Clinical Preventive Services for Older Adults: The Interface Between Personal Health Care and Public Health Services

Abstract

Healthy aging must become a priority objective for both population and personal health services, and will require innovative prevention programming to span those systems. Uptake of essential clinical preventive services is currently suboptimal among adults, owing to a number of system- and office-based care barriers.

To achieve maximum health results, prevention must be integrated across community and clinical settings. Many preventive services are portable, deliverable in either clinical or community settings. Capitalizing on that flexibility can improve uptake and health outcomes.

Significant reductions in health disparities, mortality, and morbidity, along with decreases in health spending, are achievable through improved collaboration and synergy between population health and personal health systems.

BETWEEN 2010 AND 2050, the population of Americans aged 65 years and older is expected to more than double, swelling to nearly 89 million. This “silver tsunami,” composed mostly of Baby Boomers (the first of whom crossed the 65-year line in 2011), will pose serious challenges for our nation’s public health and health care systems, along with state and federal budgets, family finances, and private sector profitability. Healthy aging, too often viewed as a peculiar product of luck or luxury, must become a priority objective for both population and personal health services—and will require innovative prevention programming to span those systems.

Chronic illness currently represents an estimated 83% of total US health expenditures and 99% of Medicare spending.¹ Increasing rates of costly chronic conditions, many of which are not well managed,^2–5 are associated with significant Medicare spending increases.^6,7 Each year, more than half of Medicare beneficiaries are treated for 5 or more chronic conditions.⁶ The average Medicare enrollee sees 2 primary care physicians and 5 specialists working in 4 different practices annually⁸; those with 5 or more chronic conditions see an average of 14 different physicians a year.⁹ Care fragmentation results in suboptimal uptake of clinical preventive services (CPS) among US adults^3,10: only 33% of women and 40% of men aged 65 years and older are fully up to date with all preventive services recommended for all adults in this age range,¹¹ and less than a quarter of adults aged 50 to 64 years have received all these services.¹² Even if adults receive recommended disease screening, a positive finding may not lead to effective treatment: although blood pressure screening in older adults is relatively high, hypertension is controlled in only half of patients.¹³

Preventing chronic diseases and keeping chronically ill older adults healthier are imperatives to drive improvements in health, quality of life, and value in US health spending.¹⁴ Population-based primary prevention works to avert disease. It must be reinforced with patient-focused primary prevention and coupled with effective secondary prevention to detect illness as well as tertiary prevention aimed at better managing existing illness and preventing additional disease and disability. To achieve maximum health results, prevention must be integrated across community and clinical settings. Many preventive services are portable—deliverable in either clinical or community settings. Capitalizing on that flexibility can improve uptake and health outcomes.

Optimal use of CPS—particularly for cardiovascular conditions—could avert an estimated 50 000 to 100 000 deaths per year among adults younger than 80 years and 25 000 to 40 000 deaths per year among those younger than 65 years.¹⁵ Increasing uptake of selected high-value CPS to 90% could produce an additional 1.89 million quality-adjusted life years.¹⁶ Outside clinical settings, the Trust for America’s Health has estimated that an investment of $10 per person per year in community-based programs tackling physical inactivity, poor nutrition, and smoking could yield more than $16 billion in medical cost savings annually within 5 years—a return on investment of $5.60 for every $1 spent, without considering the additional gains in worker productivity, reduced absenteeism at work and school, and enhanced quality of life.¹⁷ Significant reductions in health disparities, mortality, and morbidity—and attendant decreases in health spending—are achievable through improved collaboration and synergy between population health and personal health systems.¹⁸ We discuss essential CPS for older adults, emerging delivery models that encompass health care and community settings to boost uptake, and public health priorities in a changing US health system.

DEFINING ESSENTIAL CLINICAL PREVENTIVE SERVICES

Essential CPS for older adults include immunizations, disease screening, and behavioral counseling interventions. Since 1984, the US Preventive Services Task Force (USPSTF) has provided evidence-based reviews of CPS, grading them on the basis of individual (not combined) effectiveness. Category A or B recommendations are supported by available evidence; category C services are not recommended for general use, though these services might have benefit for specific patients; category D services are assessed as having no benefit or harms that outweigh benefits; services with a grade of I are deemed to have insufficient evidence for assessment.^19,20 For older adults, recommended CPS include a broad range of chronic disease screenings and behavioral interventions (Table 1).²¹ USPSTF defers to the Advisory Committee on Immunization Practices for evidence-based recommendations for immunization recommendations (Table 2).²² Seeking to address financial barriers to the uptake of CPS,^23,24 the Patient Protection and Affordable Care Act (ACA; PL 111–148; PL 111–152) expands insurance coverage and provides that services graded A or B and Advisory Committee on Immunization Practices–endorsed vaccinations will be covered at no cost-sharing in Medicare (beginning in 2011) and under nongrandfathered private health insurance plans operating in the exchanges (beginning in 2014). States are encouraged to adopt the same rules for Medicaid programs, which offer assistance to low-income seniors (the population dually eligible for both Medicare and Medicaid). In 2014, Medicaid will expand to cover all adults at or below 133% of the federal poverty level²⁵ (currently $10 890 for an individual and $22 350 for an adult and 3 dependent children).

TABLE 1—

US Preventive Services Task Force–Recommended Clinical Preventive Services in Adults Aged 50 Years and Older

Clinical Preventive Service	Group and Frequency	Age Considerations
Abdominal aortic aneurysm screening	Once, in smokers	At 65 y
Alcohol misuse screening and counseling	All	≥ 50 y
Aspirin to prevent cardiovascular disease	When benefit outweighs harm	45–79 y in men, 55–79 y in women
Blood pressure screening	All	≥ 18 y
Breast cancer screening	Women	≥ 40 y
Cervical cancer screening	Sexually active women with intact cervix	All sexually active women
Cholesterol	Adults	≥ 35 y in men, ≥ 45 y in women
Colorectal cancer screening	Frequency varies depending on method	50–75 y
Depression screening	When staff-assisted depression care and support is in place	All adults
Diabetes screening	For adults with sustained blood pressure > 135/80 mm Hg	All adults
Healthy diet counseling	Adults with hyperlipidemia, other cardiovascular risk factors, or diet-related chronic diseases	All adults
HIV screening	Adults at increased risk for HIV	All adults
Obesity screening and counseling	All	All adults
Osteoporosis screening	Women	≥ 65 y (≥ 60 y if at risk for osteoporotic fracture)
STI counseling	Sexually active adults at increased risk of STIs	All sexually active adults
Syphilis screening	At-risk adults	At-risk adults
Tobacco use screening and counseling	All	All adults

Note. STI = sexually transmitted infection.

Source. Adapted from US Preventive Services Task Force A and B recommendations.²¹

TABLE 2—

Advisory Committee on Immunization Practices–Recommended Immunizations for Adults Aged 50 Years and Older

Vaccination	Frequency	Age Considerations
Influenza	Annual	All adults
Pneumococcal	Once (or twice if adult has risk factors)	65 y (50 y if the adult has risk factors)
Tetanus–diphtheria booster	Once every 10 y	All adults
Varicella	2 doses as an adult	All adults
Zoster	1 dose	60 y if risk factors present
Measles, mumps, rubella	1 dose if risk factors present	50 y if risk factors present
Hepatitis A	2 doses if risk factors present	All adults with risk factors
Hepatitis B	3 doses if risk factors present	All adults with risk factors
Meningococcal	≥ 1 doses if risk factors present	All adults with risk factors

Source. Centers for Disease Control and Prevention.²²

OVERCOMING PREVENTION IMPEDIMENTS FOR OLDER ADULTS

Systemic barriers to preventive health care for adults include lack of insurance, rising out-of-pocket costs, the inability to find a provider, and the lack of coordination across providers and settings.^7,26 For adults with chronic illness, these difficulties are particularly concerning because they often have multiple conditions requiring lifelong management. Sociocultural factors—educational attainment and health literacy, language spoken, perceived health status and health-seeking behaviors, and trust in personal providers—may further limit uptake of preventive services.^27,28 Certain limitations specific to office-based clinical care further curtail effective CPS delivery.

There have been ongoing efforts to introduce system enhancements that dependably prompt patients and providers to adhere to preventive service recommendations. As early as 1994, the US Public Health Services’ Office of Disease Prevention and Health Promotion launched the Put Prevention Into Practice initiative to make practice guidelines and tools available to facilitate delivery of CPS.²⁹ The program has grown in sophistication and become more grounded in organizational theory, and has now been evaluated over 8 years at the University of Texas.³⁰ The Study to Enhance Prevention by Understanding Practice is another systems-level approach, specifically designed so that such systems can be tailored to the needs of individual practices,³¹ and has posted promising results at 1-year follow-up.³²

Practice enhancements can be effectively augmented by broader adoption of electronic health records (EHRs). The use of EHR software has been shown to improve physician efficiency in ordering routine screenings, keeping track of vaccinations, and maintaining patient health through testing and monitoring of chronic conditions, such as diabetes.^33,34 Multiple local, regional, state, and national initiatives promote provider implementation of clinical information systems, including decision-support tools and EHRs. Spurred by the Health Information Technology for Economic and Clinical Health Act (PL 111-5), the federal government is making an unprecedented investment in health information technology. Health Information Technology for Economic and Clinical Health Act programs work together to offer assistance and technical support to providers, to enable coordination and alignment within and among states, to establish connectivity to the public health community in case of emergencies, and to ensure the health care workforce is properly trained and equipped to be meaningful users of EHRs. Still, expanding the penetration of these systems will be slow—particularly for small- and medium-size medical practices. Early evidence suggests many barriers, including the high initial cost of investment and the technical difficulties of adapting software for individual practices. Changing long-standing organizational behaviors in outpatient settings is difficult, and significant time is needed to successfully switch from paper-based systems.³⁵

Despite the promise of greater efficiency through high-performing office systems, time constraints are still likely to limit the ability of physicians to comply with all preventive services recommendations. An analysis undertaken in 2003 concluded that to fully satisfy USPSTF recommendations, 7.4 hours per working day would be needed for the provision of preventive services.³⁶ A recent study indicated that, even among adults who have the greatest access to physician services—persons aged 65 years and older with Medicare who have a regular physician, have had a routine check-up in the preceding 2 years, and have not experienced cost as a barrier to care—fewer than 45% of men and 40% of women are up to date with recommended vaccinations and screenings.³⁷

Furthermore, broad trends, including an aging population with multiple chronic diseases, increased medical coverage through the Affordable Care Act, and a shortage of primary care physicians, suggest that the challenge for clinicians committed to delivering preventive services is likely to increase. Medical systems face an additional structural impediment in that they are exclusively in contact with persons having health complaints—that is, patients—although many CPS are targeted at adults who may have no current need for medical care. These interventions include influenza and pneumococcal vaccinations; screenings for colorectal, breast, and cervical cancers; and ongoing checks for high blood pressure and high cholesterol. This list of core preventive services is recommended based solely on age and gender rather than on the presence of specific health conditions.

Currently, CPS are typically provided by physicians working in an outpatient setting—although, increasingly, these services are successfully complemented with community-based delivery.³⁸ Office-based care is insufficient to ensure optimal disease prevention and illness management.³⁹ The majority of disease management occurs outside the health system, at home, by patients themselves, who may manage their disease inadequately.

Collaborative models of care have expanded services beyond physicians’ offices to community-spanning resources providing longer-term interventions and support, meeting adults where they work, live, play, learn, and worship.^40–43 An important objective of the various innovative models is to reinforce the centrality of the medical home, rather than to supplant, compete with, or bypass it. During the past 10 years, several delivery models built on the groundbreaking work of Wagner and others^44,45 have sought to enhance links between community programs and older patients’ primary care practitioners. The Johns Hopkins Family Heart Study, for example, is thoroughly coordinated with primary care providers, and its approach has demonstrated significant improvements in cardiovascular outcome measures for African American adults at high risk.⁴⁶ Another exemplary model, “Health Navigators,” coordinates services and referrals for uninsured patients, integrating a complex set of safety net providers and public health insurance programs for vulnerable populations.⁴⁷

A particularly promising strategy, developed by the nonprofit organization Sickness Prevention Achieved through Regional Collaboration (SPARC), seeks to establish local structures of accountability for the communitywide delivery of multiple CPS.⁴⁸ Recognizing that no local-level organization typically has the authority for ensuring populationwide delivery of preventive services,⁴⁹ SPARC envisions a collaboration of local prevention providers and stakeholders, brought together by a “neutral convener” such as a local health department or area agency on aging. These collaborations plan and deploy CPS at access points across communities, working collaboratively with medical practices. With an emphasis on local systems and on CPS delivery, the SPARC model makes an impact at both the individual and population levels. It sits astride a crucial “gray zone” between public health and medical care, identified as a transitional level in the health impact pyramid.⁵⁰

PUBLIC HEALTH INTERVENTIONS

The Guide to Community Preventive Services, launched by the Centers for Disease Control and Prevention (CDC) in 1996, provides important direction and reference materials for evidence-based community interventions, complementing the recommendations of the USPSTF and its Guide to Clinical Preventive Services and extending Put Prevention Into Practice.⁵¹ The guide highlights population interventions that have been rigorously reviewed by an independent task force of experts, and it focuses on risky behaviors (smoking, physical inactivity, and others), health conditions (diabetes, cancer, motor vehicle injuries, and others), and broad social and environmental determinants of health.⁵² More recently, in 2010, the US Department of Health and Human Services issued a groundbreaking strategic framework to achieve optimum health and quality of life for individuals with multiple chronic conditions (MCC).⁵³ The prevalence of MCC increases with age, and the unique needs of older adults are reflected in the framework’s 4 interdependent aims: (1) strengthening health care and public health systems, (2) maximizing older individuals’ ability to use proven self-care management and other services, (3) equipping care providers with better tools to support and manage older patients with MCC, and (4) closing research gaps about interventions and systems to benefit individuals with MCC.

Research and practice show that community-based interventions can be implemented as stand-alone projects or as part of an integrated model, pioneered by SPARC and others. These tactics link the provision of (or access to) CPS with nontraditional community settings, such as hair salons, senior centers, public housing, houses of worship, and others. Community-based interventions offer many advantages: greater convenience for the public, but also access to populations that may differ from groups in contact with physician offices or pharmacies. One program of this kind is Vote & Vax, which encourages immunizers to set up influenza vaccination clinics for both voters and nonvoters at polling places on Election Day. There are 186 000 polling sites in the United States, and more than 70% of voters are aged 50 years and older; in presidential election years, more than 120 million Americans go to the polls.⁵⁴ In 2008, Vote & Vax delivered more than 21 000 flu shots on a single day—and found that approximately half those immunized were not regular flu shot recipients. Among African American and Hispanic recipients, 60.2% and 64.8%, respectively, were not regular recipients of flu shots.⁵⁵

The YMCA-delivered diabetes prevention program (DPP) lifestyle intervention has similarly been proven effective, decreasing body weight and cholesterol levels⁵⁶ and reducing risk for cardiovascular disease and diabetes among at-risk adults.⁵⁷ The DPP and other large randomized trials have demonstrated that a lifestyle intervention focused on structured diet and physical activity can reduce progression to diabetes. But the DPP protocol involved intensive, one-on-one patient coaching and support, and cost about $1500 per person. By contrast, the community-based group intervention can be delivered for approximately $250 per person. The intervention in the community-based program emphasizes improving dietary choices, increasing physical activity, bolstering coping skills, and providing group support to help participants lose 5% to 7% of their body weight and get at least 150 minutes per week of moderate physical activity. These measures can reduce the risk of developing type 2 diabetes by 58% in people at high risk for diabetes.

Limited insurance coverage and reimbursement for community-based services has limited their uptake. CDC is partnering with YMCA-USA and UnitedHealthcare to diffuse the group DPP protocol. CDC is funding the DPP protocol at 10 YMCAs nationwide and UnitedHealthcare is covering YMCA-provided services at no charge to plan participants in employer-provided health insurance plans in 7 cities, the first time a private health plan has paid for evidence-based, community-delivered diabetes prevention and control programs. Recognizing the effectiveness of community-based interventions, Congress included the national DPP program in ACA (§ 399V-3). Subtitle III of the law—Creating Healthier Communities—provides for additional community-based interventions, including Community Transformation Grants (§ 4201) targeted to preventing chronic illness and the Healthy Aging, Living Well program (§ 4202) focused on improving the health of adults aged 55 to 64 years through community prevention programming.

Providing multiple recommended preventive services at one time can also increase the efficiency of interventions. Combining access to multiple services provides a mechanism to increase the delivery of the “less delivered” service by coupling it with access to a more frequently provided service. For example, facilitating access to mammography appointments at flu shot clinics was found to have doubled the 6-month mammography rate at clinics where these services are both available.⁵⁸ Public health efforts that offer influenza vaccination as well as colorectal cancer screening have also been tested, with promising results.⁵⁹ Furthermore, when several services are available, new messages can be framed that both promote disease prevention and overcome patient anxieties associated with individual services, such as cancer screenings. New messaging can also help local residents more readily accept community access as a valuable and routine extension of the preventive care that is delivered in the medical home. Despite persuasive evidence for the effectiveness of grouped interventions, however, the Community Guide to Preventive Services has not yet evaluated models of delivery that provide multiple interventions.

Research clearly supports the clinical and economic benefits of comprehensive, multidisciplinary, individualized prevention services, particularly those targeting medically complex adults.⁴³ Community health teams, authorized as a Medicare pilot program under ACA (§ 3502), work with primary care practices, adults, and their families to expand key functions and processes of the medical home outside the clinical setting. Community health teams include care coordinators, nutritionists, behavioral and mental health specialists, nurses and nurse practitioners, and social, public health, and community health workers. Teams coordinate their work with primary care practices to integrate clinical and community preventive and health promotion services, providing care coordination, links to community-based prevention services (such as weight loss and smoking cessation), health coaching, and supports that foster adherence to appropriate medication regimens. These trained resources already exist in many communities, working for home health agencies, hospitals, health plans, and community-based health organizations.

ACA authorizes pilots of other team-based approaches to improving care for adults, including accountable care organizations in Medicare and Medicaid. Accountable care organizations can comprise community health teams (or their equivalent), physicians, hospitals, and other providers. Patient-centered medical home demonstrations in Medicaid specifically target adults with chronic conditions and the community-based collaborative care network program authorizes funding for provider consortiums to coordinate and integrate health care services for low-income uninsured and underinsured populations.

PRIORITIES FOR PUBLIC HEALTH ACTION

As the delivery of CPS extends from the clinic to the community, it will be important to measure changes resulting from the deployment of new delivery models. It is unlikely that current forms of public health surveillance (e.g., the Behavioral Risk Factor Surveillance System and disease surveillance and reporting systems) will be able to fulfill this role at the local level. Health information technology—including EHRs and health information exchanges—along with Medicare and Medicaid databases already in use, offers new possibilities to assess program outcomes at the community level. Early work of this kind has already been undertaken, with Medicare data used to document the effects of the SPARC model on population-wide expansion of pneumococcal vaccine delivery at the subcounty level.⁶⁰ CDC’s Offices of Public Health Surveillance and Public Health Informatics, in collaboration with state and local agencies and the Department of Health and Human Services Office of the National Coordinator for Health Information Technology, are at the forefront of innovating public health data and information systems to drive improvements in individual care and population health.

Another promising tool for assessing program effectiveness is the measure of adults being up to date with recommended core CPS.^61–63 This metric has recently been incorporated as a target by Healthy People 2020.⁶⁴ It is similar to the pediatric measure that assesses whether children have received all age-appropriate vaccinations. The use of an adult all-or-none measure can raise the bar on performance,⁶⁵ because a person is “up to date” only if all recommended services are delivered. The measure is fully scalable and can be employed to assess the provision of services at the practice level, the health plan, the community, the state, and the nation. These and other innovative evaluative tools are vital to assessing the value of health spending, the quality of care delivered, and the outcomes realized for individual patients and populations.

Historically, medicine and public health in the United States have largely operated in separate, though sometimes intersecting, spheres. Addressing the United States' health challenges of the 21st century—a rapidly aging population, increasing rates of chronic illness, fragmented care delivery—requires a reconceptualization of its traditionally disconnected health care and public health systems and demands deliberate actions to integrate them. Physicians will need to practice with the larger community context in mind, treating patients within their social, economic, and cultural environment. They will need to forge bonds with public health agencies, community-based organizations, businesses, and other institutions.⁶⁶ For its part, public health must coordinate its work with others, based on community-wide consensus of priority needs.⁶⁷ Priorities for public health–health system action should address the most pressing community health concerns, guided by data on disease burden, preventable morbidity and mortality, and evidence-based interventions.