Leveraging Administrative Data for Program Evaluations: A Method for Linking Data Sets Without Unique Identifiers.

In community-based wellness programs, Social Security Numbers (SSNs) are rarely collected to encourage participation and protect participant privacy. One measure of program effectiveness includes changes in health care utilization. For the 65 and over population, health care utilization is captured in Medicare administrative claims data. Therefore, methods as described in this article for linking participant information to administrative data are useful for program evaluations where unique identifiers such as SSN are not available. Following fuzzy matching methodologies, participant information from the National Study of the Chronic Disease Self-Management Program was linked to Medicare administrative data. Linking variables included participant name, date of birth, gender, address, and ZIP code. Seventy-eight percent of participants were linked to their Medicare claims data. Linking program participant information to Medicare administrative data where unique identifiers are not available provides researchers with the ability to leverage claims data to better understand program effects.

Concordance between Self-Reports and Medicare Claims among Participants in a National Study of Chronic Disease Self-Management Program.

OBJECTIVES: To evaluate the concordance between self-reported data and variables obtained from Medicare administrative data in terms of chronic conditions and health care utilization. DESIGN: Retrospective observational study. PARTICIPANTS: We analyzed data from a sample of Medicare beneficiaries who were part of the National Study of Chronic Disease Self-Management Program (CDSMP) and were eligible for the Centers for Medicare and Medicaid Services (CMS) pilot evaluation of CDSMP (n = 119). METHODS: Self-reported and Medicare claims-based chronic conditions and health care utilization were examined. Percent of consistent numbers, kappa statistic (κ), and Pearson's correlation coefficient were used to evaluate concordance. RESULTS: The two data sources had substantial agreement for diabetes and chronic obstructive pulmonary disease (COPD) (κ = 0.75 and κ = 0.60, respectively), moderate agreement for cancer and heart disease (κ = 0.50 and κ = 0.47, respectively), and fair agreement for depression (κ = 0.26). With respect to health care utilization, the two data sources had almost perfect or substantial concordance for number of hospitalizations (κ = 0.69-0.79), moderate concordance for ED care utilization (κ = 0.45-0.61), and generally low agreement for number of physician visits (κ ≤ 0.31). CONCLUSION: Either self-reports or claim-based administrative data for diabetes, COPD, and hospitalizations can be used to analyze Medicare beneficiaries in the US. Yet, caution must be taken when only one data source is available for other types of chronic conditions and health care utilization.

Examining strategies to build and sustain healthy aging programming collaboratives.

BACKGROUND: Community collaboratives provide a means to build local capacity, reduce service fragmentation and duplication, maximize efficiency, and create synergies for systems change. But what are the collaborative practices that aging services providers and other stakeholders employ for system change and impact in evidence-based programming for older adults? PURPOSE: The aim of this study was to learn how aging and health collaborations created strategic partnerships to foster multisector systems change and pursue long-term goals and near-term activities to sustain and expand evidence-based health programming. METHODS: Via a multiphase process, we identified eight geographically diverse, exemplar agencies that serve as the coordinators for various community collaborations. Using an interview protocol culled from the literature, we conducted on-site, in-depth interviews with leadership and partners. RESULTS: Four creative strategies emerged across sites as contributing to the growth and sustainability of evidence-based health programming including engagement of nontraditional partners, development of new relationships with health care, building of innovative systems of structures and tools, and systematically working with vulnerable populations. Opportunities for future initiatives include enhancing linkages with health care, advocating for the value of evidence-based programming, supporting local program development and adaptation, and developing marketing strategies and business models. CONCLUSION: These eight organizations are leveraging their historic strengths and newly acquired expertise to extend health programming beyond established partners and funding silos. The four strategies and specific activities reflected in their work have laid a solid foundation for expanding and embedding future initiatives and positively impacting the health of older adults.

National study of chronic disease self-management: age comparison of outcome findings.

INTRODUCTION: The adult population is increasingly experiencing one or more chronic illnesses and living with such conditions longer. The Chronic Disease Self-Management Program (CDSMP) helps participants cope with chronic disease-related symptomatology and improve their health-related quality of life. Nevertheless, the long-term effectiveness of this evidence-based program on older adults as compared to the middle-aged populations has not been examined in a large-scale, national rollout. METHOD: We identified baseline characteristics of CDSMP participants aged 65 years or older (n = 687, M = 74.8 years) in the National Study of CDSMP from 2010 to 2012. Comparisons were made to middle-aged participants aged 50 to 64 (n = 325, M = 58.3 years). Assessments were conducted at baseline and 12-month follow-up. Linear and generalized linear mixed models were performed to assess changes in primary and secondary outcomes, controlling the key sociodemographics and number of chronic conditions. RESULTS: All primary outcomes (i.e., social/role activities limitation, depression, communication with doctors) significantly improved in both the older and middle-aged cohorts. Although improvements in illness symptomatology (e.g., fatigue, pain, shortness of breath, and sleep problems) were similar across both cohorts, only the middle-aged cohort benefitted significantly in terms of overall quality of life and unhealthy mental health days. Effect sizes were larger among the middle-aged population who were also more likely to enter the program in poorer health and be from minority backgrounds. CONCLUSIONS: The current study documented improved health outcomes but more so among the middle-aged population. Findings suggest the importance of examining how age and interacting life circumstances may affect chronic disease self-management.

The impact of chronic disease self-management programs: healthcare savings through a community-based intervention.

BACKGROUND: Among the most studied evidence-based programs, the Chronic Disease Self-Management Program (CDSMP) has been shown to help participants improve their health behaviors, health outcomes, and reduce healthcare utilization. However, there is a lack of information on how CDSMP, when nationally disseminated, impacts healthcare utilization and averts healthcare costs. The purposes of this study were to: 1) document reductions in healthcare utilization among national CDSMP participants; 2) calculate potential cost savings associated with emergency room (ER) visits and hospitalizations; and 3) extrapolate the cost savings estimation to the American adults. METHODS: The national study of CDSMP surveyed 1,170 community-dwelling CDSMP participants at baseline, 6 months, and 12 months from 22 organizations in 17 states. The procedure used to estimate potential cost savings included: 1) examining the pattern of healthcare utilization among CDSMP participants from self-reported healthcare utilization assessed at baseline, 6 months, and 12 months; 2) calculating age-adjusted average costs for persons using the 2010 Medical Expenditure Panel Survey; 3) calculating costs saved from reductions in healthcare utilization; 4) estimating per participant program costs; 5) computing potential cost savings by deducting program costs from estimated healthcare savings; and 6) extrapolating savings to national populations using Census data combined with national health statistics. RESULTS: Findings from analyses showed significant reductions in ER visits (5%) at both the 6-month and 12-month assessments as well as hospitalizations (3%) at 6 months among national CDSMP participants. This equates to potential net savings of $364 per participant and a national savings of $3.3 billion if 5% of adults with one or more chronic conditions were reached. CONCLUSIONS: Findings emphasize the value of public health tertiary prevention interventions and the need for policies to support widespread adoption of CDSMP.

Successes of a national study of the Chronic Disease Self-Management Program: meeting the triple aim of health care reform.

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

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

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

Effectiveness of a generic chronic disease self-management program for people with type 2 diabetes: a translation study.

PURPOSE: The purpose of the study was to determine the feasibility and efficacy of a generic chronic disease self-management program for people with type 2 diabetes. METHODS: English-speaking adults with type 2 diabetes who were part of a larger US national translation study of the Stanford Chronic Disease Self-Management Program (CDSMP) were invited to be part of the current study. In addition to completing self-report questionnaires, participants submitted blood samples at baseline, 6 months, and 12 months. Of the 114 participants, half had A1C values between 6% and 6.9% and half had values of 7.0% or more. RESULTS: Adults with diabetes successfully participated in CDSMP workshops in a community health setting. Participants demonstrated statistically significant improvements in health indicators and behaviors but no reductions in health care utilization. Participants with A1C of 7% and above had A1C reductions at 6 months, with smaller reductions at 12 months. Those with baseline A1C less than 7% had no changes in A1C at 6 or 12 months. CONCLUSIONS: The results suggest that the CDSMP is a useful and appropriate program for lowering A1C among those with A1C above 7% and for improving health status for people with diabetes, regardless of their A1C.

Best-practice physical activity programs for older adults: findings from the national impact study.

OBJECTIVES: We assessed the impact of existing best-practice physical activity programs for older adults on physical activity participation and health-related outcomes. METHODS: We used a multisite, randomized trial with 544 older adults (mean age 66 years) and measures at baseline, 5, and 10 months to test the impact of a multiple-component physical activity program compared with results for a control group that did not participate in such a program. RESULTS: For adults who participated in a multiple-component physical activity program, we found statistically significant benefits at 5 and 10 months with regard to self-efficacy for exercise adherence over time (P < .001), adherence in the face of barriers (P = .01), increased upper- and lower-body strength (P = .02, P = .01), and exercise participation (P = .01). CONCLUSIONS: Best-practice community-based physical activity programs can measurably improve aspects of functioning that are risk factors for disability among older adults. US public policy should encourage these inexpensive health promotion programs.

An innovative approach for building health promotion program capacity: a generic volunteer training curriculum.

PURPOSE: We examined the feasibility of creating a generic training curriculum for volunteers in health promotion programs for older adults by identifying common core content topics across 10 national programs. We also considered additional material that could augment common core content topics. DESIGN AND METHODS: We reviewed in detail program manuals and associated materials from 10 national evidence-based or best practice health promotion programs for older adults that use volunteers. In Phase I, we created a spreadsheet matrix to track and tabulate the frequency of inclusion of elements across all 10 programs. We arrayed elements under appropriate topics, and program administrators reviewed and verified the information. In Phase II, we reviewed the matrix for comprehensiveness and added elements to augment the identified core topics. Program administrators again reviewed the matrix to ensure accuracy. RESULTS: We found 67 elements of core content across 50% or more of the reviewed health promotion programs. We added 17 elements to enhance curriculum comprehensiveness; these included elements that were (a) in less than 50% of the reviewed programs but recommended by research staff, (b) introduced by research staff, or (c) recommended by program administrators. IMPLICATIONS: Although there are many steps, questions, and issues yet to consider, our findings identify a significant body of general core content that supports the feasibility of creating a generic training curriculum for volunteers as an approach to enhance capacity in evidence-based or best practice health promotion programs.

Evidence-based health practice: knowing and using what works for older adults.

Community-based health care agencies are facing demands for improved outcomes, cost-effective programming, and higher customer satisfaction. Implementing evidence-based health interventions and programs can help to address these challenges. This article provides an overview of evidence-based health practice, including the definition and advantages of this approach, other key terms and concepts inherent to evidence-based practice, and the tasks and steps necessary to its implementation. The article concludes with a list of resources to help health care providers learn about, plan, and implement evidence-based health interventions and programs.

Geriatric interdisciplinary team training program: evaluation results.

Geriatric interdisciplinary team training has long been a goal in health education with little progress. In 1997, the John A. Hartford Foundation funded eight programs nationally to create Geriatric Interdisciplinary Team Training (GITT) programs. Faculty trained 1,341 health professions students. The results of the evaluation, including presentation of new measures developed to assess interdisciplinary knowledge, are presented, and the implications of the program as a model of interdisciplinary education are discussed. Evaluation data from 537 student trainees are presented. At posttest, GITT trainees demonstrated improvement on all measures of attitudinal change, no change on the geriatric care planning measure, and a change in some of the questions on the test of team dynamics that varied by discipline. Changes were greatest for all the attitudinal measures with the self-reported Team Skills Scale indicating the most significant change--a change that is significant across medicine, nursing, and social work trainees.

A vision for older adults and health promotion.

Our rapidly aging population is expected to place heavy demands on all segments of society, particularly the health care resources needed to attend to health concerns associated with aging. Is this a looming crisis, as some predict, or a challenge to use resources more wisely and to help older adults and their caregivers share in the responsibility for health promotion and chronic disease self-management activities? Community-based organizations serving older adults are uniquely positioned to augment health care providers' health promotion counseling activities and to bridge the gap between the research and practice of health promotion in older adults. They already play a crucial role by providing appropriate health promotion education, screening and referral, service planning, and reinforcement to facilitate self-care activities and behavior changes that promote healthy aging. By increasing teamwork across the network of services for the aging, the health sector, public and private organizations, and academe, there is a great opportunity to enhance the health and well-being of all older Americans.

Using case studies to evaluate students' ability to develop a geriatric interdisciplinary care plan.

The Geriatric Interdisciplinary Team Training (GITT) program, an educational intervention funded by The John A. Hartford Foundation of New York City, has trained more than 1800 health care professions students and clinicians throughout the United States. Evaluating the effectiveness of this training intervention has proven to be quite a challenge. Core measures were collected pre- and post-GITT training to evaluate student development as a result of GITT. This paper focuses on one of these core measures, the Test of Geriatric Interdisciplinary Care Planning (TGICP). This instrument, developed for the GITT program, is one mechanism created to test trainees' ability to develop an interdisciplinary plan of care. Using a case study methodology, this two-part instrument provides an innovative approach to quantifying and correlating responses from an interdisciplinary cohort of students. This paper will describe the development of the TGICP, including the creation and validation of the case studies, the framework for the questionnaire, and the coding and scoring mechanism created to evaluate trainee responses.

Using scripted video to assess interdisciplinary team effectiveness training outcomes.

As part of the Geriatric Interdisciplinary Team Training (GITT) Program funded by the John A. Hartford Foundation, the authors of this article worked to create an instrument, the Trainee Test of Team Dynamics, to assess health care trainees' understanding of team dynamics. The Trainee Test of Team Dynamics is a five-question written test designed to capture GITT trainees' knowledge of team process and skills in addressing conflict that is administered after watching a five-minute videotape of a simulated interdisciplinary health care team meeting. The test was created to measure health professions students' abilities to recognize effective geriatric health care teams, to respond to effective and ineffective team behaviors, and to determine whether or not the team meeting achieved its purpose: to meet the patient's needs for an interdisciplinary care plan. Scripts and test items developed and tested by practitioners in social work, medicine, public health, nursing and others assured a product that compensated for differences in educational level and occupation, yet captured accurate and appropriate responses. The results reported here include an analysis of 740 trainees' baseline responses from the multi-site educational programs to determine the construct validity of the new measure.

Policy initiatives to promote healthy aging.

An overwhelming array of policies and programs can be used to help older people (and future older people) maintain healthy lifestyles. How can clinicians help ensure that their patients take advantage of these opportunities? How can these broad-scope policies, educational and information initiatives, and direct service programs be turned into tools to help older people maximize health and independence? First, physicians do not need to do it all themselves. They need to know where to send their patients. For example, case managers in local aging service organizations and social workers, nurses, and discharge planners in hospitals can help connect elderly patients to appropriate benefits and services. Physicians play a critical role in creating a bridge between patients and the array of programs and information that can help them change their individual patterns of behavior. A serious lack of integration exists between what is known about healthy behaviors and lifestyles and what is really happening and available to older people today. From the earlier articles in this issue we know that much can be done to prevent many types of age-related disease and disability. This article provides examples of mechanisms that can be used to broadly disseminate knowledge about effective behavior and treatment changes and create mechanisms to turn this knowledge into real and widespread client-level, practice-level, health system, and community-wide interventions. Second, physicians need to understand that they are not merely subject to these policies and initiatives. They can help formulate and shape them. This political involvement includes active participation in policy initiatives of professional associations, involvement in research and demonstration activities, keeping informed about policy proposals at the federal and state levels, and helping advance ideas for improving health behaviors by speaking up and working toward change. These changes go beyond health initiatives to involve improving housing, nutrition, transportation, and other arenas that play a role in the health of communities and cities. According to the IOM, the most successful interventions are aimed at families, neighborhoods and communities. Interventions are also most likely to be successful when legislative, media, and marketing efforts support them [50]. These broader policies may actually have the most potential impact in terms of developing sustainable lifestyle changes that reach all Americans, especially those with the greatest health needs. Within the aging population, those with greatest health needs include members of minority groups, recent immigrants, and the old-old. These groups are often overlooked when designing and implementing health promotion programs. It is important, however, to remember, for patients and for ourselves, you are never too old to benefit from prevention.