Being-Well: A Prototype Public Health Program

Note: This prototype program utilizes accurate health statistics drawn from credible resources as well as an actual county anonymized as “Our Sample County.” This article is for case-study purposes only, and does not promise specific results.

According to a study published in Aging and Mental Health in 2013, up to 16% of adults aged 65 and older report symptoms of depression (Loprinzi, 2013). The findings from a 2009 study published in the Journal of the American Geriatric Society which tracked seniors enrolled in a pilot Medicare disease program with either diabetes or congestive health failure and with or without diagnosed depression were significant. Health care costs were 100% higher for seniors with either of the aforementioned chronic conditions and a depression diagnosis (NIMH, 2009). In addition, “Participants with diagnosed depression spent significantly more in nearly every health care cost category, including home health care, skilled nursing facility costs, outpatient care, inpatient care, physician charges, and medical equipment” (NIMH, 2009). Furthermore, depression in the elderly is associated with longer recovery periods and poorer responses to major illness treatment programs (American Psychological Association, n.d.). Decreasing the incidence and prevalence of depression and its deleterious effects is advantageous to seniors, to health systems and practitioners managing costs under CMS value-based and bundled payment arrangements, and to federal and state governments responsible for the high costs of institutional care for medically and financially eligible elderly patients who can no longer live safely in the community.

According to the CDC’s Community Health Status Indicator for elder depression, at 13.1%, Our Sample County ranks in the bottom or worst quartile in comparison to peer counties (CDC, 2015). Based on the far-reaching consequences of elder depression, a public health program focused on this population is advisable. Fortunately, meaningful progress has been made in the last 25+ years in the areas of pharmacology and counseling, media attention and public awareness, and research findings identifying effective evidence-based interventions to reduce depression symptoms. Through the Being-Well in OSC’s program, the county has a valuable opportunity to improve the health of local seniors and create a program framework for adoption by other counties, cities, and states across the US to mitigate the emotional, physical, and financial costs of a serious health problem. A devastating national problem that without appropriate intervention will continue to grow exponentially, particularly for places like OSC.

In contrast to the 4% state-wide expected growth rate of residents 65 years of age and older between the years of 2000-2030, OSC’s is projected to experience a growth of rate of 16.8% during the same time period or 100,000 additional elderly residents (OSC’s, Aging Agency, 2012). The OSCS Aging Agency (OSCAA) provides significant financial, administrative, and professional resources to promote and maintain the well-being of elderly residents. However, of serious concern, the state allocations on which OSCAA heavily relies to provide essential services and help seniors age safely in place, rather than, transition to an institutional setting, has either remained flat or been significantly reduced (OSCAA 2012) Furthermore, a nearly nine month standoff over the 2015-2016 Pennsylvania state budget, left public agencies without funding (Langley, 2016) and reliant on bridge loans to continue operations, further compounding the impact of multiple years of insufficient funding. If history is, in fact, the best predictor of the future, it would be wise for OSCAA to acknowledge funding will remain elusive and an engaged community of local health care systems and practitioners, business owners, schools and health and well-being focused volunteers will be necessary to fill funding and human capital gaps.

Program Design

The Being-Well in OSC program’s overarching objective is to aid residents aged 65 and older in preventing and reducing depression symptoms and minimizing relapse rates. Proper condition management supported by an array of activities should greatly improve quality of life for the seniors of OSC. The initial target populations for phase I of the program will be seniors already attending a senior center and internal medicine patients of a community hospital who have been identified by their physician as at risk or currently diagnosed with low to moderate level depression and interested in participating in the Being-Well in OSC program. Though the program’s intended audience is seniors currently diagnosed or at risk for depression, it will be open to all OSC residents aged 65 and older due to the proven value of the activities, regardless of depression status, and the opportunity to promote socialization, and subsequently, foster a sense of community producing high levels of engagement.

A critical component of this program is education. First, it is imperative that seniors and other county residents are informed about the causes, symptoms, and side-effects of depression. The educational phase will explain that it is very common and can happen to anyone, and that it is neither a character flaw nor the fault of the afflicted individual. Seniors will be informed about different interventions and how they can produce positive mood changes. Then, an overview will be shared of the specific activities offered through Being-Well in OSC to help participants improve and take control of their health. Seniors comfortable with traditional treatments, such as therapy and/or pharmacology, can use the program as an adjunct intervention to support their long-term emotional and physical health. For seniors unsure about or uncomfortable with the standard model of care, but interested in taking action to improve their depression symptoms or reduce the chance of a future depression diagnosis, they will now have access to an array of non-clinical options. Non-clinical activities are the foundation of the Being-Well in OSC program and do not require physician support. Instead, activities can be implemented and sustained using the strong volunteer network already in existence in OSC in conjunction (OSCAA, 2012) with support from local healthcare systems and affiliated health care practitioners.

Engaging healthcare systems and the providers that work for/with them is an instrumental part of this program. It is through these partnerships that patients can be identified and referred to the program. It creates an opportunity for meaningful patient-physician dialogue about a serious condition from which OSC elders suffer at a greater percentage than elders in peer counties, as indicated by the CDC, and elders on a national level (Pratt & Brody, 2014). In addition, it highlights for patients that providers and the county care about health and well-being. Also, it raises program awareness, not only for the patients, but for the people whom the patient may inform about the program, such as friends and/or family members. In the current value-based health care environment, which rightfully rewards quality over quantity, there is a strong incentive for providers to collaborate with community agencies to improve the health and functioning of their patients, especially, via services for which the provider bares neither financial nor managerial responsibilities. Of great worth to the Being-Well in OSC program, provider referrals will lend significant credibility, potentially increasing the number of seniors who are willing to attend an education session, and consequently, enroll in the program.

Education sessions will be held at senior centers to increase condition awareness, present an overview of the various activities available, and provide a safe-space to ask questions, and to meet and begin socializing with peers who share the same condition. The sessions will be used to determine the number of seniors interested in participating in the Being-Well in OSC program. Also, transportation needs will be explored. This will allow senior center managers to identify who requires assistance getting to the center and to facilitate connections with seniors at the sessions willing/able to provide transportation support and/or refer those in needs to the OSC Shared Ride program to complete an application for transportation assistance. Also, other barriers to program participation can be identified and resolutions investigated.

Based on the arrangement with the community hospital, the local Senior Citizens Center has been selected as the pilot location for the Being-Well in OSC program. Education sessions and exercise/movement classes will be the primary activities for the initial site launch. Education will be provided by social workers from the OSCAA; a public agency that funds and supports the county’s senior centers. Also, volunteers with a background in behavioral health will be sought to conduct ongoing, periodic educational sessions for program participants and their families. Like all age groups, senior populations include individuals with varying levels of functional capacity, therefore, low, moderate, and vigorous physical activity and movement exercises will be provided along with movement modifications that can be performed by differently-abled participants. Volunteers with a background in physical therapy and sports physiology will be used to lead these activities. In addition to community volunteers, the community hospital alliance will supply staff volunteers to support program activities.

The long-term goal of the program is to provide seniors with an accessible, holistic well-being environment which includes condition education, support groups, and cognitive behavioral therapy. These resources will aid participants in understanding depression and how it effects them, provide a safe place to discuss challenges and successes, and encourage the creation of new thought patterns and behaviors to promote continued program involvement and ongoing self-maintenance. Physical activity/movement exercise classes and mindfulness and meditation sessions will support participants engaging in these practices at an intensity and frequency level that complements their abilities. Reminiscing activities and pet therapy will provide opportunities to socialize, share memories, connect, and laugh. The Being-Well in OSC program’s health system alliance and care coordination collaboration will promote high quality care for participating seniors.

With a tight budget and the need for a comprehensive program that supports seniors in mind, body, and spirit, funding will be necessary as the program is extend to additional senior centers. Local businesses, schools, and community residents will play a significant role in program expansion and sustainability. Depression does not discriminate and many people have been directly affected or experienced the suffering of a friend and/or loved one, therefore, fundraising partnerships with local businesses, public agencies, and schools will be established to meet the financial needs of the program, increase condition and program awareness, and promote community building.

The array of activities slated for the Being-Well in OSC program are intended to achieve multiple outcomes. Despite significant progress in the treatment of these conditions, a sizeable minority of the US population, more than 1 in 10, is taking an anti-depressant. This equates to greater than 30 million American citizens (Insell, 2011), yet, mental health issues still carry a stigma. Of significant importance, increasing awareness and dispelling the myths and misconceptions about depression that cause significant shame and deter people from seeking help. Educating seniors about evidence-based alternatives and/ or adjunct methods to enhance standard treatments, while providing easy access to low or no cost interventions, can reduce barriers to engagement, thus, expanding the program’s reach.

The Being-Well in OSC program is intended to reduce depression symptoms and support relapse prevention. Of interest, research shows patients with untreated mental health conditions have increased rates of physical complaints and care costs (Wittchen, et al, 2003). Reducing physical complaints, the potential risk of unnecessary treatment, and medical spending are three outcomes with wide-reaching effects the program would like to accomplish. Yet, to participants, possibly, the most profound outcome of this program would be improving their quality-of-life. Though we can quantify positive shifts in an individual’s quality of life, arguably, the value of reducing depressions’ negative effects and potential relapse is immeasurable to them.

Conclusion

The Being-Well in OSC Program is an ambitious endeavor due to the variety of activities planned and the target population. OSC has experienced budget cuts in recent years and a program of this complexity requires significant coordination, oversight, and volunteer capacity. To maximize the odds of short and long-term program success and the ability to create a framework that can be replicated in other counties, cities and states, a pragmatic implementation approach is essential. The Being-Well in OSC program will be piloted at a single location using a lean methodology. What this means is a minimum viable product/program (MVP) will be launched. The MVP will be structured around education and physical activity. Engagement rates will be tracked and perceived value of the activities will be evaluated using surveys and short interviews completed by participating seniors and volunteers running the activities; surveys and interviews will be conducted by senior center management. This feedback will be used to refine the current activities and address areas of stakeholder concern and/or dissatisfaction. Furthermore, it will inform the launch order of additional activities. This ongoing feedback loop is similar to the agile approach used by software developers. The agile method includes regular collaboration amongst stakeholders to ensure the work being done is consistent with specifications. It permits problems to be identified quickly and resolved earlier in the development process, thus, saving time and money while ensuring the final product best meets the end-users’ needs.

As the program matures, additional evaluation criteria will be added. Depression rates of participants will be assessed at baseline and at specified intervals during program participation. The Beck Depression Inventory, a quantitative instrument known for its high reliability (Ramirez et al., 2013), will be used to measure changes in depression levels. Also, participants will be interviewed about their perceptions of the different activities in order to identify prominent themes that may be useful to ongoing program efforts. Evaluation results will be used by county human service agencies and volunteers, local health care systems and practitioners, local businesses and schools, and program participants to understand the effects of evidence-based prevention/intervention practices at the individual and community level and to identify ways to best support program success, expansion, and sustainability.

A final consideration for program stakeholders is the time period in which today’s senior population was raised. Mental illness was neither openly discussed nor well understood during the majority of the 20th century; a time that spans the decades in which all of today’s seniors were born, raised, and entered adulthood. Based on the perceptions of mental illness and available treatments during this generations’ youth and early adulthood, understandably, they may be tentative about divulging symptoms of depression and cautious about engaging in a program developed specifically to treat this condition.

Logic Model: Being-Well in OSC Program

Inputs

  • Agency on Aging
  • Senior Centers
  • Health Systems/Provider
  • Volunteer Network
  • Community Partnerships
  • Funding

Outputs

  • Education
  • Support Groups
  • Mindfulness/Meditation Training
  • Exercise/Movement Classes
  • Reminiscing Activities
  • Pet Therapy
  • Cognitive Behavioral Therapy
  • Health Practitioner Alliances
  • Care Coordination Support

Outcomes

  • Increase condition awareness – dispel myths and misconceptions
  • Reduce stigma
  • Promote and encourage open dialogue about a common, treatable condition
  • Increase access to evidence-based treatment modalities for county residents
  • Reduce depression rates
  • Reduce relapse rates
  • Decrease unnecessary medical care/costs (patients with untreated mental health conditions have increased rates of physical complaints and care costs)
  • Improve quality of life for suffers
  • Facilitate community building through a coordinated effort to improve residents’ health status
  • Ability to support other counties, cities, and states with developing evidence-based program to reduce depression in the elderly

References

American Psychological Association. (n.d.). Aging and depression. Retrieved June 22, 2016, from http://www.apa.org/helpcenter/aging-depression.aspx

Bucks County Area Agency on Aging. (n.d.). Four Year Area Plan. Retrieved June 16, 2016, from http://www.buckscounty.org/government/HumanServices/AAA

Center for Disease Control and Prevention. (2015). Bucks County, PA. Retrieved June 24, 2016, from http://wwwn.cdc.gov/CommunityHealth/profile/currentprofile/PA/Bucks/

Insell, T. (2011, December 6). Director’s Blog: Antidepressants: A complicated picture. Retrieved June 18, 2016, from https://www.nimh.nih.gov/about/director/2011/antidepressants-a-complicated-picture.shtml

Langley, K. (2016, March 24). Pennsylvania’s budget impasse comes to an end: ‘We need to move on’ Retrieved June 23, 2016, from http://www.post-gazette.com/news/politics-state/2016/03/23/Pennsylvania-governor-relents-after-9-month-budget-impasse/stories/201603230184

Loprinzi, P. D. (2013). Objectively measured light and moderate-to-vigorous physical activity is associated with lower depression levels among older US adults. Aging & Mental Health, 17(7), 801-805. doi:10.1080/13607863.2013.801066

National Institute of Mental Health. (2009, February 13). Health Care Costs Much Higher for Older Adults with Depression Plus Other Medical Conditions. Retrieved June 27, 2016, from http://www.nimh.nih.gov/news/science-news/2009/health-care-costs-much-higher-for-older-adults-with-depression-plus-other-medical-conditions.shtml

Pratt, L., & Brody, D. (2014). Depression in the U.S. Household Population, 2009-2012. Retrieved June 20, 2016, from http://www.cdc.gov/nchs/data/databriefs/db172.htm

Ramírez, E., Ortega, A. R., Chamorro, A., & Colmenero, J. M. (2013). A program of positive intervention in the elderly: Memories, gratitude and forgiveness. Aging & Mental Health, 18(4), 463-470. doi:10.1080/13607863.2013.856858

Wittchen, H., Mühlig, S., & Beesdo, K. (2003, June). Mental disorders in primary care. Retrieved June 22, 2016, from http://www.ncbi.nlm.nih.gov/pmc/articles/PMC3181625/