Chairman's Message | Issue Briefs | 20 Actions | PBS TV Special | Chicago Forum | NGA Home | Center Home  | Task Force
Chairman's Message
Gov. Dirk Kempthorne
NGA Issue Briefs
Healthy Aging and States: Making Wellness the Rule, Not the Exception
State Innovations to Encourage Personal Planning for Long-Term Care
State Strategies to Promote Independence Among Older Residents
State Support for Family Caregivers and Paid Home-Care Workers
20 Actions Governors Can Take
Multimedia
PBS Special: Living Better: A National Conversation on Aging
Chicago Policy Forum (May 20-21, 2004)
Links + Other Resources
NGA Home Page
NGA Center Home Page
NGA Health Division



Healthy Aging and States:
Making Wellness the Rule, Not the Exception


Summary

Healthy aging can be the rule, not the exception. Poor health and long periods of dependence and disability are not inevitable consequences of aging. Although chronic conditions such as heart disease and diabetes are common and costly, many such conditions are preventable and others can be managed to minimize complications. There are proven strategies to promote independence and prevent chronic diseases, disabilities, and injuries among seniors. Strategies to prevent and manage chronic conditions can improve the health of older adults, slow the rise in medical and social service costs, and ultimately benefit people of all ages.

Chronic diseases are the leading cause of illness and disability among older Americans. Currently, chronic diseases such as heart disease, stroke, cancer, diabetes, arthritis, and obesity account for three out of four premature deaths in the United States.[1] At least 80 percent of adults aged 65 and over have at least one chronic condition.[2] The prevalence of multiple chronic conditions increases with age and also dramatically increases the cost of caring for seniors [Play Video Clip]. This observation is important, given that the percentage of the population that is over age 65 will increase dramatically in the next couple of decades, as shown in Figure 1.

Governors have led efforts to prevent and manage chronic diseases and injuries for seniors through education, health promotion, and healthcare interventions. As shown in the Appendix, Governors have implemented programs that improve the health of seniors. Strategies for states to help prevent and manage chronic diseases include the following:

• Educating and empowering seniors and their families and caregivers about the importance of health promotion and disease and injury prevention at all ages;

• Promoting physical activity among residents of all ages;

• Developing and leading statewide coalitions to increase immunization rates among older adults;

• Supporting safe driving among seniors through partnerships with private and governmental agencies; and

• Implementing disease management programs for chronic conditions such as diabetes and arthritis.






A Quick Look at Today's Seniors and Chronic Conditions

As the baby boomers grow older, the number of Americans aged 65 and older will double to 70 million over the next 30 years.[3] Over the same time period, seniors will be more racially and ethnically diverse. The coming surge in the number of seniors will significantly increase the demand for health care and social services.

Some quick facts about seniors and chronic diseases:

• At least 13 percent of U.S. residents or 34.9 million U.S. residents are over age 65.

• In Fiscal Year 2000, U.S. spending on the elderly totaled $615 billion, more than one-third of the federal budget. [Play Video Clip] [4]

• Chronic conditions cause almost half of all disabilities among older Americans. They also account for three of four premature deaths in the United States.[5] Table 1 shows the most common chronic diseases among seniors [Play Video Clip].

Table 1: Major Chronic Conditions Among Older Americans

Chronic Condition

Impact on Older Adults

Arthritis

Arthritis, the most commonly reported chronic condition among older adults, is the single leading cause of disability. Among people with arthritis, 89 percent use prescription drugs.[6]

Diabetes

By 2025, more than 20 million Americans are expected to have diabetes.[7] Older adults represent about 41 percent of diabetes cases. Prescription drug costs for adults with diabetes are four times those of the general population.[8]

Heart Disease

Heart disease is the leading cause of death in the United States. Older adults have higher rates of heart disease than any other age group and represent 43 percent of all heart disease cases.[9]

Injuries and Falls

In 2001, roughly 2.7 million older adults were treated in emergency departments for nonfatal injuries, many of which led to long-term disabilities. More than one-third of older adults fall each year, making falls the most common cause of injury in this age group.[10]

Osteoporosis

From 1988-1994, more than half of noninstitutionalized adults aged 65 and over had reduced hipbone density, which increases the risk of hip fractures. In 1996, hip fractures led to 300,000 hospitalizations among older Americans, most of them women.[11]

Overweight & Obesity

About 17 percent of adults aged 70 and older are obese. As obese adults age, though, the proportion of obese older adults can be expected to rise. Older adults who are obese are more likely to suffer from diabetes, disabilities, heart disease, and other chronic conditions.[12],[13]


• The portion of seniors with chronic conditions is increasing. Between 1984 and 1995, the prevalence of major chronic conditions—arthritis, diabetes, cancer, stroke, and heart disease—rose among those aged 70 and over.[14] Figure 2 shows the 1995 prevalence of chronic diseases among seniors 70 and older.



•  Over 80 percent of seniors have at least one chronic condition.[15]

• The prevalence of multiple chronic conditions rises with age: 62 percent of seniors and 70 percent of those over age 80 have two or more chronic conditions.[16]

• Seniors over age 85 are the fastest growing segment of the older population and at the greatest risk for multiple chronic conditions.[17]

• The percentage of seniors who are individuals from racial and ethnic minorities is expected to rise from 11.3 percent today to 16.5 percent by 2030.[18]


• Chronic conditions are the leading causes of disability among seniors. In 1999, 7 million seniors had a disability. At least 3 million older Americans report not being able to perform activities of daily living due to a chronic condition.[19] Older adults who are physically active, non-smokers, and at a healthy weight can delay difficulties with activities of daily living, such as bathing and clothing oneself (ADL) by 7-10 years. [Play Video Clip] [20]

• More than one-third of adults aged 65 years and older fall each year.[21]




Economic Burden of Chronic Conditions

The increased prevalence of chronic conditions - and multiple chronic conditions - among seniors dramatically raises health care costs for this population. Health care costs for a 65-year-old are typically four times those for a 40-year-old.[22],[23]

Estimated costs of chronic health conditions in the United States are shown in Table 2. Care for people with chronic conditions consumes 78 percent of U.S. health care spending, including 95 percent of Medicare spending and 77 percent of Medicaid spending. [Play Video Clip] [24] By 2030, health care spending will increase by 25 percent simply because the population will be older, apart from any increases for inflation or new technology costs. Other facts related to the economic burden of chronic conditions include the following:

• Medicaid spending for long-term care more than doubled from $21.1 billion to $56.1 billion between 1987 and 1997.

• Nursing home and home health care costs doubled to $132 billion between 1991 and 2001. Fifty-seven percent of this sum was paid by Medicare and Medicaid, and 25 percent was paid out-of-pocket by patients themselves.[25]

Table 2: Estimated Costs of Health Conditions in the U.S.

Health Condition

Year

Estimate $ (billion)
(direct and indirect)

Arthritis and other Rheumatic Conditions[26]

1997

$116.0

Cancers[27]

2002

$171.6

Diabetes[28]

2002

$92.0

Heart Disease and Stroke[29]

2003

$351.0

Overweight & Obesity[30]

2000

$117.0



• The average annual prescription drug expenditures for adults aged 65 to 79 are $811 and $796 for those aged 80 and older, compared with $560 for adults aged 50 to 64.[31]

• In addition, people with multiple chronic conditions represent a large proportion of prescription drug use.




Prevention Opportunities and Strategies

Many common chronic diseases are preventable. In fact, engaging in physical activity, receiving vaccinations and immunizations, and avoiding injuries are the best known ways to stem the rise in health care costs and help preserve seniors’ independence, productivity, and quality of life. Research suggests that disability can be delayed for a decade if seniors simply eat healthy, engage in moderate physical activity, and stop smoking.[32]

Increase Physical Activity   [Play Video Clip]

Every senior can benefit from physical activity. Older adults who engage in regular physical activity often experience physical and emotional improvements that exceed those of their younger counterparts. Seniors experience dramatic increases in endurance after less than a year of moderate regular activity (e.g., walking 3 to 5 times a week for at least 30 minutes).[33] Also, physical activity is essential for maintaining healthy joints and controlling symptoms of arthritis. A regular walking program involving only 10 percent of U.S. adults would save $5.6 billion in costs related to heart disease. Every $1 spent on physical activity programs for older adults with hip fractures returns $4.50.

Despite the benefits of physical activity, only one in three older adults engages in regular physical activity.[34] Physical inactivity and poor nutrition are the major culprits behind the obesity epidemic, which is linked to 300,000 deaths each year in the United States and burgeoning health care expenditures.[35] Inactive lifestyles also contribute to heart disease, osteoarthritis, osteoporosis, and other chronic conditions. One-third of men and half of women aged 75 and over engage in no leisure physical activity.


Policy strategies to increase physical activity among seniors include the following:

• Improve access to safe, senior-friendly recreational facilities and activities. Texercise, a statewide fitness campaign to educate and involve older Texans and their families in physical activities and proper nutrition. Texercise promotes physical activity policies and programs among individuals and communities. The program also works through worksites, health care offices, and mass media. [Play Video Clip]

• Creating pedestrian-friendly environments by increasing the number of sidewalks with even pavements, situating benches along sidewalks for resting, providing adequate street lighting, and assuring that traffic lights provide ample time for seniors to cross wide streets.[36]

• Increase public awareness of pedestrian laws and enforce traffic laws and regulations (i.e., red lights and speed limits) to make streets safer for older adults.[37]

• Create bike paths.

• Launching public education campaigns to increase awareness of the benefits of physical activity. The centerpiece of the "Wheeling Walks" program in West Virginia, which enrolled 2,248 residents who collectively logged 28,827 miles during the program, was an eight-week media program.[38]

In light of the growing public health concerns that states are facing due to sedentary lifestyles, the President's Council on Physical Fitness and Sports (PCPFS) offers a motivational web based tracking tool called "The President's Challenge." There are many ways that states could adopt this program as a component to their state physical activity initiatives thus giving constituents an opportunity to improve their health by increasing physical activity levels.

Influenza and Pneumococcal Immunizations

Influenza and pneumococcal infections pose substantially greater risks to senior adults than to younger adults, because seniors are more likely to have chronic conditions and compromised immune systems. Yet, despite the proven benefits and cost-savings associated with vaccination, flu and pneumococcal vaccines are underutilized among seniors.

In 2000, 30 percent of Medicare beneficiaries failed to receive a flu vaccine, and 37 percent failed to receive a pneumococcal vaccine.[39] The figures for appropriate vaccinations are worse for seniors who are ethnic and racial minorities than for whites. In 2000, for example, 57 percent of whites received a pneumococcal vaccination, compared to 33 percent of blacks and 32 percent of Hispanics.[40]

Pneumococcal vaccination saves $294 over a two-year period for each senior vaccinated.[41] Providing influenza vaccinations to noninstitutionalized older adults saves $117 a year per person in direct costs.[42]

Policy strategies to increase immunizations among seniors include the following:

• Increasing awareness of the need for older adults to receive influenza and pneumococcal vaccinations.

• Supporting community initiatives, such as the use of faith-based groups, to reach the underserved and reduce disparities in vaccination levels.

• Forming partnerships with local health foundations and corporate sponsors to eliminate out-of-pocket costs for flu and pneumococcal vaccines for low-income seniors.

• Encouraging long-term care facilities and health systems to implement standing orders for adult immunizations. Standing orders, which authorize nonphysician medical personnel to prescribe and/or deliver vaccinations to clients according to physician-approved protocols, have been proven to increase immunization rates.[43]

Preventing Injuries: Falls and Motor Vehicle Crashes

Preventing injuries due to falls.

Falls are the leading cause of injuries in seniors. More than a third of older adults fall each year. Of those that fall, 20 to 30 percent suffer injuries that reduce mobility and independence.[44] The average health care cost of a fall injury for those aged 72 and over is almost $20,000.[45] Overall, the total annual cost for fall injuries among seniors is expected to exceed $32 billion by 2020.[46] Almost half of all nonfatal fall injuries occur in seniors' homes.[47]

Policy strategies to prevent injuries due to falls among seniors include the following:

• Promoting balance and strength training to reduce the risk of falling. T’ai chi has been proven to be an effective method of preventing falls among seniors.[48]

• Encouraging seniors and their families to modify seniors' homes to prevent falls (e.g., using nonslip mats in tubs and showers, installing handrails, improving lighting, etc.)[49]

• Establishing community programs to help older individuals develop personal transportation plans, with two public transit options for times when driving is not safe or viable.[50]

Preventing injuries due to motor vehicle accidents.

Motor vehicle accidents are also a major cause of injuries in older adults. In 1999, 246,000 older Americans suffered nonfatal injuries in motor vehicle accidents. Older adults are more likely to die from a motor vehicle accident than are younger accident victims, because of their increased frailty and frequent presence of chronic conditions. Older Americans also have the second highest accident death rate per mile (exceeded only by teens). By 2020, roughly 40 million adults aged 65 and over will be licensed drivers.[51] Because driving helps older adults remain independent, it is important to keep them driving safely for as long as possible.

Policy strategies to prevent motor vehicle accidents include the following:

• Launching social marketing campaigns to encourage older driver safety. Maryland, Virginia, and the District of Columbia have piloted a model public relations campaign targeting older adults and influential family members. The GrandDriver campaign includes paid advertising, a speaker's bureau, a toll-free hotline, and a Web site (www.granddriver.info). It was developed in partnership with the American Association of Motor Vehicle Administrators, the National Highway Traffic Safety Administration, AARP, and others.

• Providing the automobile industry with incentives to focus research on the impact of new technologies on older drivers.

• Adopting transportation measures that consider the physical, sensory, and perceptual-cognitive limitations of older drivers:

• More prominent signage to reduce wrong-way movements at intersections;

• Larger lights and back-plates for traffic signals to make them more noticeable; and

• Additional signage to reduce driver uncertainty about street names (e.g., greater use of advance signage to indicate the names of upcoming cross streets).




Managing Chronic Diseases and Utilizing Technology

Proper disease management can reduce the risk of complications from chronic conditions by identifying and monitoring high-risk/high-cost patients and by empowering patients to become more engaged in their own care. For seniors already suffering from chronic illness, proper disease management can alleviate symptoms and prevent the occurrence of disabling complications (e.g., blindness or lower extremity amputations among diabetics).

The following examples suggest some of the potential benefits of disease management:

• Nutrition screenings and interventions could reduce diabetes-related costs by $132 to $330 million, hypertension-related costs by $52 to $168 million, and costs associated with high cholesterol by $54 to $164 million.[52]

• The “Arthritis Self-Help Course”, a group education program, empowers people with arthritis to manage their arthritis and may save more than $2.5 million over four years by delivering the program to 10,000 people with arthritis.

• Weight control and physical activity help people with osteoarthritis in the knees remain functional, reduce physician visits, and delay or prevent knee replacement surgery.

• The use of medication, routine eye and foot exams, cholesterol screening, nutritional interventions, and self-monitoring of blood sugar levels to reduce the complications of diabetes could improve health and economic outcomes associated with diabetes. Controlling blood sugar has been show to reduce complications such as vision loss by 30 to 60 percent.[53] Outpatient training to help people self-manage their diabetes prevents hospitalizations. Every $1 invested in such training can cut health care costs by up to $8.76.[54]

Policy strategies to increase the use of chronic disease management include the following:

• Improve provider and health plan awareness of evidence-based disease management strategies.

• Develop policies that increase providers' knowledge and skills in caring for common conditions that are common in seniors and which affect their function and quality of life. Utah implemented a social marketing campaign to educate physicians about the Arthritis Self-Help Course because of research showing that none of the women with arthritis who participated in the research had been referred to self-help courses by their medical providers. T>he Utah Department of Health implemented a program to identify factors that influence physicians' referrals to arthritis self-help programs. Physicians' knowledge, attitudes, beliefs, and practices related to referring patients to arthritis self-help programs and other educational resources for arthritis were assessed. Developed at Stanford University, the Arthritis Self-Help Course teaches people how to better manage their arthritis and minimize its effects. This course, taught in a group setting, has been shown to reduce arthritis pain by 20 percent and physician visits by 40 percent.

• Establishing more care coordination systems and improve patient follow-up to ensure compliance with disease management recommendations in Medicaid. Coordinating care for seniors with chronic illnesses is beneficial, because many seniors have multiple conditions with related risk factors; and lifestyle changes to manage one chronic condition are likely to help prevent or manage other chronic conditions.

• A disease management initiative in the state of Washington administers telephone- and community-based outreach to more than 27,000 Medicaid clients living with asthma, diabetes, heart failure, and chronic kidney disease. After a year and a half, behavior changes in self-management have led to substantial reductions in hospital admissions and emergency department visits, for an estimated savings of $2 million.[55]

• A Georgia disease management program assigns case managers to frail and disabled Medicaid beneficiaries to coordinate primary and specialty care and support services. After two years, average Medicaid costs for program participants were 30 percent lower than for nonparticipants within the same population of beneficiaries. Participants also had fewer nursing home placements and shorter hospital stays.[56]

• Incorporating telemedicine into disease management programs [Play Video Clip]. For example, automated voice mail systems to improve compliance with medication regimens are available for as little as $1 a day. A televisit with a physician, mental health counselor or other health professional typically costs $12 to $25, compared to about $100 for an in-person visit.[57]

• Incorporate automated tracking and decision support into practice settings that manage chronic conditions.

Conclusion

Chronic conditions dramatically escalate the costs states and families are required to pay for medical and long-term care services for older adults. Fortunately, many chronic conditions can be delayed or prevented using strategies - such as promoting physical activity and safe driving habits - that benefit people of all ages. States can help individuals already suffering from chronic disease to minimize complications and maximize functionality by expanding disease management programs and taking full advantage of new technologies.




Notes:

[1] Institute for Health & Aging, University of California-San Francisco, Chronic Care in America: A 21st Century Challenge; 1996.

[2] Centers for Disease Control and Prevention, U.S. Department of Health and Human Services. Healthy Aging: Preventing Disease and Improving Quality of Life Among Older Americans (Atlanta, GA 2003).

[3] Centers for Disease Control and Prevention, Healthy Aging, 2003.

[4] Congressional Budget Office, Federal Spending on Elderly and Children. Retrieved February 12, 2004 from ftp://ftp.cbo.gov/23xx/doc2300/fsec.pdf

[5] Institute for Health & Aging, University of California-San Francisco, Chronic Care in America: A 21st Century Challenge; 1996

[6] Center on an Aging Society, Health Policy Institute, Georgetown University, “Prescription Drugs, A Vital Component of Health Care,” Data Profile #5 of Challenges for the 21st Century: Chronic and Disabling Conditions, Washington, DC, September 2002. Retrieved Feb. 2, 2004, from http://ihcrp.georgetown.edu/agingsociety/profiles.html.

[7] H. King, R. Aubert, and W. Herman. “Global burden of diabetes, 1995-2025,” Diabetes Care. 21(9):1414-1431, 1998.

[8] Center on an Aging Society, “Prescription Drugs, A Vital Component of Health Care,” 2002.

[9] Centers for Disease Control and Prevention, U.S. Department of Health and Human Services. Health, United States, 1999; With Aging Chartbook. (Hyattsville, MD 1999).

[10] B.H. Alexander, F.P. Rivara, and M. E. Wolf, “The cost and frequency of hospitalization for fall-related injuries in older adults”. American Journal of Public Health. 82(7):1020-1023, 1992.

[11] Centers for Disease Control and Prevention, National Hospital Discharge Survey. 1996.

[12] U.S. Department of Health and Human Services, The Surgeon General's Call to Action to Prevent and Decrease Overweight and Obesity, (Washington DC 2001).

[13] Center on an Aging Society, Health Policy Institute, Georgetown University, “Obesity Among Older Americans: At Risk for Chronic Conditions,” Data Profile #10 of Challenges for the 21st Century: Chronic and Disabling Conditions, Washington, DC, July 2003. Retrieved Feb. 2, 2004, from http://ihcrp.georgetown.edu/agingsociety/pdfs/obesity2.pdf.

[14] Centers for Disease Control and Prevention, U.S. Department of Health and Human Services. National Health Interview Survey, Second Supplement on Aging, (Hyattsville, MD 1994).

[15] Centers for Disease Control and Prevention, Healthy Aging, 2003.

[16] R. L. Mollica and J. Gillespie, Care Coordination for People with Chronic Conditions, 2003.

[17] Chronic Disease Directors and National Association of State Units on Aging. The Aging States Project: Promoting Opportunities for Collaboration Between the Public Health and Aging Services Networks, January 2003

[18] Centers for Disease Control and Prevention, U.S. Department of Health and Human Services, “Public Health and Aging: Trends in Aging—United States and worldwide,” Morbidity and Mortality Weekly Report 52(06);101-106, 2003.

[19] Centers for Disease Control and Prevention, Healthy Aging, 2003.

[20] Vita et al NE&M 1998:338:1035–41.

[21] M.C. Hornbrook, V. J. Stevens, D. J. Wingfield, J.F. Hollis, M.R. Greenlick, and M.G. Ory. “Preventing Falls Among Community-Dwelling Older Persons: Results from a Randomized Trial,” The Gerontologist 34(1):16–23, 1994.

[22] Centers for Disease Control and Prevention, Healthy Aging, 2003.

[23] Watson Wyatt Worldwide, From Baby Boom to Elder Boom: Providing Health Care for an Aging Population, 1996.

[24] R. L. Mollica and J. Gillespie, Care Coordination for People with Chronic Conditions, 2003.

[25] K. Levit, C. Smith, C. Cowan, H. Lazenby, A. Senseing, and A. Caitlin, “Trends in U.S. health care spending, 2001.” Health Affairs. 19:191-203, 2003.

[26] Centers for Disease Control and Prevention, U.S. Department of Health and Human Services, “Direct and Indirect Costs of Arthritis and Other Rheumatic Conditions --- United States, 1997,” Morbidity and Mortality Weekly Report 52(46);1124-1127, 2003.

[27] National Institutes of Health, U.S. Department of Health and Human Services, Fact Book, Fiscal Year 2002, February 2003.

[28] AARP, “Nutrition Management Aids Healthy Aging,” Washington, DC, 2003. Retrieved Feb. 2, 2004, from http://www.aarp.org/states/md/Articles/a2003-07-24-md-nutrition.html.

[29] Centers for Disease Control and Prevention, U.S. Department of Health and Human Services, A Public Health Action Plan to Prevent Heart Disease and Stroke: Executive Summary and Overview (Atlanta, GA: 2003). Retrieved Feb. 2, 2004, from http://www.cdc.gov/cvh/Action_Plan/

[30] Centers for Disease Control and Prevention, U.S. Department of Health and Human Services, “Preventing Obesity and Chronic Diseases Through Good Nutrition and Physical Activity.” Retrieved Feb. 2, 2004 from http://www.cdc.gov/nccdphp/pe_factsheets/pe_pa.htm.

[31] Agency for Healthcare Research and Quality, U.S. Department of Health and Human Services, 1998 Medical Expenditure Panel Survey.

[32] AARP, "Nutrition Management Aids Healthy Aging," 2003.

[33] J. W. Rowe and R. L. Kahn, Successful Aging: The MacArthur Foundation Study. New York, Pantheon Books; 1998.

[34] P. M. Barnes and C. A. Schoenborn, "Physical Activity Among Adults: United States, 2000," Advance Data from Vital and Health Statistics, No. 333, May 14, 2003. Retrieved Feb. 2, 2004, from http://www.cdc.gov/nchs/data/ad/ad333.pdf

[35] Centers for Disease Control and Prevention, U.S. Department of Health and Human Services, The Burden of Chronic Diseases and Their Risk Factors (Atlanta, GA: 2002).

[36] M. E. French, "Walking and Biking: Transportation and Health for Older People," Generations 27(2):74-75, 2003.

[37] Partnership for Prevention, Creating Communities for Active Aging (Washington, DC: 2001).

[38] Partnership for Prevention, From the Field: Four Communities Implement Active Aging Programs (Washington, DC: 2002).

[39] Centers for Medicare and Medicaid Services, U.S. Department of Health and Human Services, Medicare Current Beneficiary Survey 2000 (Baltimore, MD: 2002). Retrieved Feb. 4, 2004, from http://www.cms.hhs.gov/MCBS/v2002_aug.asp.

[40] Centers for Disease Control and Prevention, U.S. Department of Health and Human Services, "Racial/Ethnic Disparities in Influenza and Pneumococcal Vaccination Levels Among Persons Aged > 65 Years—United States, 1989-2001," Morbidity and Mortality Weekly Report 52(40):958-96, 2003.

[41] K. L. Nichol, L. Baken, J. Wuorenma, and A. Nelson, "The Health and Economic Benefits Associated with Pneumococcal Vaccination of Elderly Persons with Chronic Lung Disease," Archives of Internal Medicine 159:2437-2442, 1999.

[42] K. L. Nichol, K. L. Margolis, J. Wuorenma , and T. Von Sternberg, "The Efficacy and Cost Effectiveness Of Vaccination Against Influenza Among Elderly Persons Living in the Community," New England Journal of Medicine 337:778-784, 1994.

[43] Task Force on Community Preventive Services (Centers for Disease Control and Prevention), "Effectiveness of Standing Orders to Increase Vaccination Coverage in Adults," Guide to Community Preventive Services, updated Jan. 17, 2003. Retrieved Feb. 2, 2004, from http://www.thecommunityguide.org/vaccine.

[44] B. H. Alexander, F. P. Rivara, and M. E. Wolf. "The Cost and Frequency of Hospitalization for Fall-Related Injuries in Older Adults,American Journal of Public Health 82(7):1020-1023, 1992.

[45] J. A. Rizzo, R. Friedkin, C. S. Williams, J. Nabors, D. Acampora, and M. E. Tinetti, "Health Care Utilization and Costs in a Medicare Population by Fall Status," Medical Care 36(8):1174-1188, 1998.

[46] J. A. Rizzo, R. Friedkin, C.S. Williams, et al., "Health Care Utilization and Costs," 1998.

[47] Centers for Disease Control and Prevention, U.S. Department of Health and Human Services, "Public Health and Aging: Nonfatal Injuries Among Older Adults Treated in Hospital Emergency Departments—United States, 2001," Morbidity and Mortality Weekly Report 52(42):1019-1022, 2003.

[48] Centers for Disease Control and Prevention, U.S. Department of Health and Human Services, Injury Fact Book 2001-2002 (Atlanta, GA: 2002).

[49] E. K. Parra and J. A. Stevens, U.S. Fall Prevention Programs for Seniors: Selected Programs Using Home Assessment and Home Modification, (Atlanta, GA 2000).

[50] J. F. Coughlin, "Beyond Health and Retirement: Placing Transportation on the Aging Policy Agenda," Massachusetts Institute of Technology Age Lab, October 2001. Retrieved Feb. 2, 2004, from https://dspace.mit.edu/retrieve/1219/beyond_health.pdf.

[51] Centers for Disease Control and Prevention, Injury Fact Book 2001-2002, 2002.

[52] AARP. “Nutrition Management Aids Healthy Aging, 2003.

[53] M. Piturro, “Disease Management for Diabetes in the Frail Elderly,” Caring for the Ages 4(2):42-45, 2003. Retrieved Feb. 2, 2004, from http://www.amda.com/caring/february2003/diabetesmanagement.htm

[54] Centers for Disease Control and Prevention. Preventing Chronic Diseases: Investing Wisely in Health
Preventing Diabetes and Its Complications
, July 2003.

[55] J. Stevenson, “Washington State's new approach improves clients' care, saves taxpayers' money,” Disease Management: Healthcare Where it Counts, 2003.

[56] R. L. Mollica and J. Gillespie, Care Coordination for People with Chronic Conditions, 2003.

[57] A. Kinsella, “Chronic Disease Management and Telehealthcare,” Mar. 23, 1999. Retrieved Feb. 2, 2004, from http://tie.telemed.org/homehealth/kinsella3_FT.asp.






Chairman's Message | Issue Briefs | 20 Actions | PBS TV Special | Chicago Forum | NGA Home | Center Home
National Governors Association, Hall of States, 444 N. Capitol St., Washington, D.C. 20001-1512
Telephone (202) 624-5300 | webmaster email address: webmaster@nga.org