Self-Management Programs: One Way to Promote Healthy Aging

The United States population is aging rapidly. In 2007, about 38 million people in America were aged 65 and older, about 13% of the population. That number is expected to nearly double by 2030 to an estimated 71.5 million Americans.¹

Unfortunately, chronic illnesses often accompany the aging process. In 2002, the top three causes of death for U.S. adults aged 65 or older were heart disease (32% of all deaths), cancer (22%), and stroke (8%). These illnesses accounted for more than 60% of all deaths in this age group. Currently, at least 80% of older Americans are living with at least one chronic condition, and 50% of them have at least two conditions.²

Not surprisingly, health-care expenditures increase as people age and their health deteriorates. Experts at the U.S. Department of Health and Human Services (HHS) project that the cost of health care will reach $3.6 trillion in 2014, up from $2.2 trillion in 2007. The mean annual rate of growth of health-care costs through 2018 is projected to be 6.2%. Medicare spending grew 7.2% to $431 billion in 2007. Hospital expenditures grew 7.3% in 2007, up from 6.9% in 2006. It is projected that in 2018, Medicare spending will be nearly $935 billion.³

A number of older adults, especially members of racial/ethnic minority groups, have difficulty locating health-care services. In many communities, access to quality health services—and the costs of those services—remains a major obstacle for these and other segments of the population. To ease this problem of access and provide the needed comprehensive care to older Americans, the U.S. must more than triple the current number of clinicians with specialized geriatric training, according to the Alliance for Aging Research.⁴ Indeed, the U.S. has only about a quarter of the people needed to train students, residents, and physicians in geriatrics. Additionally, the need for community-based service programs will increase, including nutrition, physical fitness, and fall prevention programs, which play a critical role in helping seniors to maintain and even improve their health. Many of the nation's leading health-care experts are recommending a combination of clinical and community-based interventions to address the growing prevalence of chronic conditions.

Community-based self-management programs will be particularly important in helping older adults manage their chronic conditions. Self-management programs help individuals gain self-confidence in their ability to control symptoms and manage the progression of several long-term and chronic age-related illnesses. Programs such as Stanford University School of Medicine's Chronic Disease Self-Management Program and Senior Services of Seattle's Enhance Fitness program significantly increase the self-confidence of older adults when it comes to their health and managing their chronic illnesses. To obtain the best possible outcomes using self-management strategies in chronic conditions, patients must have access to information and services that can help them learn about and cope with their disease. Such information will also help them gain confidence in their ability to better manage their particular illness.

Diabetes is among the most prevalent of the chronic illnesses that affect older people, and efforts to control blood glucose levels are a good example of how self-management programs can be used successfully to improve outcomes. Diabetes is an expensive chronic illness to treat. The annual cost of diabetes care of older adults is estimated to be more than $5 billion.⁵ Half of those with type 2 diabetes are older than 60 years of age, with the highest prevalence found in those older than age 80. The number of Americans with type 2 diabetes is expected to reach 40 million by 2050.⁶ Teaching people with diabetes specific self-management skills in nutrition, exercise, and medication may minimize poor health outcomes. Good communication between the health-care provider and patient also will help avoid unnecessary costs and ensure the best possible outcomes.

Additionally, there is a critical need to provide diabetes self-management training (DSMT) to Medicare beneficiaries. On a national level, 18% of all Medicare beneficiaries have diabetes. Hispanic beneficiaries are particularly susceptible to the disease and are more than four times as likely as non-Hispanic individuals aged 65 and older to experience a hospital admission due to uncontrolled diabetes (Unpublished data, Agency for Healthcare Research and Quality [AHRQ], Healthcare Cost and Utilization Project, 2004). The Medicare Part B DSMT benefit is designed to provide beneficiaries with this type of self-efficacy. The current supply of diabetes educators and self-management programs falls far short of what is needed to address the number of people with the disease. Approximately 3,200 DSMT programs have been accredited by a national accreditation organization (NAO). Medicare regulations (42 C.F.R. 410.141) stipulate that a DSMT program must be accredited by an NAO so that Medicare may determine if the DSMT program meets the program requirements set at 42 C.F.R. 410.144 when providing DSMT services for which Medicare payment is made.^7,8 Currently, there are three NAOs for DSMT programs: the American Diabetes Association (ADA), the Indian Health Service, and, most recently, the American Association of Diabetes Educators.

Self-management courses in community-based settings can augment existing DSMT programs in clinical settings to help reach older adults. For example, the Aging Network currently serves as a trusted resource for millions of older adults. With its 655 Area Agencies on Aging and its 29,000 local service provider organizations nationwide, the Aging Network has positioned itself to help older adults throughout the U.S. It is only natural that these organizations offer DSMT programs.

In partnership with HHS agencies such as the Centers for Disease Control and Prevention, Centers for Medicare – Medicaid Services, Health Resources and Services Administration, and AHRQ, as well as with the ADA and Stanford University's Patient Education Research Center, HHS's Administration on Aging is working to implement Stanford's DSMT program in a number of community-based settings in an effort to provide outreach, education, and treatment to elderly individuals of racial/ethnic minority groups who have been diagnosed with diabetes. This effort seeks to significantly reduce the use of unnecessary health services such as preventable hospitalizations and emergency room visits, as well as unscheduled physician appointments. The Stanford DSMT programs within Hispanic communities will have the option of being taught in Spanish.

Community-based, peer-led self-management programs provide older adults with the opportunity to improve the quality of their lives. These programs encourage individuals to take charge of their health by monitoring their conditions, educating themselves about their specific conditions, knowing what management and treatment options are available to them, and partnering with their doctors in tracking the progression of their disease. Community-based programs encourage individuals with chronic illnesses to be proactive about their condition by informing friends, neighbors, and family members of the illness, and by enlisting help from families and friends in managing the illness and maintaining quality of life as they get older. This is extremely important as we face a massive increase in the elderly population in the coming years.

The challenges involved in increasing access to care, improving outcomes, and reducing costs are huge. But they are not insurmountable. The President's health-care reform agenda calls on all of us to be more actively engaged in maintaining and improving our own health. Let's work together to take the responsibility to educate our families, our friends, others, and ourselves about healthy living. Good self-management will be key in helping tomorrow's older adults stay healthy.

RADM Steven K. Galson, Acting Surgeon General

SPECIAL MESSAGE FROM THE SURGEON GENERAL.

On April 26, the Department of Health and Human Services (HHS) issued a nationwide public health emergency declaration in response to human infections with a newly discovered 2009 H1N1 influenza virus. As this message is being written to the readers of Public Health Reports in early May, the ongoing outbreak of the novel influenza virus H1N1 continues to expand in the United States and internationally. While HHS expects that more cases, more hospitalizations, and more deaths from this outbreak will occur during the coming weeks and months, it is important to recognize that the United States—and the entire world—is better prepared for a potential influenza pandemic than at any time in history. Over the past few years, the preparedness measures undertaken have been an important investment from which we are now benefiting.

The federal government quickly mounted an aggressive response to this outbreak to reduce transmission and illness severity and to provide information to assist health-care providers, public health officials, and the public in addressing the challenges posed by the newly identified influenza virus. The Centers for Disease Control and Prevention's Division of the Strategic National Stockpile has sent—and will continue as needed to send—antiviral drugs, personal protective equipment, and respiratory protection devices to all 50 states and U.S. territories to help them respond to the outbreak. Additionally, HHS has deployed numerous specialized staff, including U.S. Public Health Service Commissioned Officers, to affected nations and states to support response efforts. Heightened surveillance in the U.S. and across the globe is ongoing to detect new outbreaks, better characterize the severity of the virus, respond rapidly to mitigate the impact on families and communities, and adapt our interventions to better control the disease.

HHS has begun the process to develop a vaccine for the 2009 H1N1 virus. Vaccine creation is a complex process that takes several months. One of the critical first steps underway is isolating this H1N1 flu virus to make a candidate vaccine virus that can be provided to industry, so that manufacturers can scale up for production of a vaccine, if necessary. It is HHS's intent to have a vaccine ready for the public later this year, perhaps as early as the fall.

I encourage all public health professionals to stay informed and help educate the public about the H1N1 influenza virus and how to prevent the spread of germs. Please encourage everyone to:

• Wash their hands or use alcohol-based cleansers;

• Avoid close contact with people who are sick;

• Stay at home, and keep your children at home, when sick;

• Cover your mouth and nose with a tissue or your arm when coughing or sneezing;

• Avoid touching your eyes, nose, or mouth; and

• Practice other good health habits, such as staying physically active, managing stress, drinking plenty of fluids, and eating nutritious food.

Our best defense against public health emergencies is being prepared and informed. For more on the 2009 H1N1 flu, go to http://www.cdc.gov/h1n1flu/.

Steven K. Galson, MD, MPH RADM, USPHS Acting Surgeon General