1 September 2012    Opportunity Knocks: Increasing the Use of   Clinical Preven ve Services by Older Adults   in Your Community    Tabashir Sadegh‐Nobari, Rosana Leos, Kathryn G. Kietzman and Steven P. Wallace  SUMMARY: This policy note examines the role that diverse community organizations (such as YMCAs, workplaces, pharmacies, retailers) can play to increase the use of clinical preventive services by adults age 50 and older. Successful strategies include providing incentives, facilitating access, being opportunistic, and collaborating with other organizations to promote or provide clinical preventive services. This note in- cludes real world examples and links to resources that can help community-based or- ganizations initiate similar efforts in their own communities. Related opportunities to provide clinical preventive services for aging services providers, state, local and tribal public health departments and community health centers are the focus of other policy notes in this “Opportunity Knocks for Preventive Health” series1 which highlights the promise of collaboration between diverse types of community-based organizations to improve the health of older Americans. By 2015, one in five Americans will be between the ages of 50 and 64. Over the next few decades, the population of those age 65 and older is projected to more than double – from 40 million in 2010 to more than 88 million by 2050.2 Meeting the health needs of this growing population is increasingly critical from both a public health and health care cost containment perspective. The use of clinical preventive services (CPS) – health care services that prevent disease or detect it at a very early stage when it is most treatable – can play an important role in meeting this goal.3 Adults age 50 and older are at increased risk for a number of diseases that can be prevented or treated early through CPS, such as influenza and pneumococcal vaccinations, colorectal cancer screening, and for women, breast and cervical cancer screening. The U.S. Preventive Services Task Force (USPSTF) publishes a list of all recommended services.4 These services vary with age, gender and risk factors. 2 Despite the effectiveness of potentially life-saving CPS, only 25% of adults ages 50 to 64,5 and fewer than 40% of adults age 65 and older,6,7 are up to date on a core set of recommended services. This is true despite the fact that these services are paid for by nearly all insurance plans, including Medicare and Medicaid. The Affordable Care Act eliminates most remaining financial barriers,8 but additional efforts are needed to increase CPS use. Community-based organizations are ideally situated for prevention efforts and provide a needed linkage to medical care provider systems that tend to be more focused on acute care, treatment and cure than on preven- tive health. Linking CPS to places where people routinely live, work, pray and play can reduce the effort and inconvenience incurred by seeking CPS, and can increase awareness and interest in obtaining the set of recom- mended services. This policy note highlights current efforts and untapped opportunities for community-based organizations to increase the use of CPS among adults 50+. Benefits of Clinical Preven ve Services  Expanding the range of activities provided in community settings to include CPS engagement, delivery and/or follow-up provides an opportunity for organizations to enhance their membership or customer base, increase revenues, and support organizational missions to meet community needs. Organizations that already serve adults 50+ offer a natural point of entrée and connection to extend the provision of CPS and reach those who may not otherwise be reached. While older adults can benefit from receiving CPS, the organizations that assist them may also experience gains. First, providing these important preventive health services to adults 50+ can directly or indirectly support the organizational mission, that mission being to improve the health and well-being of members of the local community. Second, by promoting or providing CPS, organizations have the opportunity to increase their visibility and strengthen their reputation as vital contributors to the community. The provision of CPS can lead to an increased customer base and higher revenues, which are important for retail businesses such as commu- nity pharmacies, as well as nonprofit organizations like the YMCA and others that are sustained largely through foot traffic. Finally, both large and small employers can benefit from facilitating or providing CPS directly to their employees. The availability of CPS at the worksite can increase employee satisfaction and reduce turnover. Use of these services can also reduce absenteeism and presenteesim (i.e., attending work while sick) by improving worker health, and decrease medical expenditures by preventing or diagnosing illness sooner. Research shows that for every dollar invested in worksite wellness programs, $3.27 is saved in medical costs and $2.73 is saved in absenteeism costs.9 Building on the Strengths of Community‐Based Organiza ons Community-based organizations have a number of strengths which allow them to lead or play an important role in increasing the use of CPS among adults 50+. These strengths will vary with organizational size, capacity and structure. Independent and smaller organizations may have more autonomy and therefore greater flexibility to provide personalized services that are tailored to local needs, or to extend the scope of services offered. Larger national organizations may be better positioned to advance CPS delivery through pooled resources and administrative systems that can better manage third-party payers and offer services that fall under the Health Insurance Portability and Accountability Act (HIPAA) of 1996 privacy regulations. 3 Whether large or small, a strength that many community-based organizations offer is proximity to and familiarity with the daily lives of community members. Adults 50+ who frequent these community sites (worksites, retail locations and community centers) may not have the knowledge, motivation, support or resources needed to access traditional medical practices to obtain CPS. Time can also present a significant barrier to the delivery of CPS because of inconvenient office hours or excessive waiting periods. Such obstacles can be minimized when a quick service like a flu shot can be obtained with little disruption to normal routines. The convenient locations of community organizations that adults 50+ frequent may reduce the structural barriers that many would otherwise face, and enable these organizations to better meet the diverse needs of older adults. Clinical Preven ve Service Provision Strategies There are a number of strategies that community organizations have used to increase the receipt of recom- mended CPS by older adults. Successful strategies include providing incentives, facilitating access, being opportunistic, collaborating with other organizations and tailoring services to promote or provide CPS. Providing Incen ves to Receive Recommended Clinical Preven ve Services Incentivizing the use of CPS is one way to increase uptake. Incentives depend on organizational resources and can be cash or in-kind benefits such as movie passes, a $5 gift-card, a 10% grocery discount or a gym mem- bership. Some employers provide health insurance premium reductions to increase employee participation in worksite wellness programs. Real world example: Quad/Graphics,10 a self-insured printing company in Wisconsin, engages employees by incentivizing the uptake of CPS, delivering a wide range of CPS, and offering follow-up through on-site primary care clinics. The company’s worksite wellness program, Lean You!, supports its 10,000 employees and their spouses in efforts to be more physically active, quit smoking, lose weight, have annual physical exams, receive recom- mended screenings and meet individualized health goals for indicators such as blood pressure, cholesterol and BMI. There are no costs to the employee to participate. The co-pay for the annual physical exam is waived and the onsite fitness center is free. Furthermore, the employee receives financial incentives to participate in these healthy behaviors and meet their health goals. Quad/Graphics also has onsite primary care clinics where employees can schedule same-day appointments for clinical preventive services such as immunizations and cholesterol tests and receive referrals for mammography and colonoscopy. The program has been successful in improving health behaviors and in detecting undiagnosed cases of cancer, diabetes, hypertension and high cholesterol, conditions that increase risks for employees as they become older. Furthermore, the program has been successful in decreasing health care costs. Quad/Graphics’ health care costs are approximately 30% less than other large companies; this difference is attributed to their onsite clinics and employee wellness program. By increasing the financial incentive from $250 to $400 and including a premium reduction, Quad/Graphics was able to increase employee participation from 35% to over 70% and recruit employees who were at risk for poor health. Employers can also take advantage of the Affordable Care Act (ACA) to increase employee participation in wellness programs and reduce associated costs. ACA provides grants to small employers that offer employee wellness programs and, beginning in 2014, will allow employers to increase incentives provided to employees who participate in wellness programs and meet health goals. These incentives could be increased from 20% to 30% of the cost of coverage for participating in the program.11 4 Facilita ng Access to Recommended Clinical Preven ve Services Facilitating CPS access by offering these services where older adults live, work, vote and/or shop can also lead to increased uptake. The Visiting Nurse Service of New York, for example, supports older adults who live in- dependently in their homes by providing in-home services such as comprehensive health assessments, blood pressure screenings, foot screenings and immunizations. Some large employers have on-site clinics that pro- vide same-day CPS. Others, like Intel, arrange for mobile mammography units to provide screenings to their employees once or twice a year. Retail walk-in clinics located within CVS/Caremark pharmacies, large corpo- rate campuses, select malls and clinics in airports can increase convenient access to CPS.12 Real world example: Goodrich Pharmacy is an independent pharmacy with six sites in Minnesota that promote customers’ need for CPS and provide selected CPS.13 For example, customers are offered immunizations and blood pressure, cho- lesterol and glucose screenings on-site. Staff also provide Medication Therapy Management (MTM) for which they assess the customer’s medical history, current medications and medical needs, and assist the individual with better medication management practices to optimize health outcomes. They may also determine if the customer has received specific CPS such as immunizations and cholesterol screening. At various times, staff members offer health education and some CPS, such as immunizations and blood pressure screenings, at other community sites – including YMCAs, senior centers, senior housing units, health fairs and grocery stores. Being Opportunis c to Provide Clinical Preven ve Services to Older Adults Opportunistic or teachable moments can also be used to increase CPS use among adults 50+. Individuals are often most receptive to health messages and activities when they are engaged in other health-related activities. Organizations that already provide health-related activities can take advantage of health promotion or service delivery encounters to further educate older adults and provide or refer them to recommended CPS. For example, there is evidence that colorectal screening rates increase when pharmacies that provide influenza vaccinations provide adults 50+ with take-home stool test cards at the same time. The screening increase is greater than an educational intervention alone.14 Similarly, a Harlem-based breast examination center took advantage of the times women came in for breast cancer screening to discuss the importance of colorectal cancer screening, set up a colonoscopy appointment at a local community hospital, and provide follow-up as needed.15 The program increased access among low-income African-American and Latina women with limited knowledge about and opportunity to receive colorectal cancer screening. Collabora ng and Pooling Resources to Provide Clinical Preven ve Services Organizations can share or exchange financial and human resources to support CPS engagement, delivery and follow-up activities. Any single organization may not have the space, staffing, funding, client base or incentives to engage in CPS activities, but collaborative arrangements between organizations with different resources can make it possible to offer services that benefit all participating organizations. Real world example: The Healthier Black Elders Center (HBEC)16 is a diverse group of educators, community members and re- searchers who work to improve the health of older adults living in the Metropolitan Detroit area. The HBEC provides free education and screening services to members of the community through health forums and an annual health conference. Clinical preventive services are delivered to community members by local health 5 care providers who, in exchange, develop a positive reputation and receive increased visibility for their services. Community members benefit by receiving recommended CPS and health education in a convenient and familiar community location. For instance, of the more than one thousand older adults who attended the 2010 annual health conference in Detroit, 82% thought the event had a positive impact on their health habits, and nearly 90% thought the screenings and health information were useful.17 Establishing collaborative relationships with the local health care system can be especially helpful for commu- nity organizations if they are not already connected. Most large academic medical centers have federal Clinical and Translational Science Awards (CTSA)18 that support efforts to advance medical technology and services in communities through collaborative arrangements. A link to a clinical setting is essential to meet the objec- tive of facilitating CPS follow-up activities for older adults with positive test results and/or with no regular source of primary care. For instance, staff members at pharmacies like Goodrich can discuss CPS screening results with patients and encourage them to follow up with a health care provider. Other national community chain pharmacies, like Walgreens, have systems in place to call a patient 10 days after a positive test result to make sure they are getting follow-up. If a customer does not have a usual source of health care, pharmacies like Goodrich and Walgreens try to connect the customer with an available provider. It is also important for community organizations to understand and abide by the regulatory parameters that in- fluence CPS activities. HIPAA privacy rules can make it difficult to exchange CPS information between an organization and a health care provider if the organization is not already housed within the health care system. Further, the scope of medical practice laws varies from state to state and may limit community organizations’ ability to deliver certain services with their current staffing. Organizations without the required medical per- sonnel, such as a licensed nurse or pharmacist to administer immunizations, will need to acquire the necessary staffing through exchange or some other arrangement. Local rules and regulations can also have an impact. For example, when planning to offer CPS on site, the AeroClinic19 must follow individual airport rules that vary by region. Before providing CPS, community organizations need to learn about the regulations that will guide their practice. Tailoring Services to Be Responsive to Local Popula ons Finally, it is important that community organizations consider how they might provide CPS in ways that are culturally appropriate. This is especially critical in efforts to improve use among ethnic minority and disadvan- taged adults 50+. These efforts might entail hiring staff who are from the community or who are bilingual. Similarly, marketing messages developed to engage the desired population must be well-targeted. For in- stance, Immunize LA Families of Los Angeles uses a narrowcast campaign20—a marketing and communica- tion strategy that is designed for specific populations—to increase adult vaccination rates. The posters and marketing products portray people living in the community and include testimonials of why a representative from that community chose to get vaccinated. Outreach posters are placed in churches, senior centers and clin- ics in the community. An evaluation found that this campaign increased self-reported immunization rates among adults over the age of 50 and that, over time, family and friends were more likely to find getting im- munizations acceptable.   Pu ng It All Together to Provide Clinical Preven ve Services in the Community: The Promise of a   Diabetes Preven on Program  The YMCA’s Diabetes Prevention Program (part of the CDC’s National Diabetes Prevention Program) is a 12-month evidence-based intervention delivered through local YMCAs (or Ys) that helps people at risk for type 2 diabetes eat healthier, increase their physical activity and make other behavior changes in order to re- duce their chances of developing the disease. Participants meet with trained lifestyle coaches and classmates 6 for 16 weekly sessions during the core portion of the program. During the 8-month maintenance period, partic- ipants meet once a month. The program can be offered anywhere in a community. Providing this intervention in a community setting was found to be just as effective at preventing or delaying the onset of type 2 diabetes as it was when provided in a health care setting, but at one quarter of the cost and with more demonstrated reach.21 The dissemination of the YMCA’s Diabetes Prevention Program received a U.S. Department of Health and Human Services Healthy Living Innovation Award. Nearly 80 Ys in more than 30 states will offer the program in 2012 and more Ys are expected to offer it over the next five years. One senior executive stated that the role of the YMCA’s national organization, Y-USA, is to “inspire YMCAs, lead YMCAs by capturing and replicating best practices [and] provide opportunities at the national level that allow YMCAs to plug into those nationally created opportunities.” The Diabetes Prevention Program serves as a potential platform for expanding the engagement, and even delivery and follow-up, of CPS such as immunizations and cancer screenings. The advancement of YMCA’s Diabetes Prevention Program provides an important example of the type of systems change that community organizations can undergo to lead or play a significant role in the delivery of CPS to older adults. This Y initiative illustrates several ingredients for success, including:  A shift in focus from individual health and fitness to community and population health.  Legal, financial and administrative support provided by the national organization, YMCA of the USA (Y-USA), to the local Ys, including grants offered for program start-up costs.  Use of a third-party administrator to set up the billing systems for third-party payers such as health insurance plans to reimburse the local Ys.  Programmatic training and follow up with staff to ensure understanding of and compliance with HIPAA regulations. In addition to these national level strategies, the local Ys have engaged in efforts to increase participation rates by being more responsive to the specific population they are serving. For example, administrators at the Valley of the Sun YMCA in Phoenix, Arizona realized that to facilitate older adults’ participation in the program they needed to offer sessions during the day since many older adults do not like to drive at night. To reduce or eliminate cultural or language barriers in the delivery of the program to minority communities, this Y also hired bilingual coaches and offered Spanish-language and culturally-appropriate materials to members of the Hispanic community. Similarly, the Valley of the Sun YMCA plans to hire members of the American Indian community to be coaches for their own community. The Y Lifestyle Coaches facilitate the group to seek life- style change that is achievable and congruent with members’ cultural beliefs and practices. Ys do not turn away anyone from programs such as the YMCA’s Diabetes Prevention Program due to their inability to pay. With specific grant support, the Valley of the Sun YMCA has been able to offer a limited number of program scholarships to older adults who are uninsured and do not have the financial means to privately pay for CPS. Any other individuals can apply for financial assistance. To incentivize continuing participation, some Ys provide free YMCA memberships to participants who continue in the program and meet their goals. Public-private partnerships with different organizations can facilitate the engagement, delivery and follow-up of CPS in the community. In the example provided by the YMCA’s Diabetes Prevention Program collabora- tion with government, the private sector and local organizations was important for development, outreach and day-to-day operations. An agreement with United Health Group’s Diabetes Prevention and Control Alliance 7 (DPCA) enables the Y to receive performance-based reimbursement of program costs for those covered by third-party payers who choose to offer the program as a benefit to their insured. Ys are also building networks with other community organizations, employers and local health care providers who can help market the pro- gram. In addition, these relationships provide a natural bridge between the community and clinical settings. Conclusion  Community organizations are well-positioned to lead or actively participate in collaborative arrangements with aging services providers, public health departments, community health centers and health care systems to increase CPS engagement, delivery and follow-up among older adults. Efforts to increase the uptake of CPS among adults 50+ need to be tailored to reflect the reality that community-based organizations vary in composition, resources and capacity to innovate. It is not an all-or-none proposition. There are a series of steps leading up to a systems approach intended to achieve the national goals and standards put forth by the U.S. Department of Health and Human Services’ Healthy People 2020,22 Action Plan to Reduce Racial and Ethnic Health Disparities,23 and National Prevention Strategy.24 Partnerships with other community providers are critical for leveraging the financial and human capital needed to initiate and sustain these efforts to improve the health of older Americans. Methodology Researchers from the UCLA Center for Health Policy Research conducted a literature review and 43 telephone interviews with a diverse group of community-based stakeholders representing public health, aging services, community health centers, and other community organizations and retailers (e.g., the YMCA and pharmacies) in 2011. A stakeholder meeting was then convened to identify opportunities to advance the provision of clinical preventive services to older adults in the community. Krist and colleagues (2012) presented a landscape paper that conceptualizes the provision of CPS in three stages: engagement (identifying need, making referrals), delivery (administering, counseling and supporting adoption) and/or follow-up (documenting and referring to additional services or treatment).25 Stakeholders then formed small groups to discuss implications for their involvement in the provision of CPS to older adults. This policy note draws upon the Krist et al. paper, the literature review, the telephone interview data and the stakeholder discussions to identify specific opportunities for community-based organizations to provide CPS, and to illustrate how they may benefit from expanding their role and increasing CPS uptake among adults 50+. Author Informa on  Tabashir Sadegh-Nobari, MPH, and Rosana Leos, MPH, are graduate student researchers at the UCLA Center for Health Policy Research. Kathryn G. Kietzman, PhD, is research scientist at the UCLA Center for Health Policy Research, and assistant researcher in the Department of Community Health Sciences at the UCLA Fielding School of Public Health. Steven P. Wallace, PhD, is associate director of the UCLA Center for Health Policy Research, and professor and chair of the Department of Community Health Sciences at the UCLA Fielding School of Public Health. Funder Informa on  This publication was supported by Grant/Cooperative Agreement Number U58DP002759-01 from the Centers for Disease Control and Prevention (“CDC”). Contractor acknowledges the contribution of the National Association of Chronic Disease Directors (NACDD) to this publication. Its contents are solely the responsibility of the authors and do not necessarily reflect the view of the CDC or NACDD. Acknowledgments  We are grateful for the contributions of the many who made this paper series possible, including the stakeholders who were inter- viewed and/or participated in the roundtable meetings, Amy Slonim, CDC-AARP Liaison, William Benson, Health Benefits ABCs, Consultant to CDC Healthy Aging Program, Lynda Anderson, Director, CDC Healthy Aging Program and other members of the research team at the UCLA Center for Health Policy Research: Ashley V. Parks and Delight Satter. We also want to thank Marialice S. Bennett, Kristen A. Binaso, Wendy Bart, Heather Hodge, Andi Crawford, Leslie A. Best, Marty Lynch and Ami M. Shah for their helpful reviews. 8 Suggested Cita on  Sadegh-Nobari T, Leos, R, Kietzman KG, Wallace SP. Opportunity Knocks: Increasing the Use of Clinical Preventive Services by Older Adults in Your Community. Los Angeles, CA: UCLA Center for Health Policy Research, 2012.   Endnotes  1 www.healthpolicy.ucla.edu/CHIPS 2 Vincent GK and Velkoff VA. The Next Four Decades, The Older Population in the United States: 2010 to 2050. Current Popula- tion Reports, P25-1138, U.S. Census Bureau, Washington, DC., 2010. 3 Farley TA, Dalal MA, Moashari F, Frieden TR. Deaths Preventable in the U.S. by Improvements in Use of Clinical Preventive Ser- vices. American Journal of Preventive Medicine, 38(6): 600-609, 2010. 4 www.uspreventiveservicestaskforce.org/uspstf/uspsabrecs.htm 5 Centers for Disease Control and Prevention, AARP, American Medical Association. Promoting Preventive Services for Adults 50- 64: Community and Clinical Partnerships. Atlanta, GA: National Association of Chronic Disease Directors; 2009. Available at: www.cdc.gov/aging 6 U.S. Department of Health and Human Services. Centers for Disease Control and Prevention, Administration on Aging, Agency for Healthcare Research and Quality, and Centers for Medicare and Medicaid Services. Enhancing Use of Clinical Preventive Services among Older Adults, Washington, DC: AARP, 2011. 7 http://apps.nccd.cdc.gov/SAHA/Default/Default.aspx 8 www.healthcare.gov/news/factsheets/2010/07/preventive-services-list.html#CoveredPreventiveServicesforAdults 9 Baicker K, Cutler D, Song Z. Workplace wellness programs can generate savings. Health Affairs, 29(2): 304-311, 2010. 10 http://innovations.ahrq.gov/content.aspx?id=2770 11 http://www.kff.org/healthreform/upload/8061.pdf 12 http://www.innovations.ahrq.gov/content.aspx?id=1772 13 https://goodrichpharmacy.com/ 14 Potter MB, Gildengorin G, Wang Y, Wu M, Kroon L. Comparative effectiveness of two pharmacy-based colorectal cancer screen- ing interventions during an annual influenza vaccination campaign. Journal of the American Pharmacists Association, 50(2): 181 - 187, 2010. 15 http://www.innovations.ahrq.gov/content.aspx?id=3043 16 http://mcuaaar.wayne.edu/healthier.php 17 Healthier Black Elders Center. Fall 2010 Newsletter. Accessed February 10, 2012 at http://www.mcuaaar.wayne.edu/ _pdfs_or_images_/hbe_newsletter_fall2010.pdf 18 http://www.ncats.nih.gov/research/cts/ctsa/ctsa.html 19 http://innovations.ahrq.gov/content.aspx?id=1753 20 Glik DC, Prelip M, Myerson A, Eliers K. Narrowcast campaign guide for community programs: Creating health messages for tar- geted media campaigns. INMED Partnerships for Children and UCLA School of Public Health 2005. Accessed February 10, 2012 at http://www.ph.ucla.edu/chs/hmrg/documents/narrowcast_manual.pdf 21 Ackermann RT, Finch EA, Brizendine E, Zhou H and Marrero DG. Translating the Diabetes Prevention Program into the Commu- nity: The DEPLOY Pilot Study. American Journal of Preventive Medicine, 35(4): 357–363, 2008. 22 Healthy People 2020: http://www.healthypeople.gov/2020/TopicsObjectives2020/pdfs/HP2020_brochure_with_LHI_508.pdf 23 U.S. Department of Health and Human Services. HHS Action Plan to Reduce Racial and Ethnic Disparities: A Nation Free of Dis- parities in Health and Health Care. Washington, D.C.: U.S. Department of Health and Human Services, 2011. 24 National Prevention Council, National Prevention Strategy, Washington, DC: U.S. Department of Health and Human Services, Office of the Surgeon General, 2011. 25 Krist A, Shenson D, Woolf S, Bradley C, Liaw W and Rothemich S. A Strategic Framework and Actions to Integrate Community and Clinical Care to Improve the Delivery of Clinical Preventive Services Among Older Adults. A paper prepared for the National Association of Chronic Disease Directors and Michigan Public Health Institute funded by The Healthy Aging Program, Division of Population Health, Centers for Disease Control and Prevention, and presented at a roundtable meeting of stakeholders convened in Washington, DC on December 15, 2011. Revised August 29, 2012.