Health Promotion Project for the Elderly

• Abstract
• Purpose of health policy or idea
• Characteristics of this policy
• Political and economic background
• Purpose and process analysis
• Expected outcome
• References

Featured in half-yearly report: Health Policy Developments 7/8

Abstract

The program is aimed at increasing the proactive involvement of independent elderly in the community and their family physicians in carrying out prevention and early detection activities, through increasing their awareness, knowledge & tools. The program was implemented in Maccabi Health Services and addressd 6 life style behaviors. Evaluation results indicate an increase in performance of preventive activities among the elderly and higher rates of counselling by physicians.

Purpose of health policy or idea

The program is aimed at increasing the proactive involvement of independent elderly living in the community and their family physicians in carrying out prevention and early detection activities, as well as increasing the elderly's personal responsibility for maintaining their health, through increasing the awareness, the knowledge and the tools available to both parties.

The program focused on six topics: innoculation for flu and pnemonia, screening tests for hearing and vision problems with treatment if necessary, nutritional evaluation and referral to treatment when necessary, instruction and counseling about physical acitvity, follow up of falls and instruction for fall prevention. 

The program was implemented in the Central District of Maccabi Health Services. It included pre-determined meetings between the family physicians and the elderly in order to monitor their health status and tailor a care plan for each. The elderly and the physicians also attended lectures (each group separately) on prevention and health promotion and received written materials. The elderly also attended physical activity groups, which were payed for by the health fund.  

Main points

Main objectives

To increase the proactive involvement of independent elderly living in the community and their family physicians in carrying out prevention and early detection activities and to enhance the personal responsibility of the elderly for maintaining their health.

Type of incentives

There were no financial incentives in this program but there were some non-financial incentives. The elderly received special care from Maccabi  health fund doctors, and the doctors were proud that they were chosen to participate in the program. The district managers saw this as proff that their district was considered a good district, suitable for pilot programs and improvements. The management of the Geriatric Division of the Ministry of Health see it as an opportunity to present their activity through support of an innovative experimental program. 

Groups affected

The elderly - Received more intensive care received on topics of prevention and health promotion, and felt that their doctors and the health fund were treating them much better than in the past, and attended free health promotion activities., Maccabi family physicians participating in the program - they received lectures about prevention and health promotion for the elderly and reported being more aware of these issues., Maccabi health fund - The health fund's presitge had risen; it expected that the prevention activities (immunizations) and early detection would cut down on service utilization (e.g. hospitalization).

Degree of Innovation	traditional		innovative
Degree of Controversy	consensual		highly controversial
Structural or Systemic Impact	marginal		fundamental
Public Visibility	very low		very high
Transferability	strongly system-dependent		system-neutral

Innovation - such a program has never been developed and implemented in Israel before. Investing resources to actively promote health among the elderly is a new concept in Israel.  However some experiments have been reported in the literature 

Controversy - the program is higly consensual and appreciated by all those involved in health promotion in Israel.

Structural impact -rather marginal since it is implemented only locally. It is based on the existing structure of providing care (the patient physician encounter).

Public visibility - the program has not yet been publicized to patients or professional forums.

Transferability - the content and process of implementation can be adopted by other systems with minor adaptations.

Political and economic background

This program is compatible with Maccabi Health Services vision statement with regard to prevention and health promotion among all its clients as well as the its wish to develop a special investment in its elderly clients.

The program is also compatible with the Ministry of Health's initiative "Health 2020", which is a national prevention and health promotion program.

Change based on an overall national health policy statement

Healthy Israel 2020 - National Health Targets

Purpose and process analysis

Current Process Stages

	Idea	Pilot	Policy Paper	Legislation	Implementation	Evaluation	Change
Implemented in this survey?

Origins of health policy idea

The program was initiated by ESHEL,  The Association for Planning and Development of Services for the Elderly in Israel, and Maccabi Health Services, the second largest health fund in Israel insuring about 24% of the population.
ESHEL is involved in identifying and developing innovative programs for the elderly, in order to enhance their well-being. ESHEL is interested in expanding health promotion for the elderly nationwide, with anyone willing to cooperate with them. The health funds are a preferred partner, because they have a shared interest in this area and because they have the infrastructure to implement health services and the target audience to address.  

ESHEL worked in cooperation with Maccabi health plan and provided significant professional input in developing the content of this program and the process of implementation. 

Maccabi's mission includes the wish to improve the quality of care for the elderly, in order to improve their quality of life and reduce future morbidity.  Prior to the development of the program, discussions were held between Maccabi and ESHEL which lasted two years, and included representatives of the Geriatric Division in the Ministry of Health, who are predominantly interested in develping prevention and health promotion services for the elderly.
These discussions examined the applicability of alternative programs as well as the most relevant prevention indicators for the elderly which the program should focus on. The discussions were based on the American and Canadian task force reports on prevention from recent years.  

Initiators of idea/main actors

• Government

• Providers

• Civil Society

Approach of idea

The approach of the idea is described as:
new:

Innovation or pilot project

Pilot project - The program was a pilot project implemented in the Central district of Maccabi Health Fund.

Stakeholder positions

ESHEL initiated the program and contributed professional input in designing the program and in financing it. They supported it as part of their mission to promote the welfare of the elderly. Their influence was strong since they contributed funds to finance the program.

MOH geriatric division - supported the program which is in line with their medical policy of enhanceing health promotion activities among the elderly. They participated in a steering committee for designing the program, and follow up on the implementation.

Maccabi Health Services supported the program believing in it's effectiveness to maintain the health of the elderly as well as contain costs, and increase member satisfaction. 

Maccabi primary care physicians -  expressed almost no opposition to this program, because during the pilot it was offered to quality physicians, who were willing to cooperate with the district management. Some physicians chose not to participate, and no pressure was applied.

Maccabi nurses - The district nurses were annoyed that they were not included in the program, despite the fact that, as they see it, they are the leaders in care of the elderly as well as in health promotion. One of the conclusions was that they need to be more involved in the future.

Actors and positions

Government
MOH geriatric division	very supportive		strongly opposed
Providers
Maccabi Health Fund headquarters	very supportive		strongly opposed
Maccbi primary care physicians	very supportive		strongly opposed
Maccabi community nurses	very supportive		strongly opposed
Civil Society
ESHEL (NGO)	very supportive		strongly opposed

Actors and influence

Government
MOH geriatric division	very strong		none
Providers
Maccabi Health Fund headquarters	very strong		none
Maccbi primary care physicians	very strong		none
Maccabi community nurses	very strong		none
Civil Society
ESHEL (NGO)	very strong		none

Positions and Influences at a glance

Adoption and implementation

The program received much support from the Geriatric Division of  the Ministry of Health. They participated in the steering committee designing the program and provided professional input. The steering committee also included members of the Clalit Health fund and Maccabi Health fund who finally implemented it.

The program can be implemented in other sites with some investment of funds. The extent of funds needed depends on the existing infrastructure (e.g. professional health promoters and a geriatric unit). One other health fund has shown some interest in the program, but to date it has not been implemented elsewhere.

Strong incentive: Free access to activities

The implementation process revealed that if the program is to be implemented on a broad scale, it should be re-designed in order to reduce operational costs. For example, one of the important incentives for the elderly was free participation in physical activity classes, that are expensive for the health plan. Once the classes were discontinued (when the pilot ended) the elderly's involvement in other activities also declined. The doctors, too, reduced their activity in the program once the pilot program ended. They reported that they needed more time in order to summon the elderly to pre-set appointments for prevention and health promotion as was allowed in the pilot program. It appears that the health fund will have to invest at least some reources in providing both physicians and the elderly with special incentives, in order to maintain the program over time.  For example, the above mentioned free physical activity groups or more time for patient visits.

 Also, in order to expand the program, there is a need for a preliminary investment of funds (though smaller than the investment in the pilot) to train and motivate physicians, and preferably also nurses. 

Monitoring and evaluation

The program was accompanied by an evaluation study, conducted by the Brookdale Institute that examined both process and outcome indicators. The study design included two control groups: elderly who were patients of the doctors participating in the program, but who were not themselves part of the program, and elderly from two other clinics in the same district.  The three groups were examined before and after the program. Data from physicians were obtained in focus group discussions and data from patients was obtained through phone interviews.  In addition data was collected from adminsitrative data sets (e.g. rates of flu shots, hospitalizations) 

The evaluation interviews with patients  indicate an increase in the rate of implementation of  health promotion and preventive activities  in the six components included in the program.

The Management of the health fund expected to see  more general outcome indices, such as a decline in the rate of hospitalizations for flu, but this could not be demonstrated because of the difficulty in isolating the effect of the program in administrative data bases.

Review mechanisms

Mid-term review or evaluation, Final evaluation (external)

Dimensions of evaluation

Process, Outcome

Results of evaluation

More tests, more supervision of patients

Process indicators of program implementation showed a considrable compliance of the elderly in the program, and moderate compliance by physicians. The findings indicate an increase in the rate of tests to identify hearing and vision deficiencies as well as in the rate of immunization for pneumonia, both in the experiment  group and in the first control group, while the second control group showed no change. There was also an increase among the elderly of the experiment group and the first control group in the rate of those reporting that the doctor asked them whether they had had tests to identify hearing and vision deficiencies and whether they had fallen recently.

The rate of elderly who reported that the doctor asked them about changes in their weight and spoke to them about the importance of maintaining physical fitness increased only in the experiment group, and remained unchanged in the two control groups.

The findings indicate that the physicians implemented what they learned in the program also on their elderly patients who were not part of the program. This is compatible with physicians' reports in the focus groups, that the program raised their awareness of the needs of the elderly. they reported paying attention to things they had previously not noticed, such as weight loss or fall hazards. However, in the focus group discussions which took place one year after the pilot, they reported that since the program was not maintained, their activity in this area declined.

Expected outcome

Shortly after the pilot program ended, the physicians report that their feeling of involvement had declined. Therefore, there is a concern that the program cannot be fully implemented in its present form. The evaluation revealed that the doctors need more time with each patient  as was provided during the pilot, if they are to provide special attention to the elderly.

Impact of this policy

Quality of Health Care Services	marginal		fundamental
Level of Equity	system less equitable		system more equitable
Cost Efficiency	very low		very high

Quality - The evaluation showed that the program has a high potential to improve the quality of care, health status, satisfaction and personal involvement of elderly living in the community.

Equity - If the program will be implemented nation wide the health of all elderly is expected to improve, in particular in disadvantaged areas where the elderly have less education and knowledge of healthy life style behaviors.

Cost efficiency - In the long term, if implemented widely the program is expected to reduce hospitalizations related to pneumonia or hip fractures that can be prevented by immunizations and fall prevention counselling.

References

Sources of Information

Bentur N, Citron D . and Chekemir S. Prevention and health promotion among the elderly in the community: an evaluation study. Myers-JDC-Brookdale research report (forthcoming, Hebrew with English abstract).

Author/s and/or contributors to this survey

Netta Bentur Myers-JDC-Brookdale Institute

Suggested citation for this online article

Netta Bentur Myers-JDC-Brookdale Institute. "Health Promotion Project for the Elderly". Health Policy Monitor, October 2006. Available at http://www.hpm.org/survey/is/a8/2