness among older persons, 12 as well as
Address correspondence to: Dr. A.C. King, Stanford University
School of Medicine, Stanford Center for Research in Disease Preven-
recommendations made by other health organiza-
tion. Suite B 730 Welch Road, Palo Alto, California 94304-1583.
tions,³ we have focused our efforts on summarizing the
This paper was a background paper for the Cooper Institute
Conference Series Physical Activity Interventions, an ACSM Specialty
highest quality studies that have targeted persons aged
Conference.
50 and older.
316 Am Prev Med 1998;15(4)
0719-3797/98/$19.00
© 1998 American Journal of Preventive Medicine
l'll S0749-3797(98)00085-3
From: RelaisFax To:
Date: 4/30/99 Time: 15:05:09
Page 3 of 19
Methods
samples relative to the younger samples on whom the
Comprehensive computerized searches of the recent
majority of the literature has been based, or, alterna-
English language literature aimed at physical activity
tively, a positive reporting/publication bias. The some-
intervention in the elderly were undertaken indepen-
what higher exercise participation rates reported also
dently at two universities (Stanford and Wake Forest). A
could be due to use of lower-intensity exercise prescrip-
number of available databases were searched on appro-
tions in many of the studies reviewed relative to studies
priate key terms and MeSH terms for all previous years
focusing on younger individuals. In some studies no
through the present, including MEDLINE, PSYC (psy-
description was included regarding how exercise par-
chological abstracts), BIOSIS (biological abstracts),
ticipation rates were specifically tracked or calculated.
ERIC (educational resources information center ab-
Although attendance rates are commonly reported,
stracts), and MAGS (magazine index) databases. In
other aspects of the prescription (i.e., exercise inten-
addition, the authors visually checked the previous six
sity, duration) often are not. In addition, some investi-
volumes of several journals on aging, including The
gators did not employ an intention-to-treat principle in
Gerontologist and the Journal of Gerontology, for relevant
reporting exercise participation rates (i.e., poor com-
articles. Articles were considered to be relevant for the
pliers or drop-outs were not included in calculating
current review if they were community-based (i.e.,
exercise patterns). This can lead to an inflation of the
included reasonable numbers of community-dwelling
adherence results.
older adults without diagnosed coronary heart disease,
Only 13 (45%) of the studies reviewed explicitly
and employed interventions that could be realistically
described or mentioned the use of specific behavioral,
generalized, as opposed to intensive training studies
educational, social, cognitive, or program-based (e.g.,
undertaken in a laboratory, medical setting, or similar
exercise type, intensity, format) strategies aimed at
highly controlled setting); employed a randomized
promoting physical activity participation. Six studies
design or a quasi-experimental design with an appro-
explicitly manipulated one or more of these strategies
priate comparison group; and included information on
as part of the study design with the aim of influencing
intervention participation rates, pre- and post-interven-
participation rates. 14-19 The most frequently included
tion physical activity levels, and/or pre/post changes in
methods to promote participation were behavioral
physical performance measures that could be reason-
strategies based on social learning theory and its deriv-
ably expected to reflect changes in physical activity.
atives²⁰ (10 studies), and strategies focused on exercise
Studies focusing on cardiac patients were excluded in
type (e.g., less vigorous forms of exercise) or format
light of their inclusion in another review in this series
(e.g., self-paced, class- or home-based) (10 studies).
(see the review focusing on health care settings). Stud-
Effective interventions included those that employed
ies of older adults with other, noncardiovascular forms
behavioral or cognitive-behavioral strategies as opposed
of chronic illness (e.g., arthritis, chronic obstructive
to health education or instruction alone. 18.21.22 The
pulmonary discase) that met the above criteria were
majority of these studies utilized a combination of
included. Relevant recent work that had been pub-
behavioral and/or cognitive tools (e.g., goal-setting
lished in abstract form was also included.
self-monitoring, feedback, support, relapse-prevention
Twenty-six randomized trials and three quasi-experi-
training). From the study descriptions available, how-
mental studies were identified that fit the above crite-
ever, there is likely a large amount of variance among
ria. These studies are summarized in Table 1.
studies with respect to the specific protocols employed
These studies were evaluated with respect to eight
in implementing these strategies. One randomized,
areas, described below.
controlled trial demonstrated the utility of systematic
training in social-cognitive strategies, enhanced
Effectiveness
through group dynamics, in increasing physical activity
frequency 3 months following the formal end of the
Across the studies evaluated, exercise participation
program. 19 Only two studies were found that systemat-
rates were defined typically as the number of exercise
ically tested the effects of specific cognitive or behav-
sessions attended or reported, divided by the number
ioral strategies in influencing exercise participation.
of sessions prescribed. The exercise participation rates
One study with chronic obstructive pulmonary discase
noted in the 19 studies that explicitly reported them
(COPD) patients found cognitive-behavioral modifica-
ranged from 36%-98% (mean = approximately 75%;
tion approaches to produce greater 3-month physical
median = approximately 80%). In light of the obser-
activity adherence and better adherence during the
vation that only about 50% of adults without heart
3-month maintenance period than either cognitive
disease who begin an exercise program will maintain
modification or behavior modification alone. 14 A sec-
participation in the program beyond 3 months, 18 this
ond study tested the effects of efficacy-based adherence
range is relatively high, suggesting the possibility of
instruction and found it to increase exercise frequency,
higher physical activity participation rates in older adult
duration, and distance more effectively than health
Am J Prev Med 1998;15(4)
317
Table 1. Physical activity intervention studies in older adults using experimental (n - 26) or quasi-experimental (n = 3) designs
From: To:
Physical activity
Dependent
Study
Sample
Design
Setting
target
variable
Intervention
Post-test
Follow-up
Arkins et al.
76 COPD pts.,
Randomized factorial;
Home-based
Walking
Walking adher.
1-1: Behav. modification
3 mos; (3 dropouts were
6 mos. from baseline;
(1984) 14a
mean age =
no apparent test for
(logs); exercise
I-2: Cognitive mod.
replaced) Three I programs had
cog.-bchav. mod.
64.8 ± 7.9 yrs;
gender effect
tolerance (graded
I-3: Cog-behav. mod.
increased exercise levels
program continued to
63% women
treadmill test); sclf-
C-1: Attention-control
compared to controls; cog.-
report superior
reported function;
efficacy expectations
C-2: Assessment only
behav. mod. produced greater
walking adherence
walking adherence than other 1
relative to other arms
All I Ss received 5 1-hr.
arms.
(based on 2/3 of
instructional sessions in
original sample).
their homes.
Blumenthal
101 nondisabled
Randomized factorial;
Community,
Aerobic exercise
Cardiorespiratory
I: Actobic exercise (3
4 mos; 96% study retention
(Emery et al., 1992)
ct al. (1989)
community-
tested for gender
group-based
fitness (peak VO2)
supervised scssions/wk)
rate; I significantly improved in
10 more mos. of
dwelling adults
effects
C-1: Yoga + flexibility
peak VO₂, (11.6%) relative to C.
supervised aerobic
(60-83 yrs: mean
C-2: Wait-list
exercise; eval. of self-
= 67.0 yrs); well-
reported activity 1 yr.
educated: 50%
later; 94% of Ss
women; no
located reported some
reported
form of continued
eligibility criteria
exercise (66%
based on
reported regular
inactivity
walking)
Buchner
105 adults with
Randomized factorial;
Community,
Aerobic
Gait and balance
I-1: Aerobic exercise (3
6 mos; 92% study retention
9 mos from baseline:
et al.
at least mild
Ss selected from a
group-based
exercise,
tests, physical health
supervised sessions/wk
rate; I Ss who did not drop out
adherence to
(1997)
deficits in
random sample of
strength
status measures.
for 35 min each using
attended 95% of scheduled
unsupervised exercise
strength and
HMO enrollees; no
training
aerobic capacity,
stationary cycles) for 26
exerc. session; Sig. increases in
reported at 58%
balance (68-85
apparent test for
sclf-reported falls.
wks;
isokinetic strength in I-2; within-
exercised 3 or more
yrs; mean = 75
gender effects
inpatient/outpatient
I-2: two sets of resistive
group increases in aerobic
times/wk, 24% twice/
yrs); 51%
use and costs
exerc. on weight
capacity for I-3. No effects on
wk, and 5% did not
women; well
machines (3 supervised
gait. balance, or physical health
exercise.
Date: 4/30/99 Time: 15:05:09
educated
sessions/wk) for 26 wks;
status; sig. beneficial effect of
1-3: 20 min of aerobic
exerc. on time to first fall and
exer. and 1 set of
total falls. No sig. group diffs. in
resistive exerc. for 26
ancillary outpatient costs;
wks;
greater days in hospital for C
C: Wait-listed 26-wk
rel. to 1. Minimal injury rates in
program followed by
all I conditions.
self-supervised exercise
in all I conditions.
Chow et al.
58 healthy
Randomized factorial
Community,
Aerobic exercise
Exercise adherence,
I-1: SO min of group
1 yr: 83% study retention rate;
No follow-up reported
(1987)
postmenopausal
group-based
(higher
calculated VO₂max
aerobic activities 3X/wk:
overall average exercise class
white women
(hospital
intensity),
1-2: same aerobic
attendance for the yr. was 70%:
(50-62 yrs): no
gymnasium)
strength
activities as above + 10
Both I groups had higher fitness
reported
training (low
min/session of strength
levels and greater bunc mass
eligibility criteria
intensity)
training using wrist and
than C, no diffs. between I
based on
ankle weights.
groups.
inactivity
C: Assessment only
Conningham
224 men retirees
Randomized
Community,
Aerobic exercise
Self-reported activity
1: Leader-led group
1 yr; 96% study retention rate; I
No follow-up reported
et al. (1987)
(55-63 YTS; mean
controlled: stratified
group-based
(walking or
(Minnesota Leisure
exercise on an outdoor
successful in increasing high
= 62.7 vis). no
on blue- or white-
jogging)
Time Activity
track. 3x/wk (30 min
intensity activity and VO₂max
reported
collar job but no
questionnaire);
of aerobic ex.)
relative to C.
eligibility criteria
apparent test of this
VO₂max
C: Assessment only
based 011
subgroup effect
inactivity
(contitued on next gage)
Page 4 of 19
From: RelaisFax To:
Table 1. Physical activity intervention studies in older adults using experimental (n = 26) or quasi-experimental (n = 3) designs
Physical activity
Dependent
Study
Sample
Design
Setting
Larget
variable
Intervention
Post-test
Follow-up
Emery and
18 sedentary
Randomized factorial
Community
Brisk walking
Field tests of
L 20-25 min of acrobic
12 wks; 81% study retention
No follow-up reported
Gatz (1990)
older adults (61-
group-based
and rhythmic
physic al fitness;
ex. (with additional
rate; group exercise attendance
86 yrs; mean =
muscle
psychological and
stretching and cool-
range = 61%-94%; poor
72 yrs) recruited
strengthening
cognitive
down), 3x/wk.
attendance in the social control
from an inner-
exercises
functioning; group
C-1: Attention-control
group Minimal between-group
city community;
attendance
(social activities)
dills. detected on fitness,
ethnically diverse
C-2: Wait-listed control
psychological, or cognitive
(56% minority);
measures.
low education
levels
Ettinger
439 community-
Randomized factorial;
Community,
Aerobic
Sclf-reported activity
1-1: 3-mo. facility-based
18 mos; 83% study retention
No follow-up reported
et al. (1997)*
dwelling adults
post hoc secondary
group- and
exercise;
(participation
walking + 15-month
rate. Participation rates in both
with knee
analyses to examine
home-based
resistance
rates), physical
home-based walking;
I arms 69%; Both I arms
osteoarthritis;
outromes by race,
exercise
function
3X/wk, 40
improved on 6-min walk and
60+ YTS (mean
gender, age, and
performance
min/session;
other perform. casks relative to
= 69 yrs): 70%
BMI.
measures
1-2: Facility-home
C. Improve. generally seen in all
women; range of
resistance training as
subgroups tested.
education; 26%
above; home programs
African
for both I conditions
American
included home visits [4]
and telephone calls [19]
C: Health education
Gillett et al.
182 healthy
Randomized factorial
Community,
Low-impact
Fitness (submax
I-1: Health + fitness ed.
16 wks; 90% study retention
No follow-up reported
(1996)¹⁵ᵃ
obese, sedentary.
group-based
aerobic exercise
bike test), body
1 X/wk.
rate; both 1 groups attended
nonsmoking
composition
I-2: Health + fitness ed.
approx. 86% of class sessions.
women (60-70
(skinfolds). self-
+ acrobic exercise.
Sig. increase in fitness in I-2 rel.
Date: 4/30/99 Time: 15:05:09
YTS; mean = 64.4
report physical
1X/wk of education
to I-1 and C; both 1-1 and I-2
YTS)
activity records.
and 3X/wk for 30
reported exercising from 3-4
attendance roster
mins/session of
days/wk; longer ex. duration
supervised low-impact
reported by I-1. No injuries
dance exercise; both I
reported.
groups led by nurses
and included
behavioral strategies.
C: Assessment only
Hamdorf
80 healthy,
Randomized
Community,
Habitual
Self-reported activity
1: 2X/wk of supervised.
26 wks; 82.5% study retention
(Hamdorf et al. 1993)
et al. (1992)
sedentary
controlled
group-based
physical activity
(Human Activity
progressive walking in a
rate; exercise adherence rate of
12 mos. from baseline
community-
patterns; fitness
Profile: Normative
group with an
I Ss completing program was
(T given community
dwelling women
Impairment Index):
enthusiastic and
90.6%; Increased babitual
ex. group list at 6
(60-70 VTS; mean
Fitness (cycle
experienced instructor;
activity patterns and fitness
mos); 77.8% of
= 64 YTS)
ergometer)
45 mins/session
relative to C; low injury rate
training group
C: Wait-listed
(5%)
reported continued
walking participation;
increases in reported
activity patterns and
fitness maintained in I
relative to C
Hopkins
65 sedentary
Randomized
Community
Low-inpact
6 functional fitness
1: 20 min. of low-impact
12 weeks; 81.5% study retention
No follow-up reported
et al. (1990)
community-
controlled
classes
aerobic danco
tests (AAHPERD)
progressive aerobic
rate: Sig. improvements over C
dwelling
dance. 2X/wk
in cardiorespiratory endurance.
medically cleared
C: Wait-listed
strength. balance, flexibility,
women (57-77
agility. and body fat.
Page 5 of 19
yrs; mean = 65.5
yrs);
continued on next page)
Table 1. Physical activity intervention studies in older adults using experimental (n = 26) or quasi-experimental (n = 3) designs
Physical activity
Dependent
Study
Sample
Design
Setting
target
variable
Intervention
Post-test
Follow-up
From: To:
Jette et al.
102 nondisabled
Randomized
Home-
Musclc strength
Peak torque in
I: One 50-min. training
12-15 wks; Ss â 72y had sig.
No follow-up reported
(1996)26
community-dwelling
controlled; tested for
based,
using resistive
lower and upper
session with PT; 30-
increase in knee extension
adults (66-87 yrs;
gender effect
mediated
clastic bands
extremities
min. home videotape.
torque rel. to C; no sex effect
mean - 72 YTS); 63%
(videotape)
3X per wk, 12-15 wks.
women; well
C Assessment only
educated; no
reported eligibility
criteria based on
inactivity
King et al.
357 nondisabled,
Randomized factorial;
Community
Leisure acrobic
Self-reported activity
1-1: Higher-intensity,
1 yr: Exercise participation data
(King Cl al.. 1995)25
(1991)*
sedentary
population-based
exercise of
(participation
class-based (3X/wh).
available on all Ss; fitness data
24 mo from baseline;
group-
community-lwelling
recruitment
based.
moderate or
rates), fitness
1-2: Higher-intensity,
available on 84% of sample;
1-yr fitness gains
adults (50-65 yrs;
strategies; test for
home-based
higher intensity
(treadmill
home-based (3X/wk).
Participation in 2 home-based
maintained for all I
mean 57 yrs); well
gender effect
(telephone-
performance)
1-3: Moderate-intensity,
arms sig. better than class arm
arms; Participation
educated: 45%
supervised)
home-based (5x/wk).
(76% VS. 53%); Treadmill
highest in higher-
women
Cog-behav. strategies
performance sig. improved in
intensity home-based
employed for all I.
all I arms compared to C.
arm
C: Assessment only
King et al.
103 nondisabled,
Randomized to 1 of 2
Community,
Moderate
Participation rates,
I-1: 2 class + 2 home
1 yr; Exercise participation data
No follow-up reported
(1997)-
sedentary
interventions;
group +
intensity
self-reported activity
sessions/wk of low-
available on all Ss; Similar exer.
(abstract)
community-dwelling
population-based
home
endurance,
(PASE. CHAMPS),
impact aerobics,
participation rates for both 1
adults (65-82 yrs;
recruitment
(telephone-
strength. and
treadmill excrcise
walking and
(82% session completion rate):
mean = 70.2 yrs):
strategies; test for
supervised)
flexibility
testing,
strengthening (resistive
adherence sig. better to home
well educated; 65%
gender effect
performance-based
hands) exercise.
exercise in both programs; 1-1
women
and self-report
1-2: class + 2 home
sig. better than I-2 on reported
measures of physical
sessions/wk of
daily energy expenditure,
function
stretching and
submax HR, upper-body
flexibility exercise. For
strength, walking impairment;
Date: 4/30/99 Time: 15:05:09
both 1, duration = 40-
I-2 sig. better than I-1 on rated
45 min/session and
daily pain
cognitive-behavioral
strategics employed
Kriska et al.
229 postmenopausal
Randomized
Community, Walking
Self-reported activity
1: 2 group sessions/wk
2 YTS, Mean blocks walked and
10-yr. results in
(1986)
community-dwelling
controlled
group +
(Paffenbarger
+ once/wk on own for
1.S1 day activity counts/hr
preparation
women who could
home
survey): LSI activity
8 wks: then group
increased sig. relative to control
physically walk (50-
monitor
optional. Behavioral
65 yrs): no reported
strategies employed,
eligibility criteria
including phone calls,
based on inactivity
logging, newsletters.
social events, incentives
Ci Assessment-only
I ord et al.
197 healthy,
Randomized
Community
Aerobic/balance/ Class attendance;
L 35-min conditioning
12 mos; 75% of I completed
(Williams and Lord,
(1995) 17*
sedentary community
controlled;
classes
strengthening
perceived and
period, 2x/wk;
posttesting and attended 26 or
1995) 18 mos from
dwelling Australian
population-based
exercises
measured physical
emphasis on social
more classes: class attendance
baseline; 53% of I
women (60-85 yrs;
recruitment methods
and psychological
interaction and
rate for those completing study
continued attending
man = 71.6 yrs)
(71% of those eligible
function
enjoyment; classes were
was 73%; 1 improved in strength
exercise classes:
took part)
easily accessible
and related measures rcl. to C
continuation
Ci Assessment only
associated with better
scores on strength,
body sway and
depression at 12 mos.
(continued UTI THE page)
Page 6 of 19
Table 1. Physical activity intervention studies in older adults using experimental (n = 26) or quasi-experimental (n = 3) designs
From: RelaisFax To:
Physical activity
Dependent
Study
Sample
Design
Setting
target
variable
Intervention
Post-test
Follow-up
Mackeen
171 healthy male
Randomized
Community,
Jogging
Physical work
I: Supervised
By 6 mo. exercise adherence
13 yrs from baseline (aged
et al.
Penn State employees
controlled
group-based
capacity; adherence
endurance exercise
dropped 10 50% and then
53-72 yrs); 28% of 1
(1985)
(40-59 yrs at entry):
(primarily jogging):
stabilized through 18 mos.
reported some continued
excluded extremely
goal of 3x /week,
(Taylor et al. 1973). At 18
jogging; E and C not
physically active men,
lasting 35-75 min
ulos, enhancement of
significantly different with
but no other
C: Assessment only
physical work capacity
regard to physical activity
eligibility criteria
compared to C
habits measured via
based on inactivity
Minnesota Leisure Time
Physical Activity interview
McAuley
114 healthy. sedentary
Randomized
Community.
Walking
Exercise behavior
I: Exercise +
20 wks; Study retention rate
No follow-up reported
et al.
community-dwelling
controlled; tests for
group-based
(program
adherence intervention
unclear; I more effective in
(1994)¹⁸
adults (45-64 yrs;
gender and age
attendance, daily
(efficacy-based
increasing exercise freq.
mean = 54.5 yrs):
effects
logs, self-reported
information begun in
duration, and distance
51% women
exerc. duration and
3rd week, delivered via
relative to C; I attended 67%
distance covered);
six 15-min biweekly
of exercise sessions compared
self-efficacy for
meetings prior to
with 55% for C; 62% of I VS.
exercise
exercise).
38% of C attended at least 2
C: exercise + attention-
exer. sessions/wk; treatment
control (health cd.).
effects appeared to be most
Both groups received a
pronounced in last 3 mos of
leader-led walking
program.
program 3X/wk for 40
min/session.
McMurdo
86 adults with limited
Randomized factorial;
Home-based
Mobility
Functional
1-1: mobility training
6 mos; 80% study retention
No follow-up reported
and
mobility and
no apparent test for
excrcise,
performance tasks
(stretching, range-of-
rate: No statistical diffs.
Johnstone
dependence in at
gender effect
strength
motion).
between arms; suspected
(1995)51
least 1 ADL (75-96
training
I-2: strength training
poor compliance, but no
YTS; mean = 82 yrs);
(above + resistive
info. available. Sample size
Date: 4/30/99 Time: 15:05:09
89% women
elastic bands) Daily 15
(power) issues raised.
min/session for both I
arms.
C: health education All
Ss received 30-min visits
by physiotherapist every
3-4 wks.
Minor el al.
120 adults with
Randomized factorial;
Community,
Aerobic walking,
Exercise tolerance,
I-1: 3X/wk of aerobic
12 wks; 80% study retention
6, 12, and 18 mos. from
(1989)
rheumatoid arthritis
stratified by diagnosis
group-based
aerobic aquatics
daily activity level
walking. 30 min/session
rate; 78% of I-1, 85% of I-2.
baseline: 69% study
(RA) or osteoarthritis
and tested for
(3-day diary), self-
(of a 1-hr class);
and 87% of C completed
retention rate at 6 and 12
(OA) (21-83 yrs:
diagnosis effect; no
reported health
I-2: 3x/wk of aerobic
the class; mean attendance
mos.; 6 mos.: Changes
mean = 61 yrs); 82%
apparent test for
status (AIMS)
aquatics, 30 min/
of class completers = 85%;
reasonably maintained
women
diagnosis or gender
session (of a 1-hr class);
Two I groups had sig.
over baseline in both I
effects
C: 3x/wk of range of
improvement in acrobic
groups: I-1 showed greater
motion, 1 hr/session.
capacity, exercise test
improve. in aerobic
duration, ATMS scores on
capacity than I-2 or C. 12
physical activity, anxiety, and
mos.: Changes reasonably
depression, and 50-ft. walk
maintained over bascline
rel. to C; RA somewhat
in both I groups; no
better net improve. than
between-group diffs.; Sig.
OA.
increase in acrobic
capacity in C; 57% of all
Ss reported at least 60
mins. of exer/wk. 21 mos:
(Minor and Brown, 1993)⁵⁵:
81% study retention rate;
mean sclf-reported exer. =
110 min/wk
Page 7 of 19
(continued on next page)
Table 1. Physical activity intervention studies in older adults using experimental (n = 26) or quasi-experimental (n = 3) designs
From: RelaisFax To:
Physical activity
Dependent
Study
Sample
Design
Setting
target
variable
Intervention
Post-test
Follow-up
Pollock et al.
57 healthy,
Randomized factorial
Community,
Walk/jog.
Participation rates,
I-1: Supervised walk/jog
26 wks; 86% study retention
No follow-up reported
(1991)37
sedentary,
group-based
resistance
VO₂max and
40 mins/session. 3x/
rate; 98% attendance rates in I
community-
training
strength testing;
wk.
groups; Sig. improvements in
dwelling adults
injury rates
I-2: Supervised 10
VO₂max (I-1) and strength (I-2)
(70-79 yrs: mean
variable resistance
rel. to C, but high injury rates
= 72 yrs); 56%
exercises 40
with jogging and I-RM testing.
women
mins/session, 3x/wk.
C: Assessment only
Rejeski and
60 healthy,
Randomized factorial;
Community,
Moderate
Self-reported activity
I-1: 12 wks, began with
6 mos.; 40% study retention
9 mos. from baseline;
Brawley
sedentary,
no tests for gender or
center- and
intensity aerobic
(Stanford 7-day
2 center- and 1 home-
rate; At 6 mos., I-1 and I-2 had
I-2 sig. higher than I-1
(1997)
community-
age effects
home-based
exercise,
recall), VO2peak,
based sessions/wk;
sig. higher peak MET capacities
in mean freq. of
(abstract)
dwelling adults
especially
health-related
moved to 1 center- and
and enhanced quality of life rel.
weekly physical
(65-78 yrs; man
walking
quality of life
4 home-based sessions/
to C; no diffs. in these
activity.
= 69 yrs); 63%
wk; home-based exer.
outcomes among two I groups;
women; 46% of
monitored via logs,
no diffs. between 1 groups on
sample had a
telephone contact.
mean freq., duration, or vol. of
high school
I-2: Focus on
physical activity
education or less
maintenance following
a structured program
in addition to above;
use of social-cognitive
adher. strategies
(buddy system, group
activities, self-regulatory
strategies).
C: Wait-listed
Rikli and
31 healthy
Quasi-cxpcrimental
Classes
Moderate-
Class attendance
L Instructor-led classes.
3 yrs: 71% study retention rate;
No follow-up reported
Date: 4/30/99 Time: 15:05:09
Edwards
community-
offered at a
intensity low-
records; step-test
20-25 min of aerobic
Approx. 80% average exercise
(1991)¹⁰
dwelling women
local
impact aerobics
performance; motor
exercise/session. 3X/
class attendance rates; I sig.
who were 1st-
retirement
and walking,
function and
wk.
improved in step-test perform.
time enrollees in
complex
general
cognitive processing
C Attention-control
in Year 1 rel. to baseline with
exercise classes
calisthenics
speed
(enrolled in
leveling off (maintenance) in
taught at a local
nonexercise hobby
yrs 2 and 3; Sig. improve. in
retirement
classes at the same
balance, flexibility
complex and 17
locale)
controls
enrolled in
nonexercise
hobby classes
(59-81 yrs; mean
= 70 yrs)
Rooks ct al.
131 healthy,
Randomized factorial;
Community
Resistance
Neuromotor
I-1: Self-paced, class-
10 mos; 81% study retention
No follow-up reported
(1997)*
community-
tested for gender
center
training, walking
performance,
based resistance
rate; mean participation rates =
dwelling adults
effect
participation rates
training without
83% in I-1 and 82% in I-2; no
(65-95 yrs; mean
expensive equipment
injuries occurred: I-1 sig. better
= 74 vrs) who
(stair-climbing with
than others on muscle strength.
participated at
weight belt: hand
reaction time (diff. from C); I-1
least twice a
weights, etc.), 3x/wk, 1
and I-2 better than C on stair
week in
hr/session.
climbing speed, balance.
community
I-2: Self-paced, group-
activities at
based walking, 3X/wk,
baseline: 66%
up to 15 min/session.
women
C Wait-listed control
Page 8 of 19
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Table 1. Physical activity intervention studies in older adults using experimental (n = 26) or quasi-cxperimental (n = 3) designs
Physical activity
Dependent
Study
Sample
Design
Setting
target
variable
Intervention
Post-test
Follow-up
Sharpe et al.
139 adults from
Quasi-experimental
Classes held
Low-intensity
Performance-based
I: Low-intensity exercise
1 yr; 79% study retention rate:
No follow-up reported
five congregate
(two I sites and 3
at
exercise,
and self-report
2X/wk; behavioral
mean I participation score =
meal centers in
comparison sites); no
congregate
including chair
measures of physical
strategies (gnal-sctring,
36%; 72% of I reported doing
South Carolina;
apparent test for
meal
movement,
function
feedback, incentives).
home exercise; I improved in
87% Black, 86%
gender effect
centers
standing dance
C: Wait-list
10-ft walk rel. to C
women (60-91
movement,
yrs; mean = 75
optional use of
yrs)
hand-weights
Stewart et al.
91 adults from
Quasi-experimental
Community
Low- to
Participation rates
1: 1 Face-to-face
6 mos; 91% study retention
No follow-up reported
(1997)
two HUD-
(1 I and 1
classes and
moderate-
at community
counseling session with
ratc; I had sig. greater
supported senior
comparison sitc); no
programs
intensity
classes; reported
telephone follow-up;
community program partic.
congregate
test for gender effect;
already
endurance and
energy expenditure
behavioral strategies
rates than C (34% vs. 34%); Ex.
housing facilities
pop.-based
being
conditioning
(CHAMPS); sclf-
employed to increase
adopters had sig. increases in
(62-91 yrs; mean
recruitment methods
offered for
exercise
report measures of
participation in
weekly caloric expenditure and
=77 yrs); 82%,
seniors
programs
function
exercise classes and
improve. in psychol. outcomes
women, mean
programs.
rel. to those who did not.
educ. yrs = 14;
C: Wait-list
Ss with health
probs. included
Stewart et al
173 sedentary
Randomized
Community
Moderate-
Energy expenditure
I: 1 Face-to-face
12 mos; 93% study retention
24 mos follow-up
(1997)
adults from 2
controlled;
classes and
intensity
(CHAMPS quest.);
counseling session with
rate; I had sig. net improvement
planned
(abstract)
Medicare HMOs
population-based
home
endurance and
participation rates;
telephone follow-up
in reported energy expenditure
(65-90 yrs; mean
recruit. methods
conditioning
functional
and monthly
(405 cal/wk increase) and
= 74 YTS); 66%
(33% of those eligible
exercise
performance tasks
informational classes;
exercise frequency (3 times/wk)
women, mean
enrolled); tests for
goal of 5 sessions/wk;
relative to C.
educ. yrs = 15.2;
age and gender
behavioral strategies
Date: 4/30/99 Time: 15:05:09
Ss with health
effects
employed to increase
probs. included
exercise participation.
C: Wait-list
Toshima
129 COPD
Randomized
Community
Walking
Exercise endurance
I: Comprehensive
8 wks: 91% study retention rate;
6 mos. from baseline;
et al.
patients (mean
controlled
rehabilitation
(treadmill and
(peak, symptom-
rehab. program, with
Exercise endurance increased
89% study retention
(1990)**
= 62.6 yrs); 27%
free-walking at
limited treadmill
12, 4hr sessions; each
relative to C; self-efficacy
rate; exercise
women
home)
test); measures of
included 2 ed. group
increased in 1 rcl. to C
endurance increases
well-being, efficacy
sessions + supervised
in I remained rel. to
exercise training
C; self-efficacy
(Individualized exercise
increases in I
Rx, support). C:
reasonably maintained
Education control (8 hr
rel. to C
total). For both I and
C, Ss required to make
up any sessions missed.
Wallace
100 community-
Randomized,
Community
Walking/acrobic
Health-related
L 3 classes/wk, 60
6 mos.; 90% study retention
No follow-up reported
et al.
dwelling,
controlled; recruited
senior
activity +
quality of life
mins. of exercise/class;
rate; >90% attendance at thrice
(1998)48
ambulatory
via a senior center; S
center
strength training
(SF-36); class
received risk factor
weekly exercise classes;
adults (mean =
demographics
classes
+ flexibility;
attendance
info. in other health
significant net improve. in
72 yrs); 73%
compared with
offered within
areas (diet, smoking,
nearly all SF-36 subscales in I
women; well-
population-based
the context of a
alcohol, etc.);
rel. to C (which declined on
educated
survey respondents
multi-factor
C: Wait-listed
this measure).
program for
disability
prevention
Page 9 of 19
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Page 10 of 19
education information. Finally, few studies are avail-
able that have compared the addition of behavioral
Follow-up
8 mos from bascline:
80% study retention
rate; I-1 had reduced
risk of multiple falls
rel. to other groups.
and/or cognitive interventions to more standard ap-
proaches in which participants are simply instructed to
exercise either through formal center-based programs
or various educational mediums. This approach would
allow for better determination of the additive effects of
such cognitive-hehavioral strategies beyond the effects
derived from typical exercise program instruction.
In addition to using cognitive-behavioral strategies.
15 wks; 84% study retention
rate; I-2 and C increased
walking distance on 12-min. Lest
relative to I-1; 93% of Ss in all
programs that also used either a supervised home-based
groups missed fewer than 2
consecutive sessions and/or
were able to make up those
format,16 or a combination of group- and home-based
formats 17,19,21-24 typically reported comparable or bet-
ter physical activity adherence relative to programs that
used a class or group format only. Ongoing telephone
Post-test
missed.
supervision of the physical activity program (used in 7
studies) was shown to be an effective alternative to
face-to-face on-site instruction, resulting in adherence
rates over extended periods of time (i.e., up to 2 years)
Intervention
I-1: 2x/wk for 45 min/
Chi; encouraged to
I-2: 1x/wk for 45 min/
session of computerized
that were as good as or better than face-io-face instruc-
session of group Tai
C: 1X/wk for 60 min/
tion. 25 In addition, the few studies that have used fully
mediated approaches such as home videotaped physi-
practice daily;
balance training;
session of health
education
cal activity instruction²⁶ or instruction via telephone-
linked computer systems,27-29 have shown some cn-
couraging, albeit short-term, results.
Maintenance
Table 1. Physical activity intervention studies in older adults using experimental (n = 26) or quasi-experimental (n = 3) designs
Dependent
variable
Strength, flexibility,
cardiovascular
endurance (12-min
walk), adherence,
Although short-term studies (i.e., 6 months or less)
have typically comprised the majority of intervention
work in the physical activity field as a whole, 30.31 it is
falls
notable that a substantial percentage of the studies
included in this review (12, or 11%) had intervention
Physical activity
Tai Chi. balance
durations of 10 months or longer. Eleven of the cited
studies have published some form of follow-up infor-
training
mation following the end of the major portion of the
target
trial, and at least two others have unpublished follow-up
data.28.32 The published follow-up periods ranged from
3 months¹⁴,¹⁹,33 to eleven and a half years. The
Setting
Community
Sample
dwelling,
"Explicit inclusion of or testing of behavioral interventions to promote physical activity.
majority of these studies, with some exceptions, re-
ported physical activity or fitness levels that were
greater than baseline levels and, when comparison
groups were still available, better than those reported
by controls. However, the quality of the measurement
Randomized factorial;
no apparent test for
employed at the follow-up point was often less rigorous
(e.g., global self-reports) than that utilized during the
gender effect
major trial.
Design
In the one published report directly comparing
long-term telephonc-supervised home-based exercise
instruction with class-supervised instruction, the tele-
phone-supervised programs generally showed better
200 community-
ambulatory
adults (70 yrs
and older; mcan
= 76 yrs); 81%
physical activity participation rates at the follow-up
period occurring 24 months from baseline relative to
women
the class program.²⁵ During the second year of the
intervention, formal telephone support and related
intervention strategies had been substantially reduced,
Study
Wolf et al.
(1996)72
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Page 11 of 19
although not eliminated entirely. In this study, the
order to have a major public health impact. Among the
higher-intensity (walk/jog) three-sessions-per-week
mediated approaches that have been tested thus far
home-based program evidenced significantly better ad-
with older populations, telephone-based strategies for
herence at 24 months than did the lower-intensity
encouraging ongoing physical activity participation,
(brisk walk) five-sessions-per-week home-based pro-
either alone or in combination with group-based for-
gram, although adherence at the end of the initial
mals, have received the largest amount of empirical
12-month period had been identical for the two pro-
support. In light of the fact that approximately 94% of
grams. This finding suggests that the added inconve-
U.S. households have a telephone (Pacific Bell, per-
nience of attempting to exercise more frequently dur-
sonal communication, 3/97), the public health impact
ing the week may override any benefits to adherence
of such approaches is potentially great.
accrued from exercising at a less-intensive level-an
A reasonably large percentage of the studies reviewed
exercise-related parameter that has typically been re-
(16, or 55%) described physical activity regimens that
ported to be extremely appealing to middle- and older-
appeared to meet or exceed the recently updated U.S.
aged adults. However, the majority of participants in
public health recommendations for physical activity
this study (67% of women and 87% of men) worked
among the general adult population." 44 However, few
outside of the household, which could have resulted in
studies focusing on more moderate-intensity forms of
greater time constraints relative to retired populations
endurance exercise (e.g., walking) strove to encourage
of older adults. The higher- and lower-intensity pro-
participants to reach the five or more days per week of
grams used in this study resulted in reasonably similar
physical activity that is currently considered to be
(and low) injury ratcs across the 2-ycar period, al-
optimal for achieving significant health-related bene-
though forms of physical activity that are more strenu-
fits. The vast majority of these studies were finished or
ous than those tested in that study have been associated
had begun prior to the publication of the current
with higher injury rates among older populations. 37.38
national recommendations. In addition, 12 of the stud-
Similarly, at least one study of older arthritic patients
ies focused on forms of nonendurance physical activity
reported that persons engaged in moderate-intensity
(e.g., strength training, flexibility exercises, balance
forms of exercise but for longer durations (e.g., in this
training) that have been increasingly identified as
study, a mean of 37.5 minutes per session) lost the
important components of the comprehensive physical
benefits of physical activity with respect to reductions in
activity regimen likely needed to preserve physical
knee pain and disability relative to participants exercis-
function and health with advancing age. 15.16 Few of the
ing for shorter durations. 39
reviewed studies, however, attempted to combine two
or more of these physical activity components in a
Potential Public Health Impact
systematic way. 17,33,47.48 Given that it currently remains
of Current Intervention Approaches
unclear what the optimal physical activity regimen is for
preserving health and function with advancing age,9
A number of the studies reviewed illustrated that struc-
efforts to continue to refine the best regimens for older
tured class- or group-based physical activity formats can
populations need to proceed in parallel with interven-
result in reasonably high short-term (i.e., 6 months or
tion efforts aimed at promoting long-term physical
less) physical activity participation rates. In addition,
activity participation.
several studies reported satisfactory longer-term class or
group participation rates, extending up to 3 years in at
least one case,⁴⁰ among some groups of older adults.
Effects on Subgroups
The data presented by Rejeski and Brawley, who
Of the eight studies that explicitly tested for gender
developed a behavioral intervention that explicitly took
effects, few significant differences in physical activity
advantage of the group structure to enhance physical
participation or physical performance outcomes were
activity levels following termination of the formal
found between men and women. Notably absent in this
group, are particularly encouraging. In that study, the
literature are well-controlled studies that systematically
center-based contacts were limited in number and
examine the effects of ethnicity, lower economic status,
intentionally spaced at greater intervals over time to
or age (e.g., "young-old" versus "old-old") on physical
encourage the development of self-sustaining strategies
activity participation rates. Only three studies in this
to promote long-term maintenance.
review either specifically targeted one or more of these
These innovations notwithstanding, in light of the
important subgroups or systematically tested for their
large percentage of older adults who are underactive,
effects. 21,49.50 In addition, the one study reviewed that
and the data indicating that a substantial proportion of
focused primarily on adults in the older age range
older adults prefer to engage in physical activity outside
(mean age = 82 years), who had limited mobility at
of a formal class or group,41-43 additional alternatives
baseline, reported the poorest adherence rates at
to traditional class approaches will be necessary in
6-month post-test.51
Am J Prev Mcd 1998;15(4)
325
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Page 12 of 19
Although persons with significant chronic conditions
lower-intensity home-based) relative to the underactive
or disabilities represent the majority of the community-
subgroup.5
dwelling adult population aged 45 years and up,5
relatively few rigorous studies were found that focused
Replication
specifically on such subgroups (excluding cardiac pop-
ulations, who were not included in this review). The
With few exceptions, systematic replication of promis-
two well-designed trials focused on arthritis sufferers
ing intervention strategies has been minimal. Among
demonstrated that relevant intervention programs can
the few strategies reviewed that have received such
be fashioned to promote long-term physical activity
replication are the telephone-supervised home-based,
participation sufficient to reduce disability among this
or home-plus group-based, physical activity programs.
prevalent segment of the older adult population. 21,52.53
To date there have been at least twelve randomized
One of these studies, however, noted that exercise
controlled investigations that have systematically ap-
adherence had declined to 50% by 18 months.2 In
plied such approaches in order to promote physical
addition, some promising, albeit short-term, results
activity participation in a range of population groups,
have been reported for older COPD patients. 14,22
including middle-aged adults,⁵⁸⁻⁶⁰ overweight men and
Among persons with multiple chronic conditions, drop-
women, men and women aged 50-65 years, 16,25 mid-
out and nonparticipation may be particularly problem-
dle- and older-aged cardiac patients.⁶³ community sam-
atic, as suggested in an uncontrolled investigation of
ples of men and women aged 65 and older, 17,24.32 and
older VA outpatients participating in a 4-month exer-
older adult informal caregivers of relatives with Alzhei-
cise program.⁵⁴ Of note, however, 36 (47%) of the
mer's disease or related dementias. The telephone-
original participants were able to complete 2 years of
supervised approach appears to be effective in older as
the supervised, multicomponent physical activity pro-
well as younger age groups, and has been used success-
gram and achieve significant pre-post improvements in
fully among older adults to promote physical activity of
various intensities,¹⁶ types (e.g., endurance, strength,
cardiovascular function and flexibility.53 Programs that
flexibility, general and formats
are fashioned specifically to the needs of such sub-
(e.g., home-based, class-based, home plus class or
groups and that can demonstrate a significant impact
group Adequate physical
on promoting long-term behavior change continue to
be indicated. 24,32
activity participation has been achieved and maintained
via this method for periods of up to 2 years. 25 There is
Population-based recruitment methods were noted
also some evidence from at least one of the studies
in six of the articles reviewed. Given, however, the
available that less-educated older adults (i.e., a high
individual level of commitment required to participate
school education or less), particularly those with rela-
in all of the studies evaluated, it is likely that the vast
tively low initial fitness levels, might benefit especially
majority of the individuals studied were already in the
from telephone-supervised home-based approaches
contemplation, preparation, or early action phases of
through 2 years. Because a number, although not
motivational readiness to make physical activity chang-
all,62 of these studies were undertaken in northern
Few data are currently available on fashioning
California, the generalizability of the supervised home-
appropriate interventions for the noncontemplator seg-
based approach to other regions of the United States
ment of the older adult population, for whom targeted
remains to be verified. Currently ongoing multi-site
interventions are particularly warranted. Similarly, little
physical activity trials such as the NHI.BI-funded Activ-
is known about the physical activity preferences and
ity Counseling Trial (ACT) will add useful information
needs of the most sedentary segment of the older adult
in this regard.
population, who may have the most to gain in areas of
The use of cognitive-behavioral strategies to increase
health and functioning from physical activity increases.
both initial and longer-term physical activity participa-
At. least one study in the literature has found that
tion, whether delivered via telephone or in a face-to-
different determinants delineated the subgroup of sed-
face format, also has been found to be a useful inter-
entary, versus intermittently active, older adults who
vention tool in a number of the studies reviewed.
agreed to participate in a randomized trial focusing on
physical activity promotion.⁵ These two subgroups also
responded differentially to the two different forms of
Generalizability
recruitment (random-digit-dial telephone survey; com-
As noted earlier, the vast majority of the physical activity
munity-wide promotion) implemented in the study.
intervention studies undertaken with older adults have
Finally, the sedentary subgroup had significantly lower
not included important subgroups, such as lower in-
one-year physical activity adherence rates across all
come individuals, persons of nonwhite ethnicity, and
three physical activity programs evaluated (i.e., higher-
the oldest old. The generalizability of current interven-
intensity group-based, higher-intensity home-based,
tions to these segments of the population is thus
326
American Journal of Preventive Medicine, Volume 15, Number 4
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Page 13 of 19
currently unknown, and constitutes an important target
ical activity promotion in older adults, few are based on
for future research in this area.
specific, rigorously controlled research. In addition,
The above issues notwithstanding, the types of prom-
relatively few physical activity printed materials and
ising intervention approaches that have been reviewed
programs aimed at older adults that exist in many
(e.g., use of cognitive-behavioral strategies; implemen-
communities throughout the United States explicitly
tation of telephone-supervised programs) are poten-
include the types of behavioral, cognitive, social, and
tially generalizable to a broad segment of the older
program-based strategies that have been shown to be
adult population. Most of the telephone-supervised
effective in promoting physical activity participation
programs utilized a 20- to 40-minute initial face-to-face
rates in older as well as younger adults. A recent
instructional session in combination with 12 to 15 brief
example of efforts to do so include dissemination, in
(approximately 10 minutes) staff-initiated telephone
book form and through training seminars and similar
contacts during a year's period. There is some evidence
formats, of the rigorously undertaken research on
suggesting that the frequency of telephone contact
strength training in older adults conducted by Tufts
could be reduced once the exercise program has been
researchers." The telephone-based approach to pro-
established. 61,65 Possible channels for delivering such
moting ongoing physical activity participation awaits
programs are currently in place in most communities
systematic dissemination efforts, although efforts to
throughout the United States through the auspices of
explore methods of doing so are currently underway in
a variety of community organizations and agencies,
California, through the auspices of the state health
including local parks and recreation departments, se-
department.
niors' centers,⁴ community colleges, local health de-
partments, medical clinics, nonprofit health organiza-
Additional Issues
tions (e.g., the American Heart Association). and
organizations focusing on seniors (e.g., the American
Physical Activity Assessment among Older Adults
Association of Retired Persons). However, a mechanism
Progress in the intervention area continues to be
for the training and subsequent oversight of potentially
constrained by the dearth of physical activity assessment
appropriate community groups who could deliver such
instruments that are sensitive to the more moderate
interventions effectively is currently lacking. An impor-
forms of physical activity typically undertaken and
tant part of all such interventions in this area is the
preferred by older adults. Although in recent years
appropriate ongoing tailoring of a physical activity
several promising physical activity assessment instru-
regimen (e.g., physical activity content, intensity, for-
ments have been developed specifically for older pop-
mat) to the needs and preferences of the individual,
ulations, 32,67-70 efforts to evaluate their sensitivity to
regardless of the types of behavioral or program-based
change with appropriate physical activity intervention
strategies that are employed to increase subsequent
have been scarce. Three recently completed studies
physical activity participation.
have indicated that the CHAMPS physical activity ques-
tionnaire for older adults developed by Stewart and
Cost-Effectiveness
colleagues³² is sensitive to change in response to 6-to-
Attempts to evaluate the cost-effectiveness of interven-
12-month physical activity interventions focused on
tion approaches in older adults, either relative to no
light to moderate-intensity endurance activity. 17,24.32 In
treatment, usual care, or other active interventions,
one of these investigations, which focused on a 1-year
have been minimal. The few published studies that
program of moderate-intensity endurance activity in
have systematically collected cost data have focused on
healthy, community-dwelling seniors,¹⁷ estimated en-
medical utilization and cost savings related to health
ergy expenditure as measured via the CHAMPS ques-
outcomes of interest (e.g., costs of inpatient and out-
tionnaire was found to be sensitive to change in the
patient services), 33 rather than cost-effectiveness analy-
endurance activity program relative to a stretching and
ses related to the interventions themselves. Such anal-
flexibility program. In contrast, the Physical Activity
yses should occur in concert with intervention
Scale for the Elderly (PASE)⁶⁸ was not found to be
development and evaluation efforts. At least one re-
sensitive to change in the same sample.
cently completed study has such cost-effectiveness anal-
yses currently underway.24
Defining the Appropriate
Physical Activity Stimulus to
Implementation
Target in Interventions for Older Adults
Few systematic attempts have been made to date by the
As noted earlier, the optimal physical activity stimulus
scientific community to disseminate successful pro-
for gaining appropriate health and functioning bene-
grams to the public. Although there are a plethora of
fits among older populations has yet to be adequately
popular books and manuals available focusing on phys-
defined or agreed upon via scientific consensus. Such a
Am I Prev Med 1998;15(4)
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regimen will likely require a combination of endur-
childhood physical activity competencies and move-
ance, strength, and flexibility/balance activities. 45,46
ment capabilities occurring decades earlier.74 Such
The systematic evaluation of physical activity programs
findings underscore physical activity participation in
that may improve balance, in particular, is an area that
older age as a lifelong process influenced by preceding
has received relatively little systematic attention, al-
life experiences and stages of development.
though two of the FICSIT (Frailty and Injuries: Coop-
Several studies evaluating the determinants of physi-
erative Studies of Intervention Techniques) investiga-
cal activity adherence among older adults noted that
tions suggest that physical activities such as tai chi
factors influencing physical activity participation may
chuan and walking may improve balance and/or re-
be phase-specific (i.e., dependent on what stage of the
duce risk of falling better than other forms of activity
program is being evaluated, e.g., initial adoption phase,
(e.g., use of a cycle ergometer). 71.72 A significant chal-
longer-term maintenance phase). 39,53.85 Results from a
lenge facing this field is the development of interven-
study of older arthritic patients also indicate that the
tion strategics to promote ongoing participation in all
determinants of a physical activity regimen may differ,
of these physical activity domains.* Although there are
at least for some older adult samples, for various
likely strategies that will be effective across all such
exercise participation parameters (i.e., physical activity
domains (e.g., cognitive-behavioral strategies), the po-
attendance as opposed to the actual amount of time
tential for additional intervention approaches that may
spent exercising). 39
be specific to each of these physical activity types
Similar to the older adult intervention literature, few
remains unexplored.
determinants studies have evaluated the importance of
An appropriate physical activity stimulus for older
different variables in specific subgroups of the older
adults must be considered both from subjective and
adult population. In one epidemiologic study of 3,223
objective points of view. That is, in addition to the
residents from two communities in South Carolina.
operational aspects of the regimen (e.g., exercise type,
reported receipt of physician advice was significantly
intensity, frequency) deemed desirable by the scientific
associated with involvement in leisure-time physical
community, the individual's perceptions of the pro-
activity among both white and African-American men
gram and how it "fits" with personal needs, values, and
and women." Among the perceived benefits and bar-
circumstances require attention.73
riers to exercise discussed in a recent study of older
African-American women were the importance of
Applications of
enjoyment, mental health improvement, and physical
Determinants Research in this Area
enhancement as top benefits of physical activity, and
inconvenient locations, safety, social embarrassment.
Relatively few studies undertaken to date to clarify the
and perceived unpleasantness of physical exertion as
types of determinants associated with physical activity
the major reported barriers to physical activity. Similar
participation have focused specifically on older popu-
to determinants studies of healthy older adult popula-
lations. 11 Such determinants research may help to
tions, determinants of exercise maintenance in older
identify important contributors as well as barriers to
arthritic patients have been reported to include initial
physical activity participation among older adults,
fitness level, mood disturbance (e.g., anxiety, depres-
thereby potentially leading to more effective interven-
sive symptoms), social support, and previous exercise
tions. Although the current determinants literature
behavior, in addition to changes in pain. 39.53 In one of
identifies some variables (c.g., educational level, smok-
these studies, ethnicity, gender, and body mass index
ing status, overweight, social support, exercise-related
were not found to be predictive of either exercise
self-efficacy, motives to improve physical fitness and
frequency or duration over an 18-month period.
appearance) that arc associated with physical activity
Specific determinants of potential importance for
participation among younger and older adult popula-
other major subgroups of older adults (e.g., the oldest-
tions alike, 31,39,74-79 other variables appear to be espc-
old, the disadvantaged, those with other specific disabil-
cially influential for older adults. These include trans-
ities) remain largely unexplored. Recent applications
portation problems75,80.81; medical concerns, including
of signal detection methods to the physical activity
fear of injury75.78.79.81; physician advice to exercise⁸¹,⁸²;
field⁶⁴ may provide a useful means for identifying
attitudinal barriers, including perceived lack of ability
clinically meaningful subgroups of older adults, based
and erroneous beliefs about exercise and physical
on initial demographic, behavioral, psychosocial. and
activity?8.83,84, and illness and injury. 78,81 In addition, at
physiological variables, for which to better tailor inter-
least one study that employed population-based recruit-
ventions.
ment strategies to survey 327 women aged 70 to 98 years
Finally, at least one intervention study reviewed
living in Vancouver, British Columbia, found that self-
noted an increase in physical activity participation,
efficacy for performing fitness-oriented exercise later in
resulting in significant improvement in aerobic power,
life was significantly associated with recollections of
following the end of the formal study intervention
328
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period among participants randomized originally to an
thereby helping to clarify the most critical research
attention-control (range of motion) condition. The
agenda in this area. It will also provide a firm basis on
authors hypothesized that the exercise content may be
which interventions aimed at promoting a more com-
less important than a positive exercise experience in
prehensive physical activity program (i.e., combining
motivating at least some subgroups of older adults to
endurance, strengthening, flexibility, and balance-ori-
maintain exercise or seek out other types of exercise
ented activities) among older adults can continue to be
programs.32 This issue deserves further exploration.
built.
Practice and Policy Implications: Clarification and
consolidation of current scientific consensus in this
Summary and Recommendations for
area will help to reduce confusion and enhance efficacy
Future Research and Practice in the Field
related to physical activity prescription and interven-
tion among health care service providers and exercise
The present review underscores a number of gaps in
specialists working with older adult populations. It will
the current physical activity intervention literature for
also allow for a more consistent and specific physical
this important population segment that are in critical
activity message to be delivered to the older adult
need of further attention and systematic investigation.
population as a whole.
These gaps are subsumed in four major recommenda-
Recommendation 2: Systematically evaluate the general-
tions that provide a framework that may guide future
izability of currently supported interventions in more diverse
efforts in this area. These recommendations have sci-
subgroups of older adults. Important subgroups include the
entific, practice, and policy implications for the field.
frail elderly; those with various chronic conditions and disabil-
Recommendation 1: Continue to adapt and refine the
ities in areas of physical, psychological, and cognitive func-
current national physical activity recommendations to address
tion; ethnic minorities; lower socioeconomic status groups; the
the specific issues raised when the largel is older adults.
rural elderly; the oldest-old (aged 85 years and above); and
The current national recommendations proposed by
socially isolated and depressed older adults.
the U.S. Centers for Disease Control and Prevention
Research Implications: The implementation of pilot
(CDC), the American College of Sports Medicine
work in this area to clarify how current behavioral
(ACSM), the American Heart Association, and other
interventions, such as those utilizing cognitive-behav-
national organizations lay the groundwork for an ex-
ioral strategies or telephone-based delivery channels,
panded set of physical activity regimens (e.g., those that
should be adapted to optimize their effectiveness in
include more moderate forms of endurance-based
targeted subgroups is critical. As part of this endeavor,
physical activity), with enormous applicability to older
the development of specific intervention strategies that
populations. Yet, additional scientific consensus is
aid effective coping with the chronic illness and injury
needed in other areas related to physical activity pre-
that often derail attempts among older adults to main-
scription for older adults, including an increased focus
tain long-term physical activity participation is strongly
on additional parameters of the physical activity regi-
indicated. In addition, the field as a whole would
men (e.g., strengthening, flexibility, and balance) as
benefit from an exploration of the types of demo-
well as expanded physical activity-related outcomes
graphic, physical, psychosocial, and environmental di-
(e.g., health-related quality of life, functional status,
mensions and domains that would be most useful for
depression), which are of particular importance to the
segmenting the older population into meaningful sub-
day-to-day health and functioning of the older adult.
groups for intervention.
Furthermore, the most effective means for defining
Practice and Policy Implications: Implementation of
what constitutes moderate as opposed to more vigorous
the above recommendation will help to clarify how
intensities of activity in older adults (i.c., using absolute
much tailoring will be required to successfully enact
versus relative criteria), as well as the optimal physical
physical activity interventions across these different
activity prescriptions for specific subgroups of older
subgroups. This will allow for the delivery of more
adults (e.g., those with chronic conditions, the frail
powerful interventions to those subgroups who may
elderly, those at increased risk of falls) remain unclear.
have the most to gain, from a health and quality-of-life
This recommendation might be most readily achieved
perspective, in becoming more regularly active.
through convening a panel of scientific experts similar
Recommendation 3: Develop evidence-based protocols to
to that convened in developing the current CDC/
aid health care providers and physical activity specialists in
ACSM recommendations for the American adult pop-
appropriately and efficiently assessing older adults in order to
ulation as a whole.
triage them to the most appropriate physical activity interven-
Research Implications: These consensus-building ac-
tion programs.
tivities would help to define more clearly those areas of
Research, Practice, and Policy Implications: Research
physical activity prescription for older adults for which
focused on developing and testing such empirically-
adequate scientific evidence is currently lacking,
derived protocols is an important step in the develop-
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ment of an orchestrated public health approach aimed
further systematic exploration of fully mediated ap-
at tailored intervention delivery and dissemination
proaches to physical activity promotion among the
throughout the older adult population.
older population. Such approaches are essential if
Recommendation 4: Encourage the systematic study of
current public health goals are to be reached with the
environmental and policy-level approaches to the promotion of
older population.
physical activity among older adults.
systematic efforts to disseminate those intervention
As noted earlier, it has become increasingly apparent
strategies (e.g., telephone-based intervention) that
that increases in routine and lifestyle forms of physical
have shown effectiveness and replicability.
activity that can be incorporated naturally throughout a
exploration of the potential utility of intergenera-
person's day may provide the most effective means for
tional physical activity programs that facilitate partic-
increasing physical activity levels in the population at
ipation among family members (e.g., grandparents
large. Yet, little information is currently available con-
and grandchildren) as well as among community
cerning the types of environmental and lifestyle inter-
subgroups of varying ages (e.g., seniors and pre-
ventions that could be most potent in facilitating such
school or school-aged children).
natural forms of physical activity, particularly among
applications of a lifespan, developmental perspective
seniors.
to the understanding of physical activity participation
Research Implications: The field could benefit
in later life, as a means of better understanding how
greatly from qualitative and determinants research that
physical activity experience and participation early in
would allow a better understanding of how and where
life sets the stage for physical activity participation
older adults spend their day and time, as a means of
and motivational readiness as one ages.
beginning to define relevant situations for which ap-
continued efforts to systematically apply conceptual
propriate interventions could be targeted. In addition,
or theoretical models to this area as a means of
research evaluating interventions aimed at different
broadening and potentially strengthening interven-
aspects of the physical and social environment, includ-
tion development.
ing mass media, as well as policy-level interventions is
critically needed.
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a supervised exercise program in a geriatric population.
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71. Buchner DM, Cress ME. de Lateur BJ, et al. A comparison
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of the effects of three types of endurance training on
trends in physical performance following supervised ex-
balance and other fall risk factors in older adolts. Aging
crcise among community-dwelling older veterans. J Am
Clin Exp Res 1997;9.
Geriatr Soc 1991;39:986-992.
72. Wolf SL, Barnhart HX, Kutner NG. et al. Reducing Trailty
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1994;26:1400-4.
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57. Young DR, King AC, Oka RK. Determinants of exercise
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Am J Prev Med 1998;15(4)
333
PREVENTING DISEASE AND PROMOTING HEALTH IN OLDER AMERICANS
Funding New Research
Allocating $25 million for applied research on health promotion and disease prevention. This
proposal would provide $25 million for the Department of Health and Human Services to
research the effectiveness of alternative providers and settings when implementing a successful
health promotion and disease prevention strategy and conduct studies to identify the most
effective means of educating and encouraging beneficiaries. Any new research effort will reflect
the medical behavioral, and social aspects of care for the elderly, including the impact on
expenditures and quality of life. In addition, these new research efforts will be developed,
monitored, and evaluated by an interagency work group. The Secretary is required to report to
Congress in 2002 with the results of the overall applied research efforts and recommendations for
the modification of the Medicare program if SO indicated.
Advancing original research on health promotion and disease prevention. This proposal would
provide the National Institute on Aging with $100 million over five years to conduct research on
ways to improve quality of life for the elderly, ways to prevent or delay the onset of chronic
illness and disability, and the development of new means to assess the long term cost
effectiveness of health promotion and disease prevention efforts for the elderly.
Adding New Benefits
Elimination of copayments for preventive health services. In order to promote utilization of
preventive services, cost sharing for these services will be eliminated.
Reimbursement of smoking cessation counseling. Smoking cessation has major and immediate
health benefits for men and women of all ages. Benefits apply to persons with and without
smoking-related disease. Smoking cessation decreases the risk of lung cancer, other cancers,
heart attack, stroke, and chronic lung disease. This proposal would provide smoking cessation
consultation counseling in with accordance their primary with the care NIH provider, clinical seek practice to enter guidelines treatment. for individuals pay for? who, in How?
Reimbursement for screening for hypertension. Screening for hypertension is recommended for
all children and adults. Hypertension is a leading risk factor for coronary heart disease,
congestive heart failure, stroke, and renal disease. These complications of hypertension are
among the most common and serious diseases in the U.S., and successful efforts to lower blood
pressure could thus have substantial impact on population morbidity and mortality This proposal
would reimburse providers for screening patients for hypertension and educating them about
ways to lower their blood pressure to a healthy level.
7
Reimbursement for counseling for hormone replacement therapy. Estrogen therapy after
menopause produces clinically important improvements in bone density and blood lipids, is
associated with significant reductions in the risk of heart disease and fractures, and can
substantially reduce morbidity and mortality from coronary disease and osteoporosis in older
women. This proposal would reimburse providers for counseling their patients about the benefits
of estrogen replacement therapy. Counseling would be conducted along NIH guidelines and
include asking about presence and severity of menopausal symptoms (hot flashes, urogenital
symptoms), as well as assessing risk factors for heart disease, osteoporosis, and breast cancer.
Reimbursement for screening for early detection of glaucoma. Glaucoma is the second leading
cause of irreversible blindness in the U.S., and the leading cause among African Americans. The
prevalence of glaucoma is four to six times higher in blacks than whites, and it increases steadily
with age. Other risk factors for glaucoma diabetes mellitus, myopia, a family history of
glaucoma, and a diagnosis of ocular hypertension. This proposal would reimburse providers for
screening of high risk individuals.
New authority to cover preventive benefits. This proposal would provide the Secretary of Health
and Human Services with the authority to provide a service to Medicare beneficiaries when she,
in consultation with the Office of the Chief Actuary and the Congressional Budget Office,
determines that the provision of the service will save Medicare resources in the long-run by
delaying the onset of a more expensive disease, detect the disease at a more treatable and less
expensive stage, or save the cost of treatment in a more costly setting.
Educating Beneficiaries
Development of an education and awareness campaign to prevent falls in the elderly. (see details
problem statement earlier in paper). The Department of Health and Human Services, together
with private sector partners, would launch a nationwide media campaign to educate older
disc/
Americans about the best way to modify their environment in order to avoid potentially harmful
mand
and debilitating falls. The campaign would utilize radio, television, and print media, and would
emphasize the following messages: use anchor rugs; minimize clutter on floors; use nonskid
mats; install handrails in bathrooms, halls, and along stairways; light hallways, stairwells, and
part
entrances; and wear sturdy shoes.
of Met
National outreach effort to educate beneficiaries about available preventive benefits. The
Choice
Department of Health and Human Services, together with private sector partners, will launch a
nationwide media campaign to educate beneficiaries about the benefit and availability of
preventive benefits. Currently, HCFA has developed several brochures and advertisements to
educate beneficiaries about the availability of preventive benefits, but they are not widely
disseminated to beneficiaries. This campaign will allow HHS to partner with private
organizations to distribute existing materials through provider offices, senior centers, the Meals
on Wheels program, religious organizations, and state health insurance assistance programs. It
will also include prevention messages on materials routinely sent to beneficiaries, such as
Medicare Part B benefits statements and Medicare summary notices.
Educating Providers
National outreach effort to educate physicians about the importance of preventive benefits.
Although sound clinical reasons exist for emphasizing prevention in medicine, studies
have shown that clinicians often fail to provide recommended clinical preventive services. This
is due to a variety of factors, including uncertainty among clinicians as to which services should
be offered and skepticism about their effectiveness. The Department of Health and Human
Services, together with advocates for the aging and provider organizations, would launch a
national provider education campaign to emphasize the importance of preventive care for older
Americans, disseminate information about the efficacy of critical preventive benefits, educate
providers about nationally accepted treatment guidelines, and provide tools, such as "cue cards"
with a list of the preventive services recommended for older Americans, to encourage the
provision of preventive benefits.
How petail
White House Conference on Improving the Health of the Elderly. This Conference will include
advocates for the aging, representatives of provider organizations, researchers with an interest in
elderly issues, and other appropriate parties. The goal of the conference is to develop a consensus
on a program to empower the elderly to protect and improve their own health; to assure that the
elderly are provided the highest standard of care, with emphasis on assuring that standard
practice is also best practice; to more effectively meet the needs of the elderly through the
Medicare program, and to outline a research and demonstration agenda to further these
objectives.
Funding Demonstration Programs
Partab
Dual- Duagibe Packge
Funding new programs to provide high quality, cost effective services to individuals with serious
and chronic illnesses. This proposal would fund demonstration programs to provide case
management and disease management services. It would also fund interventions designed to
prevent hospitalization of nursing home patients. The Secretary can waive provisions necessary
to carry the demonstrations out and may contract with centers of excellence or other entities or
individuals with special expertise in providing quality services, utilize incentive payments for
favorable cost and quality outcomes, capitate payment for selected services, and provide services
not usually covered under Medicare. These programs must not abridge freedom of choice of
provider, except to the degree that beneficiaries choose to join a program limiting choice of
provider for some or all services, and they must not prevent providers not participating in a
program from receiving payment for caring for other Medicare beneficiaries.
Funding community based health promotion teams. Studies indicate that older adults view health
promotion activities as beneficial to their health, engage in numerous health behaviors more
frequently than do younger adults, and participate in and report benefits from health promotion
programs. This proposal would fund demonstration programs providing health promotion
services, such as group or individual counseling; education about important lifestyle behavior
modifications, such as exercising or diet modification, with monitoring to ensure that the
Danil
beneficiary is making the recommended change; and at home visits to help make necessary
environmental modifications.
indivate? this
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Research
Aged care in the community
Health promotion and older people: a qualitative study of
general practitioners' views
Ngaire M Kerse, Michael J Murphy, Leon Flicker and Doris Young
H
ealth promotion and disease pre-
Abstract
vention are neglected areas in the
health care of older people.
Objectives: To explore general practitioners' (GPs') beliefs about health promotion
Despite research indicating their bene-
for older people and attitudes towards educational strategies likely to improve
fits, preventive activities and behaviours,
practice in this area.
such as influenza vaccination and exer-
Design and setting: Four discussion groups, each lasting one and a half hours,
cise, are infrequent in older populations.¹
completed in Melbourne, Australia in August and September 1995. Interviews were
General practitioners (GPs) are well
transcribed verbatim and analysed for major themes.
placed to emphasise health promotion
for this group, as older people make up
Participants: A convenience sample of 20 GPs took part; 11 university affiliates, four
one in four of GP consultations, and
participant contacts and five GPs from telephone book listings.
70% of older people consulting a GP
Results: GPs' perceptions of their health promotion practice varied from "integrated
have follow-up visits planned within the
into all medical care", to "something separate from usual practice". Positive views of
next three months.² Yet Australian GPs
older people contrasted with ageist views, with a few GPs expressing a nihilistic
are reluctant to introduce lifestyle coun-
approach to medical care of older people. Regardless of the GPs' attitudes, lack of
selling into consultations unless
time and reimbursement disincentives were perceived to limit preventive practice and
prompted by the patient,³ and detection
the potential impact of health promotion interventions. GPs felt overwhelmed with
rates of risk behaviours can be
their workloads, and initial reactions to the idea of any "new" program were negative.
improved.4 GPs may see health pro-
Reactions to educational strategies varied, with choice and relevance to ease of
motion for older people as an activity for
practice being important for GP participation.
which the individual patient is respon-
Conclusions: GPs differ in their views of health promotion and in their approaches to
sible,6 and it is not known how GPs'
its delivery for older people. Educational programs are often viewed negatively, but if
attitudes towards ageing⁷ influence their
they offer the opportunity to save time, increased participation may be more likely.
preventive practices with older patients.
Exploratory research about Australian
MJA 1997; 167: 423-427
GPs' attitudes and beliefs about health
promotion specifically for older people
sample of GPs was selected from the
motion for older patients and reactions
is scarce.⁸
University of Melbourne list of practices
to ideas for educational tactics for
We report the results of a qualitative
accepting fifth-year medical students,
intervention strategies. To avoid facili-
study exploring GPs' attitudes towards
contacts of those interested in partici-
tator bias, MM and NK ran two groups
and beliefs about:
pating, and GPs from the telephone
each, using a set discussion guide, and
Health promotion for older patients,
book medical listing for two suburbs in
altered the order of discussion of edu-
including current practices and
the Melbourne metropolitan area. The
cational strategies (Box 1). NK was pre-
perceived barriers.
GPs were telephoned and sent a letter
sent for all groups and transcribed the
Ideas for educational strategies aimed
about the discussion groups. Continuing
tapes verbatim.
at improving their practice in this area.
medical education (CME) points were
To identify the major themes emerging
available for participation in the study.
from the discussions (Box 2), we
Methods
Group discussions lasted about one
analysed the transcripts with no a-priori
We planned four focus group discus-
and a half hours and were audiotaped.
themes posed. 10 NK read the tran-
sions to explore GPs' views about
Discussion included the attitudes and
scripts and identified the themes, and the
health promotion.9 A convenience
beliefs held by GPs about health pro-
transcripts were then colour-coded and
cut and pasted into thematic groupings.
NK and MM read and summarised the
General Practice Unit, Department of Public Health and Community Medicine,
theme groups. GPs' reactions to the edu-
University of Melbourne, Melbourne, VIC.
cational interventions were grouped
Ngaire M Kerse, MB ChB, Research Scholar; and Research Scholar at National Ageing Research
together by subject, and their overall
Institute, Melbourne, VIC.
reactions summarised (Box 3).
Doris Young, MBBS, FRACGP, Head.
Market Access Consulting and Research, Melbourne, VIC.
The range of views expressed during
Michael J Murphy, BA, DipAppSci(Nat), Director of Research.
these focus group discussions is
National Ageing Research Institute, Melbourne, VIC.
reported. As it is not appropriate to gen-
Leon Flicker, PhD, FRACP, Senior Lecturer in Geriatric Medicine.
eralise the results from small non-rep-
Reprints: Dr NM Kerse, GP Unit, Department of Public Health and Community Medicine,
University of Melbourne, 200 Berkeley Street, Carlton, VIC 3053.
resentative groups to larger populations,
E-mail: [email protected]
percentages of participants with each
MJA Vol 167 20 October 1997
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Aged care in the community
Research
thematic view are not reported; this is
return at a less busy time to discuss
but there are people at home who probably
the accepted practice with qualitative
health promotion.
don't read papers, or watch television, or
data derived from groups. 11,12
Some GPs had a concrete concept of
certainly don't read women's magazines
health promotion - that it consisted of
which carry all the health information
Results and synthesis
traditional preventive activities, such as
it's a lot harder to reach them."
pap smears, mammograms, and choles-
Other GPs had negative attitudes
Four focus groups were held, with four
terol measurement.
to older people - expressed in the
to seven participants each, during
"Most of the elderly I see, I see on a
statement:
August and September 1995. A total of
curative basis."
"More and more of my practice seems to
20 GPs (seven women and 13 men) par-
These GPs practised prevention sep-
be looking after people in hostels and
ticipated; 11 were affiliated with the
arately, tending to discuss issues only
nursing homes - people who nobody else
University of Melbourne, 5 were
when directly asked by the patient.
wants
recruited from the telephone book list-
"I mean, it's really hard when someone
GPs outlined difficulties with caring
ing and 4 were contacts of other parti-
comes in with an illness, to sort of give that
for older people, such as memory prob-
cipants. Most (60%) had graduated
framework for talking about other
lems, lack of comprehension, and poor
from medical school during the 1980s,
preventable things.
compliance with medication regimens.
with seven (40%) graduating before that
In two of the groups, GPs were dis-
Some of these GPs felt that older
couraged and felt that preventive sug-
people "sat around all day and got
decade. Fourteen had 10-20 years'
experience in general practice, with four
gestions were not welcome, and when
bored". The negative views affected the
having more than 20 years. All GPs were
offered, mostly had little effect.
health promotion advice offered to
vocationally registered, and 11 listed
"How many patients do you have that
older people.
postgraduate qualifications. The Uni-
you know, you go through all this about
"It's pretty hard to tell a 90-year-old to
weight loss. and how many of them are
stop smoking. I wouldn't bother with that."
versity of Melbourne Human Ethics
really
successful?
I've had very few
The extreme of these views was thera-
Committee approved the project.
patients who seem to lose much weight,
Informed consent was obtained from
peutic nihilism. Some GPs spoke of
despite all the talking about all this."
futility in pursuing medical manage-
participating GPs.
ment, let alone health promotion, for
GPs' views of older people
older people.
GPs' views of health promotion
Some GPs felt that age of the patient
"I'm struck by the idea that they are all
Three main concepts of health promo-
had little to do with their preventive
going to die. Patients are all a bit
unrealistic when they think I can treat their
tion emerged, spreading across a spec-
practice; some formed categories of
heart and keep them well for ever and all
trum; we categorised them as: abstract,
older patients according to their needs,
that
broad, and concrete (Box 2). GPs with
while others felt that health promotion
"I think I'm a bit more pessimistic than
the abstract concept saw health promo-
was not important for older age groups.
[another participant], actually. I like to
tion as giving encouragement and
A positive attitude to older people in
make them feel better, so I don't know how
promoting positive thinking, and con-
all groups was expressed by some GPs,
much curing medicine does do actually."
sidering the patient's social context.
who felt that the patient's individual
"I provide the facility for people to treat
characteristics were more important
than age. Chronological age alone was
Barriers to practice of health
themselves. You provide the opportunity
for them to ask or talk about it and then
seen as a poor indicator of health
promotion
you develop it from there."
status, with the presence and chronicity
GPs with these views integrated health
of illness and functional status being
Time
promotion into all practice, seeing it as
more important. These GPs saw that
Lack of time was the main barrier to
good general practice, whether the
they could be treating older people for a
health promotion practice noted by
nearly all of the GPs, regardless of their
focus was acute, curative care, mainten-
further 20-25 years; therefore emphasis
ance of patients with chronic illness or
on health promotion was as important
concept of health promotion or attitude
preventive management.
as in younger groups.
towards older people.
Neutral views were held by some of
"It all just takes too long."
"I've got my finger on it all the time and
the GPs who grouped older people by
Time pressure was felt with patients
I do see my patients at regular intervals."
their needs, varying their approach to
with limited mobility, as well as with
The intermediate view, that "health
health promotion accordingly. Patients
practice pressures from the full waiting
promotion is a broad concept", covering
who had poor understanding of medical
room. GPs felt overwhelmed with their
such activities as medication review,
issues and lacked basic biological know-
workload and its effect on their home
home visits and exercise advice, was held
ledge were contrasted to those who
life.
by most GPs, whose preventive practice
knew more than the GP about their
was opportunistic, separated from
health.
Government regulation
"usual care". These GPs reported "fit-
"Certainly, those who are members of
Linked to the time barrier was a concern
ting it in" if a patient had a brief request,
the local bowling club get all the
that Medicare reimbursement was
or alternatively asking the patient to
information and they know everything,
related to a "valid medical indication"
424
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Research
Aged care in the community
assist in health promotion. The main
1: Discussion guide for GP focus groups
difficulties with these methods were lack
Health promotion and older people
of time and the need for self discipline.
When you think of health promotion for older people, what do you think of?
"There's always so many pressures on us
What does health promotion/disease prevention for older people mean to you?
all the time; so and so rings up wanting to
How do you feel about health promotion for older people? How important is
know about this and that, and there's
it to you?
people to see and it's always your records
that take second place."
What do you do in your practice in the area of health promotion, and what
considerations do you think are most important in this area?
GPs' responses to health promotion
Can GPs improve? How?
- interventional and educational
Would you like to do more in this area? Why, and what?
strategies (Box 3)
What would help, assist in this area? What resources?
What stops you from doing more health promotion in your practice?
For many GPs the initial response to
What, if anything, would help you improve in this area?
new resources shown during these dis-
cussion groups was that they would add
Perceived value of specific educational strategies
to their workload rather than be helpful.
What reactions are there to audit, written materials, academic detailing,
Previous programs presented to the GPs
prompt/reminder systems, and patient education materials as interventions to
as aids for health promotion were
improve health promotion for older people? What else would be useful?
thought to be designed and distributed
with the needs of the patient and health
for consultation. Preventive activities
behaviour (e.g., that GPs should spend
promotion agency in mind, rather than
the needs of the GP.
and health promotion were not felt to fit
more time with younger, rather than
this description.
older age groups) that GPs felt were dif-
"I think it'd be useful, it depends what
"You have 10-15 minutes to do all that
ficult to challenge.
was in it and whether I felt it was
applicable to me and my situation and to
sort of preventive stuff and it's a huge
amount of work, and personally I don't
Structural limitations
the old people that come in In other words,
know whether I should be doing it."
Some GPs believed that they were not
is it something we are going to use?"
seen as "good health promoters" for
Some GPs believed they would be
"But it's silly that something that seems
so reasonable should still be, from a gov-
older patients, and the role of Divisions
much more likely to adopt a strategy if
ernment point of view so suspicious, so
of General Practice, other health pro-
it was designed to meet their needs and
dubious
fessionals, government bodies and the
also saved them time.
Some GPs believed that too many
media in facilitating delivery of health
"I think I'd need an incentive to do it
long consultations for prevention would
promotion to older people was repeat-
like when they send a survey in the mail
bring them to the notice of the Health
edly outlined. Limitations in the avail-
if it was to help someone out, I'd prob-
Insurance Commission.
ability of such services as physiotherapy,
ably do it, but if it was for my own bene-
occupational therapy and transport
fit, I'd say: 'Yes, I will do that."
Ageism
were seen as barriers to health promo-
"You've got to put a carrot in there to
Some GPs perceived that older patients
tion, with poorer patients being most
get me to do it, see. So we'll give you a
had negative attitudes about health
disadvantaged by these constraints.
resource kit a list of all the facilities that
promotion.
have anything to do with geriatrics in your
Practice organisation
area then I'm thinking, now there is
" my concern is that I don't think
Keeping adequate records and using
something I can use, that's good
so
it
that they value it (health promotion) very
summary sheets, medication lists and
becomes carrots and rewards."
highly."
prevention check-lists were reported to
These attitudes were partly a result of
These GPs felt that older people
would be unnecessarily bothered by vig-
orous health promotional practice, seeing
2: GPs' concepts of health promotion
it as an intrusion. Some believed that
older people had a poor self image, seeing
Themes emerging from focus groups discussions by general practitioners (GPs)
themselves as being "old" and having had
about health promotion for older people. The GPs' perceived practice of health
enough of preventive procedures.
promotion paralleled the concepts they held.
" problem is with all this prevention,
View of health promotion
Practice of health promotion
the patient is going to wonder where on
Abstract concept
Integrated approach
earth we are all coming from."
All good medical care is health promotion
All consultations
A perception that society devalued
Broad concept
Opportunistic approach
older people emerged, with one of the
A broad range of activities
When I have time
GPs using the phrase "negative societal
Concrete concept
Separated approach
construct of the aged". This perception
Specific preventive activities, e.g., Pap smear
Difficult in everyday practice
brought with it expectations of doctors'
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Rese rch
from all specialties had more negative
3: GPs' reactions to educational strategies
attitudes towards older people than did
Favourable responses (most comments in favour)
younger doctors.⁷ The group with neg-
ative attitudes needs to be considered
A prompt or reminder card designed to be attached to the record of older
patients' files before the consultation was shown to the group and generated
when GP interventions for older patients
a positive response.
are planned.
Audit of patient records or consecutive consultations was felt to be a
Emphasising positive experiences with
powerful learning tool, with feedback seen as essential to its effectiveness.
older people during medical training
Resource directories of activities and services for older people were seen to
may affect future doctors' attitudes.
be useful, and an incentive for participation.
Seminars were felt to be an acceptable learning format for this topic.
Perceived barriers to practice of
Intermediate responses (divergent opinions expressed)
health promotion
Reading material (booklets) was shown to the groups. Many liked the format
Although GPs believe it is their respon-
and content but felt it was difficult to find the time for such activities. All
sibility to practise health promotion, 15-17
GPs expressed difficulty in keeping up with the desired amount of reading,
they doubt their success in altering
feeling inundated and overwhelmed.
patient behaviours,18 and are reluctant to
"When do you find the time to stop and read all this?"
raise the subject³ even though patients
Unfavourable responses (most comments not in favour)
may want them to. 19,20 Our study partly
Academic detailing, or educational visiting, sparked vigorous debate in all
agrees with one of these surveys,16 in
groups. Many GPs felt imposed upon by detailer's visiting. Others would
that we found that health promotion is
prefer a professional, preferably a GP, to visit rather than a health promotion
important to GPs, but we also found
expert or a nurse.
that concepts of health promotion and
Patient pamphiets were not popular. While some GPs believed them to be a
attitudes towards its practice vary.
good source of information, others felt that the content was sometimes
Regardless of their concept of health
inaccurate. Updating was a constant problem, and the different paper sizes
promotion, GPs in our study voiced
made them both difficult to store and untidy.
common barriers to its practice, the
main ones being time and reimburse-
ment issues - identical to the barriers
GPs being inundated with materials and
similar to that of all Victorian GPs.
identified in Bonevski's review.21
resources. Many commented that they
While a larger study with a more repre-
In the most recent edition of the
usually did not have the opportunity to
sentative group of GPs is needed to
Guidelines for preventive activities in gen-
assess all the materials, and acknowl-
establish the extent of these views, a
eral practice,2 the Royal Australian Col-
edged that they probably missed out on
broad range of themes was identified.
lege of General Practitioners has
some information that would be helpful.
Indeed, focus groups provide valuable
reiterated the acceptability of preventive
A small number of the GPs were not
information necessary to explore issues
practice for Medicare reimbursement.
This advice does not seem to have
receptive to any strategy offered. They
in depth, and can provide the content
changed the views of these GPs about
would not read educational material or
for surveys to be used with larger rep-
the appropriateness of prevention. As
participate in audit programs and felt
resentative samples.¹⁴
guidelines are considered to have a low
that health promotion was not impor-
impact on everyday practice,23 other
tant for older people - "nothing would
GPs' views of health promotion
strategies are needed to increase health
help". For the remainder, having a range
promotion.
of techniques was important, allowing
Our thematic analysis showed views of
them to select the methods best suited
health promotion ranging across a spec-
to them and their practice.
trum from an abstract concept -
GPs' responses to health promotion
widely integrated into practice - simi-
interventions/educational strategies
Discussion
lar to the findings of Saltman and
In reviews of 50 trials of continuing
Therin,6 to more concrete concepts, sep-
medical education (CME) interven-
In general, the GPs participating in our
arating health promotion from usual
tions, combinations of educational
study felt that health promotion for
practice.
strategies were most successful in alter-
older patients was an important part of
ing doctors' behaviour.24.25 Academic
their practice, and reported a compre-
GPs' attitudes to older people
detailing was found to be an effective
hensive range of activities. In this con-
intervention in Australian general prac-
venience sample, more doctors who
Some ageist attitudes were expressed
tice²⁶,²⁷ but was not popular with the
graduated during the 1980s¹³ and more
during the focus group discussions. We
participants of our study. They favoured
university-affiliated GPs are represented
were unable to find other published
audit (a process which has been shown
than would be expected in a random
reports of ageist attitudes in Australian
to improve recording of risk factors and
sample, although the sex distribution is
GPs, but older United States doctors
management of asthma²⁸) and reminder
426
MJA Vol 167 20 October 1997
006
05/03/99
14:15
301 496 2809
NLM BETHESDA
Research
Aged care in the community
or prompt cards, similar to the health
Understanding the way resource
12. Hawe P, Degeling D, Hall J. Evaluating health promo-
summary cards favoured for preventive
materials will be received by GPs, and
tion; a health workers guide. Sydney: MacLennan and
Petty, 1990: 183-184.
care by Queensland GPs, in focus
presenting them so they are perceived as
13. Australian Institute of Health and Welfare. 1995. Health
groups. Some strategies that drew
saving time and helping in the GPs'
Labour Force 1992 3; 3: 15-46.
favourable responses in our study, such
practice should increase participation in
14. Mainous AG, Houghland JG. Survey sampling issues
as seminar format CME (Box 3), are not
and the success of future projects.
in primary care research. Fam Med 1991; 23: 539-543:
15. Ford A, Ford WS: Health education and the primary
regarded as effective. While the views
Planners of programs aimed at
care physician: the practitioner's perspective. Soc Sci
of GPs need to be taken into account,
increasing health promotion delivery to
Med 1963; 17: 1505-1512.
the effectiveness of strategies, as well
older people can expect to encounter
16. Cockbum J. Killer D, Campbell E, Sanson-Fisher RW.
Measuring general practitioners' attitudes towards
as their acceptability, should be consid-
some GPs with ageist attitudes and a
medical care. Fam Pract 1987; 4: 192-199.
ered when intervention programs are
negative approach to educational inter-
17. Bruce N, Burnett S. Prevention of lifestyle related dis-
designed.
ventions. Further research could exam-
ease: general practitioners' views about their role,
effectiveness and resources. Fam Pract 1991; 8:
When our study participants were pre-
ine a larger and more representative
373-377.
sented with a range of possible strate-
sample of GPs to more accurately
18. Valente CM, Sobel J. Muncie HL, et al. Health pro-
gauge their attitudes towards health pro-
motion: physicians' beliefs, attitudes, and practices.
gies, their receptivity towards the idea of
Am J Prev Med 1982; 2: 82-88.
a "new program" varied. Many felt that
motion, as well as the relationship
19. Siama K, Redman S. Cockbum J, Sanson-Fisher RW.
there were too many programs being
between these attitudes and the actual
Community views about the role of general practi-
tioners in disease prevention. Fam Pract 1989; 6:
offered and that they were approaching
delivery of health promotion to older
203-209.
"burnout" with clinical workloads and
people. In the meantime, the results of
20. Cogswell B, Eggert M. People want doctors to give
demands for change in practice struc-
our study have been used to develop an
more preventive care; a qualitative study of health care
consumers. Arch Fam Med 1993; 2: 611-619.
ture. This is a concern, as the potential
educational intervention for GPs about
21. Bonevski B, Sanson-Fisher RW, Campbell E. Primary
for improved practice and its impact on
health promotion and older people.
care practitioners and health promotion: a review of
population health can be realised only
current practices. Health Promotion J Aust 1996; 6:
22-31.
by high rates of GP participation in pre-
Acknowledgements
22. Preventive and Community Medicine Committee of the
ventive programs. Success in GP recruit-
Royal Australian College of General Practitioners.
ment for intervention studies designed
We acknowledge the support of the National Health and
Guidelines for preventive activities in general practice.
Medical Research Council, Foundation Public Health and
4th ed. Melboume: RACGP, 1996: 7.
specifically for general practice varies.
Research Development Committee in the form of a
23. Gupta L, Ward J. Hayward SA. Clinical practice guide-
For example, 68% of GPs approached
research scholarship, and the Victorian Health Promotion
lines In general practice: a national survey of recall, atti-
for a project in rural Australia³⁰ chose to
Foundation for a project grant towards completion of the
tudes and Impact. Med J Aust 1997; 166: 69-72
project. We thank the GPs for their participation.
24. Green L, Eriksen MP, Schor E. Preventive practices by
participate, while only 29% of GPs in a
physicians: behavioural determinants and potential
metropolitan area31 enrolled in another
interventions. Am J Prev Med 1988; 4 (Suppl): 101-107.
project. The importance of response
References
25. Davis DA, Thomson MA, Oxman AD, Haynes RB.
Changing physician performance. A systematic review
bias in research is well documented"
1. Nicholson KG. Immunisation against influenza among
of the effect of continuing medical education strate-
and can be avoided only if participation
people aged over 65 living at home in Leicestershire
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rates are adequate. Appropriate choice
during winter 1991-1992. BMJ 1993; 306: 974-976.
26. Pond CD, Mant A, Kehoe L. et al. General practitioner
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and range of resource methods and rel-
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evance to each individual GP's ease of
Med J Aust 1992; 157 Suppl Oct 19: S1-S56.
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27. De Santis G, Harvey KJ, Howard D, et al. Improving the
Final report from the Medical Society of Victoria and
quality of antibiotic prescription patterns in general
may promote GP participation in pro-
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posed programs.
Health Promotion Foundation, grant no. 89-0785. Mel-
Aust 1994; 160: 502-505.
bourne: Australian Medical Association, Victorian
28. Bryce FP, Neville RG, Crombie IK, et al. Controlled trial
Branch, 1991.
of an audit facilitator in diagnosis and treatment of
Conclusions
4. Sanson-Fisher RW, Hennrikus D. Why don't primary
childhood asthma in general practice. BMJ 1995; 310:
care physicians detect psychological disturbance in
838-842.
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29. Heywood A, Wise A. Jones B, et al. Final report on pre-
The GPs who participated in this study
Handbook of social psychiatry. Canberra: Elsevier Sci-
ventive care management in general practice. A pilot
expressed a range of attitudes toward
ence, 1988.
project funded by the General Practice Evaluation Pro-
older people and differed in their con-
5. Dickinson JA, Wiggers J, Leeder SR, Sanson-Fisher
gram. Canberra: Department of Health and Family Ser-
RW. General practitioners' detection of patients'
vices. National Information Service, 1994.
cepts of health promotion, how they
smoking cessation status. Med J Aust 1989; 150:
30. Jeffs DA, Gray T, Wenzel W. Involving general practi-
practised it, how relevant they believed
420-426.
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Aust Fam Physician 1991; 20: 30-34.
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31. Driver B, Britt H, O'Toole B, et al. How representative
cational strategies they favoured.
7. Swanson Hellbush J. Corbin D, Thorson J, Stacy R.
are patients in general practice morbidity surveys? Fam
Regardless of their beliefs, common bar-
Physicians' attitudes towards aging. Gerontol Gerietr
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Educ 1994; 15: 55-65.
riers to the provision of preventive care
32. Cockbum J, Campbell E, Gordon JJ. Sanson-Fisher
8. Bull FCL, Schipper ECC, Jamrozik K, Blanksby BA.
RW. Response blas in a study of general practice. Fam
were identified, suggesting that while
Beliefs and behaviour of general practitioners regard-
Pract 1988; 5: 18-23.
impediments to increasing health pro-
ing promotion of physical activity. Aust J Public Health
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9. Kitzinger J. Introducing focus groups. BMJ 1995: 311:
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10. Berg BL. Qualitative research methods for the social
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11. Murphy B, Cockbum J, Murphy M. Focus groups in
matic approach.
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(Received 9 Jul, accepted 19 Aug 1997)
MJA Vol 167 20 October 1997
427
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Fax To:
Date: 4/30/99 1
09:09:02
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JAGS
SPECIAL SERIES
:
ils
eat the
MODELS OF GERIATRICS PRACTICE
Serics Editor: David B. Reuben, MD
anu
in hip
The CARE Program: A Nurse-Managed Collaborative
to ger
Outpatient Program to Improve Function of Frail
search
Older People
Lois K. Evans, DNSc, RN, FAAN, Johanna Yurkow, RN, MSN, and
Eugenia L. Siegler, MD, FACP
DESCRIPTION OF THE POPULATION: In its first 8
BACKGROUND AND OBJECTIVES: Frail older adults are
months of operation, the program received 97 referrals and
especially vulnerable in a health system that is fragmented
admitted 53 clients. Clients were, on average, 78 years of age.
and fails to focus on preservation or restoration of function.
Over three-fourths (77%) were women and 58% were black.
The School of Nursing at the University of Pennsylvania,
The average stay in the program was 6 weeks. FIM scores,
together with the School of Medicine and the Hospital of the
which improved a mean of 2.4 points, were found to lack
University of Pennsylvania, established the Collaborative As-
sensitivity to the functional improvements achieved by
sessment and Rehabilitation for Elders (CARE) Program to
clients.
meet the needs of this population. We used the British Day
Hospital as a model because it provides a comprehensive
CONCLUSION: Under existing Medicare and third party
approach to care and a bridge between acute, home-based,
reimbursement policies, it is feasible to establish a nurse-
and institutional long-term care. We have designed our pro-
managed comprehensive outpatient rehabilitation program
gram to provide innovative, interdisciplinary care as well as
designed to meet the needs of frail older persons. Preliminary
to be reimbursable under current and future payment struc-
data support the beneficial effects of the program as well as
tures. This nurse-managed, collaborative practice secks to
the economic feasibility of this approach. J Am Geriatr Soc
maximize independent functioning, promote health, and en-
43:1155-1160, 1995.
hance quality of life for chronically ill, frail older adults living
in the community whose needs are left unmet by existing
services. The program was certified as a Comprehensive
Molder people is a complex task and involves meeting
health of frail community-dwelling
Outpatient Rehabilitation Facility (CORF) in December
1993 to maximize reimbursement of services through Medi-
any of a combination of nursing, medical, rehabilitative,
care and other third party payers. With a Gerontological
mental health, social, or other needs. A series of falls, the flu,
Nurse Practitioner as care manager, clients receive an inten-
or even a brief hospital stay can severely reduce functioning
sive, individualized, time-limited program of nursing, reha-
and cascade into rapidly declining health status. Attention to
bilitation, mental health, social, and medical services in one
the rehabilitative needs of this population is essential if they
setting several days each week. Additional geriatric services,
are to be maintained in the community. Further, coordina-
such as primary care, are available in the same location when
tion of social, health, and rehabilitative services is imperative
needed.
if further fragmentation of care is to be avoided. Although
SETTING: The program is housed in renovated space de-
outpatient and home rehabilitative services arc available to
voted to the care of older people. The academic and clinical
individuals with functional impairments, an exclusive focus
offices of the University of Pennsylvania's nursing and medi-
on rehabilitation may leave other problems unaddressed or
cal gerontologic and geriatric faculty are in the same building.
poorly integrated. Moreover, those who live in underserved,
PARTICIPANTS: We have targeted those persons older than
urban areas often lack access to even the most basic rehabil-
itative services in the home.
age 65 who have complex health problems and are living at
home. Individuals must need multiple services, including at
The British healthcare system has recognized the need for
least one rehabilitation therapy, and they must he unsuitable-
broad-based interdisciplinary health care for older adults.
for inpatient rehabilitation.
The day hospital, an outpatient facility that provides inter-
mittent comprehensive care to community-dwelling older
people, plays a pivotal role in providing continuity between
This article is one in a series on Models of Geriatrics Pracrice.
Address correspondence to Lois K. Evans, DNSc. RN, FAAN, The CARE Pro-
ambulatory/home care, acute, and long-term care services.
gram, Ralston-Penn Center, 3615 Chestnut St., Philadelphia, PA 19104 2676.
The British day hospital serves as a model for one component
JAGS 43:1155-1160, 1995
0 1995 by the American Geriatrics Society
0002-8614/95/$3.50
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Date: 4/30/99 Time: 09:09:02
Page 3 of 7
1156
EVANS ET AL
OCTOBER 1995-VOL. 43, NO. 10
JAGS
of a comprehensive care system that would benefit frail older
The University of Pennsylvania's Institute on Aging and
persons in the United States.
academic offices of the Division of Geriatric Medicine, the
Although the literature is equivocal in its support for day
Program in Geriatric Psychiatry, and the Gerontological
hospitals, 1-8 only some of these studies have examined day
Nursing Practices, in addition to some offices in the Depart
hospitals that have a strong rehabilitation component. 2-6 It
ment of Rehabilitation Medicine, are housed at Ralston
has been suggested that for certain subpopulations, the day
House. Other clinical programs of RPC include the compre-
hospital would be a cost-effective approach to care delivery.¹
hensive geriatric assessment clinic, mood and memory disor.
To this end, we sought to create a program that would
ders clinic, geriatric primary care clinic, the gerontological
provide care to a group of underserved older people in West
nursing consultation service, and the nurse-managed conti-
Philadelphia. In addition, we sought to explore the feasibility
nence program.
of developing and maintaining a large-scale, interdiscipli-
The CARE Program's clinical space consists of One room
пагу, clinical program to be managed by nurse practitioners,
and is located 111 the same corridor as the geriatric clinic. The
thereby demonstrating the kind of self-supporting clinical
room is partitioned into office space, which can be used for
service that a school of nursing could implement as part of its
physical examinations and treatment, private interviews,
academic practice in collaboration with other components of
family meetings, and speech therapy and counselling. is well
a medical center. The CARE program (Collaborative Assess-
as a reception arca, a rest area, occupational therapy (OT)
ment and Rehabilitation for Elders) has been operational
space, and physical therapy (PT) space (See Figure 1). Toilets
since October 1993.
accessible to the disabled are adjacent to the room, and the
PROGRAM DESCRIPTION
administrative offices are located elsewhere in the building. A
comfortable, homey environment is achieved through liberal
Program Structure
use of living plants, colorful curtains and screens, recliner
The CARE Program is sponsored by the University of
chairs, large windows, and antique design features.
Pennsylvania School of Nursing (SON) in collaboration with
The program's physical proximity to the geriatric clinic
the School of Medicine (SOM) and the Hospital of the
allows the Care Program to use preexisting technical services
University of Pennsylvania (HUP). The Executive Director is
such as phlebotomy and ECG, to consult physicians on an
a standing faculty member of the SON. Overall clinical
emergency basis as necessary, and to schedule CARE pro-
services and operations are managed by a masters-prepared
gram services on the same day as primary care services when
gerontologic nurse practitioner (GNP). Clinical staff and
appropriate. Although each clinical program in the RPC
faculty from the relevant rehabilitation departments in the
operates independently, consultations and referrals between
hospital, three departments in the SOM, and the SON form
programs occur on both formal and informal bases. Patients
an interdisciplinary team, directed by the GNP, that provides
are often enrolled simultaneously in more than one program.
care on a day-to-day basis. For each client, a GNP also serves
Coordination of services and communication are enhanced
as care manager, coordinating, monitoring, and providing
by physical proximity as well as through interdisciplinary
care in close collaboration with team members as well as with
committees and a weekly patient care conference attended by
the medical director and the client's own primary care pro-
interdisciplinary staff from all programs. The services that the
vider. Thus, collaboration occurs at three levels: institution
CARE Program offers are listed in Table 1. The program
(schools and departments), interdisciplinary team, and GNP/
readily accommodates an active cascload of 22 to 25 clients,
physician.
with 6 to 8 attending any half-day session.
As an outpatient interdisciplinary service designed for
Table 2 lists the types of personnel and current F IT. The
community-dwelling, chronically ill older adults, The CARE
main source of reimbursement is through Medicare and other
Program is designed for those who need more than simple
third party payers. The CARE Program is certified as a CORF
outpatient rehabilitative services and who are not appropri-
(Comprehensive Outpatient Rehabilitation Facility)9 and can
ate candidates for inpatient rehabilitation. It is part of the
charge for rehabilitative, mental health, social work, and
Ralston-Penn Center (RPC), which is housed in the Ralston
rehabilitative nursing services. Physician, podiatric, and die-
House, an historic, Victorian, former residential home for
titian services (e.g., clinical encounters) occur outside the
older women that has since been converted to office and
CORF structure and are billed through the Clinical Practices
clinical space devoted largely to the needs of older people.
of the University of Pennsylvania or HUP, as appropriate.
B
Figure 1. Layout of the CARE Program clinical
D
area. A: Occupational Therapy; B: Rest Area: C:
Reception Area; D: Physical Therapy: E: Con-
F
ference Room; F: Nursing.
C
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AGS
JAGS
OCTOBER 1995-VOL. 43, NO. 10
MODELS OF GERIATRICS PRACTICE
1157
and
The medical director, a collaborating physician, meets
Table 1. Assessments and Services Available
the
weekly with the GNPs to discuss routine medical care issues
ical
and is available by beeper to consult on urgent medical issues.
Nursing
irt-
Care management
In addition, the medical director signs all treatment plans
ton
Mental health and family therapy
and, with the director of clinical services, approves each
ore-
Physical therapy
client's admission to the program. The physiatrist is con-
-or-
sulted as needed.
Occupational therapy
ical
Social work
All clients see the GNP, physical therapist, and occupa-
nti-
tional therapist as part of their initial assessments. Table 3
Speech-language pathology
lists the assessment tools used in the evaluations of clients. In
Primary care*
om
Medical consultation
addition to general clinical assessments to determine needs
The
Nutritional counselling
for service, these instruments were selected to provide more
for
Blood and urine laboratory tests*
objective baseline measures of status in areas commonly
WS,
Physiatric consultation
expected to respond to intervention in a program such as
vell
Orthotics/Prosthetics
ours. Further, the instruments depict initial status in func-
)T)
tional areas known to affect client response to rehabilitative
Podiatry*
lets
care (e.g., depression) and help identify areas for further
Continence
the
evaluation. The instruments include measures of affect, cog-
:.A
Provided in the adjoining Ralston-Penn geriatric clinic.
nitive function, ADL/IADL function, physical and mental
ral
health, and sensory and nutritional status. Initial assessment
ner
is ordinarily completed in one to two half-day sessions. Based
Table 2. Personnel
on the referral, the initial findings, and the client's own goals,
nic
the team at its weekly meeting recommends appropriate
Provider
FTE
services and creates a plan of care that the medical director,
ces
care manager, and client sign. The scope of any client's
an
Executive Director
0.4
personal treatment program, then, is based on outcome of
ro-
(Nursing Faculty)
comprehensive assessment and determination of reasonable
en
Director of Clinical Services
0.5
PC
goals.
(GNP)
Clients ordinarily come to the program 2 or 3 half days a
een
Care manager/Gerontologic Nurse Practitioner
1.5
week for a period of 2 to 9 weeks, depending on the identified
nts
Medical Director
0.2
needs, goals, and the plan of care. Each client's program is
m.
(Geriatrician)
red
individualized according to need acuity and degree of frailty;
Mental Health Clinical Nurse Specialist
0.4
the weekly schedule is determined by the intensity of PT and
ary
Physical Therapist
1.0
OT regimens. Typically, a client arrives at either 9 AM or 1
by
Physical Therapy Aide
1.0
PM and is scheduled to see three different clinicians in each
the
Occupational Therapist
1.0
half-day session, e.g., PT, OT, and GNP. Clinician sessions
am
Speech-Language Pathologist
0.1
range from 30 to 60 minutes each, depending on the client's
its,
Social Worker
0.5
tolerance. Brief rest periods are available between clinician
Consultant physiatrist
0.1
visits. In addition to receiving these services, clients and/or
The
Business manager
1.0
families may participate in weekly transition group sessions
her
Program assistant
1.0
to help them prepare practically and emotionally for dis-
RF
Administrative support
2.0
charge. These sessions are co-led by the mental health clinical
can
TOTAL FTE
10.7
nurse specialist (CNS) and the social worker.
nd
Collaboration among members of the interdisciplinary
lie-
team is enhanced by the open design of the environment for
the
Process of Care Delivery
service provision as well as formal weekly team treatment
ces
We sought to reach a group of frail older people who are
conferences. Team members can readily see a client's re-
not already served by existing inpatient and outpatient reha-
sponse to another therapist's interventions, and these obser-
bilitation programs and who would benefit from a more
vations can assist in assessment validation and treatment
intensive program than could be provided in the home. Ad-
planning.
mission criteria include the following: (1) Age greater than 65
(exceptions can be made on a case-by-case basis); (2) Having
need for at least one rehabilitation therapy (e.g., physical,
occupational, or speech) and one other service (e.g., nursing,
Table 3. Database
cal
mental health); (3) Neither suitable for inpatient rehabilita-
C:
tion, nor casily managed in ordinary outpatient rehabilitation
Functional Independence Measure¹⁰
n-
clinics; and (4) Living at home, either alone or with a care-
Geriatric Depression Scale¹¹
giver.
Hearing Handicap Inventory for the Elderly¹²
Clients are referred by a physician who usually is, but
History and physical (brief)
need not be, the primary care provider. A GNP does the
Mini-mental State Exam¹³
initial screening histories and modified physical examina-
Medical Outcomes Survey Short Form 36 (MOS-36)¹⁴
tions, assesses health and self-care status, and serves as care
Nutrition Screening Initiative¹⁵
manager for each client from admission through discharge.
From: RelaisFax To:
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1158
EVANS FT AL.
OCTOBER 1995-VOL. 4.). NO. to
AUS
The GNP provides skilled nursing services and also
paid for renovations. Additional support has been obtained
serves as care manager, coordinating services that are part of
from the Pew Charitable Trust, the Killough Trust, the Esther
the client's treatment plan and planning for services after
Gowan Hood Foundation, and the Scholler Foundation.
discharge. The GNP typically sees the patient one to two
times per week and is available to monitor health status
Participants
changes or attend to urgent problems on a daily basis. Having
In the first 8 months of operation, 97 clients were re.
a seasoned advanced practice nurse in this combined role is
ferred, 66 were evaluated, and 53 were admitted. Of those
essential for this frail population, where early detection and
admitted, 77% were women, 58% were black, and the aver-
intervention can make the critical difference between main-
age age was 78 (range 59-91). Seventy-one percent were
taining functional independence and hospitalization.
widowed, divorced, or never married, and 67% were living
Coordination with all existing services is essential for
with a relative, mostly daughters. The average length of stay
client success in the program and to assure appropriate fol-
for the spring quarter of FY '94 was 6 weeks (range 2-9
low-up. Since the referring physician and the primary care
weeks). Inasmuch as this quarter is most representative of
physician are not always the same person, the primary care
program functioning after initial start-up, some descriptive
physician receives a copy of the initial plan of care as well as
data for the 21 clients discharged during this 3-month period
60-day updates (when appropriate) and a discharge summary
will be described.
at the end of the treatment period. This information is also
Seventy-one percent of these clients had an admitting
sent to the referring physician, based on his/her level of
rehabilitation diagnosis of osteoarthritis, and 19%, stroke.
involvement in the client's care. When medical issues arise,
All had Medicare as primary insurance. More than 90% were
the GNP phones the primary care physician either to convey
referred by the RPC geriatric clinic and, after rehabilitation,
information or to ask the physician's preference, for example,
returned to these health care providers for primary health
regarding medication management. The medical director's
care services. Transportation arrangements were provided by
involvement in direct client care is limited to health status
ambulance or van for 38% of the clients, with the remainder
changes of sudden onset, for example chest pain, or to treat
providing their own transportation.
short-term acute episodes of illness such as upper respiratory
Initial screening determined that 57% of clients were at
infections. The medical director remains available to the
high nutritional risk. 15 These clients received counseling ei-
GNP to provide guidance in managing more complicated
ther by nurse practitioners or registered dietitians, depending
medical situations.
on their needs. Eight of the 21 scored 11 or higher on the
Contact with social service agencies occurs in a similar
Geriatric Depression Scale (GDS)¹¹ and, following assess-
manner. Many patients have existing care management ser-
ment by the mental health CNS, received psychiatric referral
vices through community agencies or are receiving services
and/or counseling by the CNS.
through a home health agency. These services are identified
early in the program by the GNP and contact is made to
Preliminary Functional Data
promote coordination, prevent service duplication, and de-
On admission, clients scored in the modified dependence
termine gaps in service provision.
range on the Functional Independence Measure (FIM)" (nv-
If a client needs access to primary geriatric or psychiatric
erage per item score 5.5, range 2-6.9). Of the 21 clients
care, an appointment may be arranged with a provider
discharged in the spring '94 quarter, scores for six (28.6)
though the adjoining clinic at the client's discretion. Other
remained the same, and 15 (71.4%) showed improvement;
professionals (e.g., podiatrist, orthotist, dietitian) come to the
the average overall improvement in score was 2.4 points.
site as needed.
Nineteen clients had pre-post general measures of ambula-
tion; six (32%) improved significantly in the amount of
Costs of the Program
distance travelled, and 13 (68%) maintained independent
During the start-up phase, the PT and OT worked only
states with or without assistive devices.
part rime, there was no program assistant, and only one GNP
In addition to these descriptive data, we have made some
was on staff. After the first year of operation, the FTE of the
general observations. Although clients clearly benefit from
medical director was decreased slightly (from 0.3 to 0.2 FTE)
the program in terms of increased safety, diminished pain,
and the FTE of the speech-language pathologist was de-
and improved ambulation distances, the FIM¹⁰ is not sensi-
creased from 0.25 to 0.1 (see Table 2 for current staffing
tive enough to pick up these data; in addition, when older
levels).
people are given assistive devices, some of the components of
Startup costs included (1) salary support; (2) a feasibility
their FIM score may decrease. Because of the lack of sensitiv-
study; (3) consultants to design the business plan, assist with
ity of the FIM for trail outpatient populations, we are explor-
cost reporting, and help with the writing of policies necessary
ing the utility of Granger's General Assessment of Functional
for meeting certification criteria as a Comprehensive Outpa-
Ability scale (available from the author) in our population.
tient Rehabilitation Facility (CORF); (4) purchase of equip-
Alternatively, we are developing and testing an extension to
ment and supplies; (5) installation of an OT kitchen;
the FIM to measure safety awareness, pain, and endurance.
(6) partitioning and furnishing of offices and work areas, and
(7) rent.
DISCUSSION
The CARE Program received considerable assistance in
its start-up phase. The Robert Wood Johnson Foundation
Problems and Limitations
funded a feasibility study, and the William l'enn Foundation
The CARE Program faces and has faced a number of
partially supported the planning and initial start-up. In addi-
obstacles. The first was the establishment of a nurse-managed
tion, the Hospital of the University of Pennsylvania donated
practice with the cooperation of the Medical Center. this
some old rehabilitation equipment, and the Ralston House
required 3 years of negotiation and considerable re-education
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AGS
JAGS
OCTOBER 1995-VOL. 43, NO. 10
MODELS OF GERIATRICS PRACTICE
1159
led
about nursing of medical center personnel. The establishment
lance service that provides the bulk of our services also
per
of the program served as a lesson in overcoming institutional
provides limited van service to less impaired clients;
barriers to collaboration. This process is described in detail
Limited focus of size and services covered under
elsewhere.
16
CORF regulations. Providing a more comprehensive
The second major obstacle is financial. Breaking even
range of services to approximate those in the British
re-
requires a minimum of 250 billable units (15-minute inter-
Day Hospital, including more intensive observational
se
vals) a week, a considerable volume for the space, personnel,
assessment, close surveillance during titration of med-
er-
and type of client population served. Although being certified
ical treatment, and outpatient preparation for diag-
ere
as a CORF makes the CARE Program eligible for Medicare
nostic procedures, will require further development,
ng
and other third party reimbursement, the amount of time and
perhaps outside the CORF structure;
tay
attention required by frail older people makes care far less
Space. Expansion of the program is limited by lack of
-9
efficient than that in work-hardening programs (those that
additional space in the current building;
of
rehabilitate individuals from an occupational injury) or day
Lack of adequate community-based services and pro-
ive
hospitals that concentrate on one type of problem (e.g.,
grams for clients who have completed the CARE pro-
od
psychiatric). Limitations on reimbursement for social work,
gram. Clients clearly benefit from socializing during
care management, and mental health services, essential com-
their rehabilitation; we have found it difficult to find
ng
ponents of care for this population, present further chal-
adequate senior center facilities that cater to the needs
ke.
lenges. We are still accruing the necessary experience to
of physically frail but cognitively intact older adults.
ere
determine the best case mix for the maximum efficiency and
Education and Research
n,
effectiveness.
Ith
As a CORF, the CARE Program's services are reim-
As a component of the School of Nursing's academic
by
bursed on a reasonable cost basis. Overhead expenses for
practice, the CARE Program serves as a laboratory for edu-
der
administration, capital equipment, and so on are reimburs-
cation and research. The interdisciplinary, collaborative na-
able aspects of the overall cost of operating the program and
ture of the practice is ideal as a clinical site for students from
at
may be substantially recovered at the end of each fiscal year.
many health professions. To date, students from gerontologic
ei-
Nursing, mental health, social work, and care management
nurse practitioner, geropsychiatric clinical nurse specialist,
ing
services, ordinarily not well reimbursed on a fee-for-service
nursing administration, and senior level BSN programs, as
the
basis, are allowable costs in a CORF, and in this respect, the
well as students in social work, OT, speech, and business,
ss-
structure lends itself more casily to meeting comprehensively
fellows in geriatric medicine and geriatric psychiatry, and
ral
the multiple needs of the frail older adult.
physiatry residents have been involved. The richness of the
The appropriateness, effectiveness, and efficiency of ad-
client population and clinical dataset will be instrumental in
vanced practice nurses (i.e., masters degree-prepared nurse
evolving clinical and health services research. A pilot evalua-
practitioners or clinical nurse specialists) in assessment, care
tion of ourcomes is underway, and eligible and interested
ice
management, and provision of rehabilitation and mental
clients are being enrolled in a study regarding depressive
av-
health services is well established. 17,18 Services for frail older
symptoms in medically ill older persons. An electronic inte-
nts
people can be designed and managed appropriately by a team
grated management information system and health care
.6)
of interdisciplinary providers using a geriatrician as medical
record, in the planning stage, will facilitate exploration of
nt;
consultant.
nursing and health care questions in the care of older adults.
its.
Another challenge has been establishment of a steady
la-
Generalizability
referral stream. Early in the program, an abundance of refer-
of
rals from our colleagues in the geriatric assessment and
We believe that the nurse-managed aspect is generaliz
ent
primary care clinics lulled us into postponing the develop-
able to other systems, such as continence clinics, wellness
ment and nurturing of additional client sources. This ulti-
centers, and other primary care services. The CORF struc-
me
mately resulted in a reduction in referrals and lower than
ture, while potentially unwieldy for a broader range of ser-
on
desired census (average 18). We have since developed a
vices, has utility under the current reimbursement system and
in,
strategy for systematizing and diversifying our referral
is one of the few mechanisms that recognizes nursing, an
isi-
stream, which includes working closely with hospital units
essential component of any service for frail older adults, as a
der
that discharge large numbers of older adults, and increasing
covered charge. Clearly, the types of clients seen in our
of
social work FTE to accommodate a heavier commitment to
program are readily managed by advanced practice nurses
tiv-
such a liaison. This has resulted in a higher patient acuity
with special expertise in gerontologic and mental health
or-
level, with resultant implications for case mix and volumes.
nursing. The concept of the day hospital for frail older adults
nal
Other limitations include:
is a natural fit for schools of nursing, especially those that are
on.
part of health science centers with divisions of geriatrics.
to
The need to avoid competing with pre-existing pro-
C.
grams in the health system. We have taken great pains
Directions for Further Innovations
to admit only those clients who would not be better
Given the frailty of our client population, we are explor-
served by standard outpatient PT and OT or by inpa-
ing the possibility of instituting a brief readmission, perhaps
tient rehabilitation programs;
on an every 3 months basis, to determine whether partici-
Transportation. Our program is too small to justify
pants experience a "booster effect" that might further stave
of
the expense of its own van. Public paratransit systems
off functional decline resulting in nursing home placement.
;ed
are rarely able to ensure that clients will arrive or be
We are seeking funding to explore expansion of services to
his
picked up at prescribed times. Thus, we are dependent
respond to the limitation in CORF coverage described earlier.
on
on family and ambulance transport. A private ambu-
Finally, we see the CARE Program as one component of a
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Page 7 of 7
1160
EVANS AL.
OCTOBER 1995-VOL. 43, NO. 10
AGS
true continuum of care for older adults. Thus, we are explor-
5. Morishita L, Siu AL. Wang RT et al. Comprehensive genatric care in a day
ing potential partnerships with existing and to-be-developed
hospital: A demonstration of the British model in the United States. Geron-
rologist 1989;29:336-340.
services that could round out the continuum in as seamless a
6. Cummings V, Kerner JF. Arones S. Steinbock C. Day hospital in re-
model as possible. To this end, consideration of a PACE-type
habilitation medicine: An evaluation. Arch Phys Med Rehabil 1985;66:86
model (Program of All-Inclusive Care for the Elderly, based
91.
on the On-Lok model¹⁹) is underway.
7. Eagle DJ, Guyatt G, Patterson C, Turpie I. Day hospitals' cost and effective
ness: A summary. Gerontologist 1987:27:735-740.
CONCLUSIONS
8. Zeeli D. Isaacs B. The efficiency and effectiveness of geriatric day hospitals.
Postgrad Med J 1988;64:683-686.
We have created a nurse-managed day hospital that
9. Health Care Financing Administration. Federal Register 1989: 42 CFR (H
seeks to meet the needs of a subpopulation of community-
IV (10-1-89 Edition), 379-386.
dwelling older adults who have often "fallen through the
10. Forer 5. Granger C et al. Functional Independence Measure. Buttalo, NY:
The Buffalo General I Hospital, SUNY-Buffalo, 1987.
cracks" because of gaps in services. To do so, we have utilized
11. Yesavage JA, Brink TI., Rose TL et al. Development and validation of ! geri-
the special knowledge and skills of advanced practice geron-
atric depression screening scale: A preliminary report. J Psychiatr Res
tologic nurses who collaborate with a range of other disci-
1983;17:37-49.
plines to provide high quality team care for frail older adults.
12. Ventry IM, Weinstein BE. Identification of elderly people with hearing prob.
lems. ASHA Rep 1983;25:37-42.
The program has afforded us the opportunity to begin exam-
13. Folstein MF, Folstein SL, McHugh PR. Mini-mental state: A practical enide
ining the effectiveness and efficiency of nursc-managed mod-
for grading the cognitive state of patients for the clinician. I Psychant Res
els of health care, especially for vulnerable and underserved
1975;12:189-198.
populations, and determining the means of achieving finan-
14. Stewart AI., Hays RD, Ware JE Jr. The MOS Short Form general health wr.
vey. Med Care 1988;26:724-735.
cial viability of such programs.
15. Lipschitz DA, Ham RJ, White JV. An approach to nutrition screening for
older Americans. Am Fam Phys 1992:601-608.
REFERENCES
16. Evans LK. Overcoming institutional barriers to collaboration. In: Stegled FL.
1. Chapko M, Ehreth J, Hedrick SC. Kothman MI.. Effects of adult day health
Whitney FW, eds. Nurse-Physician Collaboration: Care of Adults and the
care on utilization and cost of care for subgroups of patients. Med Care
Elderly. New York: Springer. 1994, PP 33-42
1993;31:562-74.
17. Office of Technology Assessment. Nurse practitioners, physician assistants,
2. Weissert WG, Wan T. Livicratos B et al. Effects and costs of day care ser-
and certified nurse-midwives: A policy analysis. Health Technology Case
vices for the chronically ill. Med Care 1980;18:5677-5684
Study 37. Washington, DC: US GPO, 1986..
3. Tucker MA, Davison JG, Ogle SJ. Day hospital rehabilitation - Ellectiveness
18. Safriet RJ. Health care dollars and regulatory sense: The role of advanced
and cost in the elderly: A randomised controlled trial. Br Med J
practice nursing. Yale I Reg 1992;9:417-489.
1984;289:1209-1211.
19. Miller JA. The On-Lok Senior Health Services consolidated model of long
4. Eagle DJ, Guyart GII, Patterson C ct al. Effectiveness of a geriatric day hos-
term care. In: JA Miller, ed. Community-Based Long Term Care: Innovative
pital. Can Med Assoc J 1991;144:699-704.
Models. Newbury Park, CA: Sage, 1991, PP 202-215.
F
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Journal of Advanced Nursing, 1997, 26, 408-417
Promoting autonomy and independence for older
people within nursing practice: a literature
review
Sue Davies Bsc Msc RGN RHV
Lecturer in Nursing) Department of Gerontological and Continuing Care Nursing
Sard Laker BA RGN
Research Assistant, School of Nursing and Midwifery
and Lorraine Ellis BA MSc RGN RNT
Research Associate, School of Nursing and Midwifery) University of Sheffield, Sheffield,
England
Accepted for publication H July 1996
DAVIES S., LAKER S. & ELLIS L. (1997) Journal of Advanced Nursing 26, 408-417
Promoting autonomy and independence for older people within nursing
practice: a literature review
The principles of promoting autonomy and independence underpin many
approaches to improving the quality of nursing care for older people in
whatever setting, and are in line with wider developments in health care such
as the Patient's Charter. However, these concepts require careful definition if
nursing practices which might promote autonomy and independence are to be
identified. Although the generalizability of the research-based literature in this
field is limited by a focus upon older people in continuing-care settings, a
review of the literature found a number of indicators associated with attempts
to promote patient autonomy and independence. These were grouped into the
following categories: systems of care delivery which promote comprehensive
individualized assessment and multidisciplinary care planning; attempts to
encourage patients/clients to participate in decisions about their care; patterns
of communication which avoid exerting power and control over patients/clients
and attempts to modify the environment to promote independence and
minimize risk. It is suggested that the review identifies a number of principles
for nursing practice which can be applied in a range of care settings in order to
promote the autonomy and independence of older people.
Keywords: older people, autonomy, independence, nursing care
in any attempts to develop a scientific knowledge base.
INTRODUCTION
Many of these abstractions defy adequate definition in
The abstract nature of many of the concepts central to
spite of their familiarity within everyday language.
nursing practice presents nursing with major challenges
Autonomy and independence are two such concepts and
are currently the focus of a research project funded by the
Correspondence: Sue Davies, Samuel Fox House, Northern General
English National Board for Nursing, Midwifery and Health
Hospital, Herries Road, Sheffield S5 7AU, England.
Visiting. The 2-year study aims to evaluate programmes of
408
© 1997 Blackwell Science Ltd
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Promoting autonomy and independence
nursc education in relation to the extent to which they
individual's autonomy in the short term in order to promote
enable nurses to promote the autonomy and independence
their long-term autonomy. An example would be the admin-
of older people in their care.
istration of medication without a patient's consent if it were
The motivation for this paper arose from a need to define
thought that the medication would restore the capacity for
and operationalize these concepts and to consider, through
determination in the future.
a review of the literature. ways in which the nurse might
A number of authors suggest that, in order to make an
promote autonomy and independence for the older person.
autonomous decision, an individual must be capable of
This review will outline some of the characteristics of
rational thought and self-governance (see for example
autonomy and independence before considering why
Hogstel 1991). Again there is a challenge here for nursing
these concepts are of such significance to the nursing care
practice to recognize when an individual is capable of
of older people. Factors which appear to be associated with
making autonomous decisions. Moreover, the need to bal-
the promotion of patient/client autonomy and indepen-
ance the promotion of autonomy and independence with
dence within nursing practice are then explored. The
the need to minimize risk constitutes an important
review concludes with some general principles for caregiv-
dilemma. Beauchamp & Childress (1989) go some way
ing, appropriate to a range of settings, which may enable
towards resolution in suggesting that although decisions
nurses to promote the autonomy and, where appropriate,
are rarely fully informed or autonomous, none the less they
the independence of older people in their care.
can be adequately informed and autonomous.
CHARACTERISTICS OF AUTONOMY,
Independence
INDEPENDENCE AND DEPENDENCE
Independence is frequently used as a synonym for auton-
Autonomy
omy. However. it is perhaps more appropriately viewed
as one dimension or a contributing factor to personal
Any study of autonomy in old age requires a conceptual
autonomy. Independence is most frequently associated
definition that is broadly applicable yet amenable to
with an individual's level of physical functioning and
empirical validation (Horowitz et al. 1991). Unfortunately,
ability to perform the activities of daily living unaided.
definitional precision is rarely encountered within the lit-
Indeed, many older people equate their own level of health
erature and autonomy remains a widely used but loosely
or wellness with their level of functional ability
defined concept (Beauchamp & Childress 1989). One defi-
(McLymont et al. 1991). It would therefore seem appro-
nition which appears to have value within the context of
priate for nurses to aim their interventions at maintaining
the nurse-patient/client relationship is formulated by
or recovering the older person's optimal level of physical
Horowitz et al. (1991), who suggest that autonomy is:
functioning.
the exercise of self-determined, goal-oriented behaviour that is or
It is of course possible, however, that the need to
can be potentially threatened or inhibited by a variety of circum-
promote autonomy may conflict with the need to promote
stances, real or symbolic, intrinsic or external to the person.
independence: people requiring care may choose to
(Horowitz et al. 1991 p. 23)
become more dependent. Autonomy and independence
should therefore be viewed as separate but potentially
Atkinson (1991) and Macmillan (1986) agree that auton-
overlapping goals of care.
omy is concerned with sclf-determination and the ability
to make choices. Hertz (1993) suggests three defining attri-
butes: voluntariness, individuality and self-direction.
Dependence
From those definitions it becomes apparent that the notion
Our understanding of the concept of independence can
of autonomy is both multidimensional and context-
perhaps be advanced by considering the notion of depen-
dependent (Collopy 1988). Sciegaj & Capitman, for
dency, which has been described both as a continuum
example (Sciegaj & Capitman 1994), propose that all indi-
(Hockey & James 1993) and a relationship (Phillips 1984).
vidual autonomy is embedded in particular relationships
The relationship usually implies a degree of inequality
and circumstances.
between the dependant and the depended upon (Bond &
Collopy et al. (1991) make the important distinction
Bond 1987) and is characterized by loss of control on the
between decisional autonomy (decision making) and
one part and loss of personal freedom on the other. Walker
executional autonomy (implementing decisions). The risk for
(1982) identifies four dimensions: life-cycle dependency,
nursing practice is that decisional autonomy can easily be
physical and psychological dependency, political dopen-
denied when executional autonomy is diminished or lost. A
dency and economic dependency. Older people requiring
second important distinction is between short- and long-term
nursing care are frequently dependent in some or all these
autonomy (Brown 1995, Collopy et al. 1991, Lindley 1988).
dimensions. However, this does not imply that they cannot
For example, it may be considered ethical to compromise an
make autonomous decisions in these areas.
© 1997 Blackwell Science Ltd, Journal of Advanced Nursing, 26, 408-417
409
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S. Davies et al.
constituted a healthy life identified three main conditions:
AUTONOMY AND INDEPENDENCE: WHY
acceptable function in daily life, positive self-esteem
ARE THESE IMPORTANT CONCEPTS FOR
NURSING?
(related to a present experience of independence and
autonomy) and experience of peace of mind (Nystrom &
Within the context of the 'new nursing' (Salvage 1992,
Andersson-Segesten 1990).
Pearson et al. 1988), enabling a patient or client to be as
A further study in a similar setting (Oleson et al. 1994)
autonomous and independent as possible is seen as an
used a phenomenological approach to compare nurses'
integral part of nursing's therapeutic function. Clay (1986),
and residents' perceptions of factors contributing to a good
for example, suggests that a caring environment is one
quality of life for older people. Analysis of semi-structured
offering individuals the opportunity to develop their own
interviews with nine nurses and ten residents from three
potential and the freedom to choose their own course of
nursing homes in south-west England identified a number
action.
of themes which were common to both respondent groups.
As nursing moves away from a medical model of care
These were: individuality (concerned with the unique
towards a more biopyschosocial model of nursing, the
characteristics of residents), connectedness (referring to
patient's role is being redefined. Patients are now expected
creating and maintaining relationships), professionalism
to take an active part in their care and to divulge essentially
and physical functioning. However, there were different
private information to enable the nurse to create an indi-
emphases in nurses' and residents' responses: in particu-
vidual care plan which recognizes all the patient's needs.
lar, residents described their quality of life in terms of how
A6 a further consequence, patients are now held to be more
successfully they were able to create meaning in their lives
responsible for their own health (May 1995, Tmobranski
by effectively coping with and adapting to the age-related
1994, Salvage 1992). However, a number of commentators
changes of increased dependence - a factor which was
have questioned whether patients actually welcome this
not described by the nurses. The authors conclude that the
'new role' and the 'new nursing' it involves (May 1995,
difference in perceptions between residents and staff may
Waterworth & Luker 1990).
result in residents' needs not being met.
Nonetheless, the emphasis within nursing practice upon
Higgs et al. (1992) investigated the effects of insti-
developing individualized, patient-centred caro is in line
tutionalization for elderly patients on long-stay wards (n=
with wider developments within health care. The advent
291). Structured interviews focused upon the degree of
of consumerism within the British National Health Service
choice which patients felt they had in relation to daily
(NHS) has introduced the notion of choice in health care,
activities. Eighty per cent of those interviewed expressed
at least in theory (DoH 1991, 1993). Within the context of
satisfaction with their own level of personal autonomy.
the Patient's Charter, for example (DoH 1992), older people
However, elderly patients may be more likely to express
in receipt of health services are afforded the right to certain
satisfaction than younger people for reasons of social desir-
standards of care.
ability and fear of reprisals (Breemhaar et al. 1990), and
Of particular relevance to the current discussion are the
this should be taken into account. Perhaps a more signifi-
following standards:
cant finding of the Higgs et al. study was that 46% of those
interviewed considered that loss of independence was the
the right to be given a clear explanation of any treatment
worst thing about being admitted to a long-term care
proposed, including any risks and any alternatives;
facility.
respect for privacy, dignity and religious and cultural
beliefs;
Personality type
arrangements to ensure everyone, including people
with special noeds, can use services;
McWilliam et al. (1994) highlight the contribution of
information to relatives and friends. (DoH 1992)
personal characteristics to the achievement of personal
autonomy. In a study of patients and carers (n=21 and
Patient's charter
n=139 respectively), it was found that those with a posi-
tive 'mindset' did not have threatened autonomy even
Although the empirical basis of the Patient's Charter (DoH
when cared for in a paternalistic manner. This suggests
1992) has not been clearly identified, there is some
the need to make an assessment of an individual's person-
cvidence to suggest that many of the principles embodied
ality type in considering how best to promote his or her
within it are of particular importance to older people. For
autonomy and independence.
example, there is evidence to support the notion that, for
Despite the assertion hy many older people themselves
older people, a sense of being competent, autonomous and
that autonomy and independence are important to a good
appreciated is basic to the experience of a good life
quality of life. nurses working in institutional settings fre-
(Nystrom & Segesten 1994, Oleson et al. 1994, Higgs et al.
quently observe passivity and dependence among older
1992). A study of nursing home residents' views of what
people in their care (Barder et al. 1994). One theory used
410
© 1997 Blackwell Science Ltd. Journal of Advanced Nursing. 26, 408-417
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Promoting autonomy and independence
to explain this apparent dissonance is the learned helpless-
people in a range of care settings, a number of these more
ness theory (Seligman 1975), which proposes that a
objective indicators were found to recur repeatedly. These
condition of helplessness develops when individuals
included:
experience uncontrollable life events.
implementation of systems of care delivery which pro-
There is a growing body of evidence to suggest that
mote comprehensive individualized assessment and
nurses themselves can contribute to dependent behaviours
multidisciplinary care planning;
in older people (Waters 1994, Miller 1985, Baltes et al.
attempts to encourage patients/clients to participate in
1983, Avorn & Langer 1982). Avorn & Langer (1982), for
decisions about their care;
example, present evidence to suggest that nurses inadver-
patterns of communication which avoid exerting power
tently cause dependence in elderly people by performing
and control over patients/clients;
helping activity beyond their physical requirements. The
attempts to modify the environment to promote auton-
message conveyed to the patients is that they are them-
omy and independence and minimize risk.
selves incapable of performing the task.
There is some evidence to suggest that the desire for
The remainder of this paper will be devoted to a more
control over health care decisions is lower among elderly
detailed consideration of these dimensions. The review is
people when compared with younger adults (Le Sage et al.
by no means comprehensive, but aims to provide some
1989). However, Rodin (1986) asserts that the needs of
indicators for nursing practice which might enable nurses
older people for self-determination may be fulfilled by
to promote autonomy and independence appropriately in
allowing them to choose not to exercise control. Kenny
their work with older people.
(1990) highlights the significance of the social exchange
theory of agcing in relation to patient autonomy and par-
Systems of care delivery which promote
ticipation which may explain why older people are more
comprehensive individualized assessment
reluctant to collaborate in decisions about their care (Dowd
1975). This suggests a possible educational role for nurses
There is a growing body of evidence to suggest that the
in encouraging older people to recognize the contribution
way in which nurses organize their care can affect patient
which they make both within relationships and within
outcomes relating to autonomy and independence (Faucett
societal groups.
et al. 1990, Naqvi & Wilson 1988). In particular, an individ-
ualized approach to the delivery of nursing care has been
HOW CAN NURSES PROMOTE PATIENT/
associated with the maintenance of independence for older
CLIENT AUTONOMY AND INDEPENDENCE?
patients in hospital for more than 1 month (Miller 1985).
In an observational study of nurse-patient interaction on
The most appropriate nursing actions to enable an older
wards practising primary, team and functional nursing,
patient or client to be as autonomous and independent as
Thomas (1994) found that regardless of staff grade nursing
possible will to some extent be context-dependent
staff in wards practising primary nursing gave patients
(Collopy 1988): what is appropriate in an acute hospital
more choice, offered more explanations about their care
ward may differ from what is appropriate in a continuing-
and spent more time seeking feedback from patients.
care setting. Moreover, the vagueness of concepts such as
Wade (1983) identifies four different models of long-term
autonomy and independence within the literature
care based upon interviews with older people and care
hampers attempts at operationalization.
staff in private nursing homes and hospital geriatric units.
Even where broad concepts such as autonomy have
These models, termed supportive, protective, controlled
been broken down into more precise dimensions, for
and restrained, were derived from a consideration of two
example maintaining individuality and respecting dignity
dimensions of care: person versus task-centred and open
(Willcocks et al. 1987, Booth 1985), these dimensions
versus closed (see Figure 1). The author advocates the sup-
remain at the abstract level and require the identification
portive model of care for older people in continuing care
of more objective practice indicators in order to be mean-
settings, characterized by consultation and involvement of
ingful (Gilloran et al. 1994). For example, one indicator of
elderly people in the care regime, involvement of visitors
attempts to promote patient autonomy might be seen in
including relatives, volunteers and children, and a break-
the degree of choice offered to patients in relation to vari-
ing down of barriers between the institution and the wider
ous aspects of care, such as having a bath, eating meals
community.
and going to the toilet. The provision of information to
A number of authors have described how use of a
patients before and throughout an activity might be seen
nursing model has helped them to work more collabor-
as another objective indicator of attempts to promote self-
atively with patients and their families. Bowles et al.
determination.
(1995) adapted aspects of Neuman's model and Orem's
Upon reviewing empirical studies which have
model to develop the assessment documentation within a
attempted to measure the quality of nursing care for older
rehabilitation unit for older people, highlighting improved
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S. Davies et al.
Person-centred
1994). This accords with the current political emphasis on
Supportive model
Protective model
patients as consumers of health care (DoH 1992), but also
Consultation
Consultation
finds a rationale in a growing body of research evidence
Patient/resident committees
Limited choice
to suggest that active patient participation leads to
Choice
Little or no involvement
improved patient outcomes and better patient adjustment
Salience
of visitors
Involvement of visitors
No outings
(Horsley 1983, Wilson-Barnett & Fordham 1983).
Provision of diversional
Limited therapeutic Input
Like autonomy, the notion of patient participation
activities
Restricted visiting
involves a number of dimensions including collaboration,
Therapeutic input
Unrestricted visiting
partnership and involvement (Brearley 1990). Brownlea
Open
Closed
(1987) provides the following definition:
Controlled model
Restrained model
participation means getting involved or being allowed to become
Emphasis on routine
Emphasis on routine
involved in a decision-making process or the delivery of a service
Lack of choice
Lack of choice
or the evaluation of a service or even simply to become one of a
Activitles/outings organized
No outings
by staff
Restricted visiting
number of people consulted on an issue or matter.
Unrestricted visiting
Limited therapeutic input
(Brownlea 1987 p. 605)
Limited therapeutic input
Non-involvement of visitors
in the care regime
Brearley (1990) highlights the important contribution of
Task-centred
informed consent, patient teaching and the provision of
relevant information. However, the relationship between
Figure 1 Typology of models of care delivery (Wade 1983).
patient participation and patient autonomy is not clear cut.
In particular, the issue of choice in relation to participation
requires further study as the limited empirical work in this
communication with families as a result. Kenny (1990)
area is largely exploratory and inconclusive.
proposes the use of Imogene King's model of nursing
Waterworth & Luker (1990) report a qualitative study
which advocates greater patient participation through
to identify how patients perceived being involved in
mutual goal-setting, keener awareness of the patient's per-
decisions about their care. Informal interviews were car-
ceptions and the establishment of an equal, reciprocal and
ried out with a convenience sample of 12 patients on three
collaborative relationship between nurse and client.
medical wards within one hospital. Unfortunately, the age
However, these findings are based largely upon subjective
range of the patients interviewed is not stated. One major
opinion and personal experience and should perhaps
theme emerged from the data: that of 'toeing the line'. The
be interpreted with caution. Certainly, any relationship
data suggested that some patients are more concerned
between the use of a particular nursing model and the
about 'doing what is right' and about pleasing the nurse
promotion of patient autonomy and independence has yet
than about participating in decisions concerning care. The
to be established empirically.
authors contend that, by adopting practices which encour-
Mention should be made of the potential for effective
age patient involvement, nurses may unwittingly be coerc-
teamwork on the part of the multidisciplinary team to con-
ing patients to comply.
tribute to patient autonomy and independence. Nurse-led
The need to ensure that attempts to involve patients in
team care, where a named nurse coordinates the care of
decision-making are based upon an individualized assess-
individual patients, has been evaluated in a range of set-
ment of need are sclf-apparent. On the whole, research
tings providing care for older people (Griffiths & Evans
into the area of patient participation has failed to take into
1995, Davies 1994. Pearson et al. 1988). Taken collectively,
account factors such as educational background, character,
findings suggest that individual patients' needs are more
gender, age and diagnosis - factors which may have an
likely to be taken into account within this particular model
effect on whether a patient wishes to be involved.
of care delivery. Contrarily, there is some evidence to sug-
It has been suggested that involvement in decision-
gest that where there are conflicting professional perspec-
making assumes rationality and capability [Macmillan
tives on an individual patient's needs and appropriate
1994). Biley (1992) explored the relationship between
interventions, this may act as a barrier to patient autonomy
capability and autonomy in interviews with eight surgical
by limiting patient participation and reducing continuity
patients ranging in age from 21 to 75. Thematic analysis
of care (Reed 1994, Evers 1981, Webb & Hobdell 1980).
identified three types of situation that affect patient choice
and participation in decision making about their nursing
care. These were: 'If I'm well enough', 'If I know enough'
Attempts to encourage patients/clients to
and 'If I can'. Patients were more concerned with less tech-
participate in decisions about their care
nical information such as medication and activities of
During the past decade, there has been an increasing
daily living when very ill and there was some evidence
emphasis on patient involvement in care (Trnobranski
that when patients were acutely ill they were willing to
412
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Promoting autonomy and independence
relinquish control to the nurse. Although this study
are indicative of a view of a patient as an individual with
involved a small sample and categories did not reach satu-
inter-related needs, and that these strategies can be facili-
ration. the report does provide some indication that
tated by a one-to-one relationship between nurse and
patients' desire to participate in decision about their care
patient.
will be affected by a number of factors, not all of which
Davies (1992) also perceived a relationship between the
are within the nurse's control. Biley's study also suggests
use of verbal strategies such as offering choice, explanation
that patients can benefit from being in control of what
of actions and eliciting feedback and the success (or other-
might amount to only a small aspect of their care in an
wise) of a verbal exchange for elderly patients in a continu-
environment where they essentially lack control.
ing-care unit. This study used an exploratory observational
An action research project reported by Sheppard (1994)
technique with a small sample (twelve nurses and eight
also lends weight to the importance of involving patients
patients) in one setting. The findings are therefore tentative
in thoir care and identifies specific strategies through
but, it is suggested. would merit further investigation.
which patients might be encouraged to participate.
Marck (1990) identifies the concept "therapeutic reci-
Interviews with older people following discharge ident-
procity' as one approach to considering the nature of
ified three key areas where changes were needed: the pro-
nurse-patient interaction. It is argued that therapeutic
vision of information to patients, continuity of care and
reciprocity is based upon a genuine exchange of feelings,
empowerment of patients to allow them to be critical.
thoughts and experiences which lead to the creation of
Subsequent interventions included the establishment of a
shared meaning and understanding. In practice, this could
patient forum, adoption of a non-uniform policy and the
involve a nurse sharing information about her or his life
development of an information video to be shown to
outside work, or letting the patient know that she or
patients and new staff.
he (the nurse) gains from the relationship with the
patient.
Nolan & Grant (1993), however, highlight the difficulties
Patterns of communication which avoid exerting
power and control over patients/clients
of establishing therapeutic reciprocity with continuing-
care patients who may have limited abilities to share
A wealth of research has suggested that interactions
thoughts and feelings, and suggest that these difficulties
between nurses and older patients are frequently short,
contribute to the tendency to develop custodial relation-
initiated by the nurse and largely task-orientated
ships in such settings. Lack of reciprocity is also high-
(Armstrong-Esther et al. 1994, Seers 1986, Wells 1980).
lighted as a factor contributing to feelings of inferiority
Moreover, in a wide-ranging review, Lanceley (1985) high-
among nursing home residents (Nystrom & Segesten 1994).
lights the potential for nurses to use controlling language
Davies (1992) identified 'giving of self' as one category of
in the rehabilitation of older people and argues that
interaction that appeared to be associated with successful
relations between nurses and older patients are charac-
exchanges between nurses and older patients in receipt of
terized by opposition between those who have power and
continuing care. The potential for nurse education to
those who are subordinate to that power. Use of the
enable nurses to establish relationships with older people
patient's Christian name, pluralization of the patient as
that incorporate a degree of reciprocity has yet to be
'we', use of 'must' and 'ought' and reference to the patient
ostablished.
as a passive object are highlighted as examples of con-
trolling language. In support of this position, Kenny (1990)
Attempts to modify the environment to promote
suggests that verbal interaction is:
autonomy and independence and minimize risk
a major avenue for social control on a large scale and
Characteristics of the total institution first identified by
inter-personal dominance on a small scale.
Goffman (1961) have since been reported in a range of stud-
(Kenny 1990 p. 571)
ies investigating the quality of nursing care for older people
However, the use of language may also be a mechanism
(Reed 1994, Waters 1994, Evers 1981, Baker 1978, Miller &
for attempting to protect an older person's human rights
Gwynne 1972). These characteristics strip patients of their
(Block & Simnott 1979), for example by ensuring that lan-
identity and limit their sense of control. Any attempts to
guage used in care delivery is acceptable to the older
'deinstitutionalize' the environment through efforts to
person and respectful of their cultural beliefs and practices
recognize and meet individual needs could be seen as pro-
(Phillips et al. 1990).
moting personal autonomy. It has been suggested, for
Based upon an observational study, Thomas (1994)
example. that the provision of individual clothing is an
identified categories of talk in an attempt to measure the
important contributor, not only to the older person's
quality of interaction between nurses and elderly patients.
self-respect and dignity but also to the attitudes of those
Thomas suggests that categories such as giving patients
providing care, by encouraging them to view the person
choice, offering explanations and encouraging feedback
as an individual (Burgess et al. 1988, Meredith 1987).
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Wade (1983) highlighted a number of organizational
reduction of risk in order to avoid litigation, posing a
barriers to individualized care and personal autonomy in
dilemma for health care professionals (Archea et al. 1993,
nursing homes: for example, difficulties in offering
Conely & Campbell 1991, Yorker 1988, McHutchion &
patients choice about what time they got out of bed in the
Morse 1986). Resolution of the potential threat to auton-
morning were related to the fixed time at which breakfast
omy and independence posed by the notion of 'risk'
was served, a point also noted by Barnes (1988). The
appears to require an attitude shift on the part of these
removal of such constraints may require negotiation at a
organizations as much as behaviour change on the part of
number of levels within an organization.
individual nurses.
Safety is another important environmental feature when
There is a need for nurses to have the opportunity to
considering measures to promote autonomy and indepen-
discuss their views on patient rostraint and to consider
dence for older people. Nurses working with older people
possible alternatives. Stilwell (1991), for example, found
are frequently called upon to weigh up the rights of an
that 63% of a sample of 500 nurses had received no
individual against possible risks, leading potentially to a
instruction on the use of physical restraint on geriatric
decision that may limit autonomy and independence if
wards. A recent joint publication of the Royal College of
the risks appear too great (Nystrom & Segesten 1994).
Nursing and the British Medical Association provides
Certainly, there is little empirical evidence to demonstrate
useful guidance on issues relating to consent and restraint
how hurses balance the need to promote patient autonomy
when caring for older people (BMA 1995). However,
and independence with the need to minimize risk.
there is a need for empirical work to investigate nurses'
Norman (1980) argues that, in excessive cases, the need
decision-making processes in relation to the balance
to minimize risk can limit the therapeutic value of an insti-
between promoting patient/client autonomy and main-
tution. Indeed, there is some empirical evidence to support
taining patient/client safety.
this notion. Bowling & Grant (1992) report a randomized
controlled trial to compare patient outcomes for patients
DISCUSSION
admitted to health-authority-funded nursing homes and
long-stay care of the elderly wards in one inner London
As a result of the varied dimensions of the topic, a wide
authority. The findings suggest that although accident rates
range of research approaches have been used to investigate
were higher in the nursing homes, quality of life was better.
both the process and outcome of nursing interventions
In discussing the implications of this study, the authors
aimed at promoting autonomy and independence for the
question whether much of what is described as 'risk'
older client/patient. Given these varied approaches, and
does in fact pose a serious risk to health or whether it
the range of settings in which research has been conduc-
relates more to the feelings or inconvenience of the carer.
ted, it is difficult to compare and contrast individual stud-
Again the importance of an individualized approach is
ies in order to generate clear indicators for nursing
emphasized rather than systematic adherence to a rigid
practice. In effect, the body of research literature indicates
policy.
rather more of 'what nurses could try' rather than 'what
Bowling & Grant (1988) propose that if the outcome of
nurses should do' (Hunt 1981).
greater freedom and flexibility in nursing homes is an
In particular, there is little information to inform
increased degree of risk, then managers and staff of these
decisions related to the balance between minimizing risk
institutions have a responsibility to ensure that all possible
and promoting patient/client autonomy. However, this is
preventive measures have been taken. Askham et al. (1990)
essentially a moral debate which can perhaps only be
reviewed the literature relating to the prevention of falls
informed to a limited extent by empirical work. In justify-
and identified a number of preventive measures in relation
ing and defending standards of care that meet basic
to the environment. These include: identifying and
humanitarian principles (Ebrahim et al. 1994), nurses fre-
observing high-risk individuals, ensuring a barrier-free
quently need to rely upon sources of knowledge other than
environment, providing beds with adjustable heights and
the purely empirical (Carper 1978).
chairs with correct backs and arm rests, ensuring nonslip-
Most research related to the topic has been carried out
pery floors, and provision of hand-rails. Given the ethical
in long-term care settings and it may not always be appro-
dilemmas posed by the need to balance maximum patient
priate to extrapolate from one care setting to another.
autonomy with the minimum risk, the importance of
Empirical evidence to identify factors associated with the
ensuring that all possible preventive measures have been
quality of care for patients in acute, rehabilitation and
implemented is clear.
community settings (other than nursing homes) is limited.
At its extreme, the denial of patient autonomy is perhaps
Moreover, research which has sought the views of older
epitomized by the use of physical restraint. McHutchion
people themselves has focused upon those without a sig-
& Morse (1986) suggest that while nurses empathize with
nificant degree of cognitive impairment. There is an obvi-
the restrained patient they often see no alternative. Several
ous need for further research. particularly in relation to
authors identify that many institutions emphasize the
identifying the views of service users themselves.
414
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Promoting autonomy and independence
Pointers for nursing practice
nursing interventions aimed at promoting autonomy and
independence.
In spite of these methodological limitations, the body of litera-
However, in the absence of firm predictive evidence,
ture does provide some pointers for nursing practice. A con-
there is sufficient descriptive research to suggest that the
sistent theme is the need to ensure that nursing care is tailored
principles identified within this paper should provide a
to individual needs if patients and clients are to achieve opti-
basis for nurse education and practice at the present time.
mal levels of autonomy and independence. Individualized
assessment and care planning underpins many of the stra-
Acknowledgement
tegies associated with the promotion of autonomy, indepen-
dence and high-quality care within the literature. Systems for
We would like to acknowledge the financial support of the
care delivery which support patient-centred practice such as
English National Board for Nursing, Midwifery and Health
primary nursing and nurse-led team care have also been
Visiting. We would also like to thank Charlie Brooker and
associated with higher levels of self-determination and
Tony Warnes for their helpful comments on an earlier draft
patient satisfaction, although the evidence to date has
of this paper.
emerged from a series of small-scale studies.
The evidence supporting the use of communication stra-
tegies which encourage patient choice and participation
in decision making is more persuasive. In particular, it
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