Improving Hispanic Elders' Health:
Community Partnerships for Evidence-Based Solutions
Project Overview

• Purpose
• Prevalence of Health Disparities
• Growth and Diversity of the Elderly Hispanic Population
• The Need for Partnerships
• Data and Evidence-Based Resources for Addressing
  Disparities and Improving Services
• The Workshop
• The Learning Network
• Composition of the Eight Selected Community Teams
• APPENDIX A. Contact Information for Community Team Leads/Coordinators
• APPENDIX B. AHRQ Analyses of CMS Administrative Data Examining Disparities Among Hispanic and non-Hispanic White Medicare Beneficiaries at the Metropolitan Statistical Area (MSA) Level

Download PDF version of Project Overview, Press Release (6/13/07), Press Release (8/23/07)

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Purpose

Persistent and growing health disparities indicate that many elderly Hispanics are not receiving the level and type of health care and related social services they need to live healthy, productive lives. To address this problem, five federal agencies have collaborated to assist local communities in developing coordinated strategies for improving the health and wellbeing of elderly Hispanics. The purpose of this pilot project has been to bring together teams of local leaders from communities with large numbers of Hispanic elders to review the latest research findings and examples of promising practices, and to provide assistance as the communities use this information to create and implement their own local plans for addressing one or more health disparities. The project has emphasized the importance of working across organizational boundaries to link aging services providers, medical care providers, Hispanic community organizations, and public agencies to promote the use of the new Medicare benefits, low-cost evidence-based prevention programs, and other initiatives that can reduce health disparities among Hispanic elders.

Phase I of the project featured an in-person workshop for eight teams from major metropolitan areas selected on a competitive basis. The metropolitan areas selected to take part in the pilot project include Chicago, IL, Houston, TX; Los Angeles, CA, Lower Rio Grande Valley/McAllen, TX; Miami, FL; New York, NY; San Antonio, TX; and San Diego, CA. Each team consists of approximately six people representing local Hispanic community organizations, aging services providers, health care providers, local public health agencies, and the Area Agency on Aging.

Phase II of the project has involved the facilitation of sharing of ideas and information across these eight teams through a national "learning network" for approximately one year. Within the first few months of their participation in the network, each local team was asked to articulate its plan for addressing one or more health disparities in their community. No grants have been made through this project, but technical assistance has been available to teams, as well as travel support for team members who otherwise would not be able to participate in the Phase I workshop. The following project overview provides more detail about the problem of health disparities among Hispanic elders, the need for more collaboration across agencies, and the eight community teams selected.

The initiative has been organized by the Administration on Aging (AoA), the Agency for Healthcare Research and Quality (AHRQ), the Centers for Disease Control and Prevention (CDC), the Centers for Medicare and Medicaid Services (CMS), and the Health Resources and Services Administration (HRSA), all part of the United States Department of Health and Human Services (DHHS).

Prevalence of Health Disparities

According to the National Healthcare Disparities Report (NHDR)¹, an annual report to the Congress prepared by AHRQ, significant health disparities exist for Hispanic elders compared to the majority, non-Hispanic white, elderly population, ranging from poorer access to health care to poorer diabetes control. The measures listed below highlight prominent disparities experienced by Hispanic elders.

1. Less likely to achieve diabetes control (e.g., more likely to be hospitalized for diabetes).
2. Less likely to receive vaccinations for pneumonia or influenza.
3. Less likely to receive recommended hospital care for pneumonia.
4. Less likely to receive cancer screening services (e.g., mammography, colorectal cancer screening).
5. Less likely to have an ongoing source of care.
6. More likely to fall multiple times in one year.²
7. Less likely to receive counseling to increase physical activity, if overweight.

Elderly Hispanics face many obstacles to health care, including language and cultural barriers, that if not addressed will continue to exacerbate the growing health disparities among this population. These disparities, according to the data, continue to grow, and for some measures, are worse than for any other minority group.

Text version of Percent of pneumococcal vaccination of high-risk adults, 2004 (NHIS) chart

Text version of Admissions for uncontrolled diabetes without complications, per 100,000, 2004 (HCUP) chart

Growth and Diversity of the Elderly Hispanic Population ³

Hispanics comprise the most populous minority group in the United States and, while the number of older Hispanics is currently small, the population is growing rapidly. According to the 2005 U.S. census, Hispanics are the largest ethnic or race minority at 42.7 million (14 percent of the population), yet the population is generally quite young (median age is 27.2) and accounts for less than 2 million (about 6 percent) of all persons aged 65 and over. By 2050, however, Hispanics will be the fastest growing population in the 65 and over age cohort, reaching 15 million, and will likely double that figure for those age 50 and over.⁴

The U.S. Hispanic community is also quite diverse, representing numerous countries of origin. Nationwide, about 66.9 percent of Hispanics are of Mexican descent, 14.3 percent are from Central and South American nations, 8.6 percent are Puerto Rican, 3.7 percent are Cuban, and 6.5 percent are from other Hispanic nations.⁵ At the local level this distribution can vary significantly. Cubans, for example, are the largest subgroup in the south Florida area, while Puerto Ricans and other Caribbean Islanders are prominent in the greater New York City area.

The urban areas with the largest numbers of elderly Hispanics are greater Los Angeles, greater New York City, and greater Miami, according to the 2000 U.S. census. Several other metropolitan areas with major concentrations include the areas in and around Chicago, San Diego, and Texas cities of San Antonio, El Paso, Houston, as well as the lower Rio Grande River valley (McAllen, Edinburg and Mission, Texas).

The Need for Partnerships

The initiative seeks to foster partnerships at multiple levels in order to overcome barriers that impede wider use of appropriate services by elderly Hispanics, especially those with chronic health conditions and fewer resources. These partnerships will build upon the existing levels of support within the Hispanic community. Hispanic elders are typically surrounded by family, friends, and neighbors who care deeply for them and represent the front line of care givers and advocates. In addition, Hispanic community organizations of varying sizes and strengths form the next layer of support and help link Hispanic individuals and families to broader civic, economic, and social structures, including city, county, state, and federal governments.

Hispanic elders often look to the leaders and staff of these community groups for direct services and referrals to social and health services. For example, CMS has found Hispanic community organizations to be effective in helping to inform Hispanic Medicare beneficiaries about the Part D drug benefit. Similarly, this new initiative will seek to involve such organizations in partnership with other medical care and social services agencies to overcome social, educational, and language barriers and help optimize service delivery for Hispanic elders.

Historically, there have been a number of legal, financial, and organizational "silos" or barriers that have separated clinical services providers, public health agencies, and aging services organizations.⁶ While great efforts are being made to bridge these divides, the sponsoring agencies realize that this can be difficult and therefore want to assure that representatives from all three are part of the local teams that will participate in this initiative.

Culturally and linguistically appropriate services for elderly Hispanics are not always available across the country. Hispanic community organizations may provide medical care, counseling, nutrition programs, exercise classes or other programs, but very few have sufficient resources or expertise to meet the needs of the growing elderly population, especially those who are frail. Health and social services organizations that have traditionally served English-speaking populations may not employ bilingual staff or translators in sufficient supply.

To overcome these obstacles this initiative is designed to initiate partnerships and/or foster existing partnerships and connections among the various organizations that in some way are already serving elderly Hispanics or otherwise seek to serve them more effectively. At the national level, the five DHHS agencies have asked national Hispanic organizations for assistance in planning the initiative, including the National Hispanic Council on Aging, the National Hispanic Medical Association, and the National Alliance for Hispanic Health. Stakeholders from select communities will be invited to form local teams consisting of leaders from the aging services, public health, and medical care sectors and to involve researchers in order to help promote use of existing evidence, available data, and sound evaluation methods. Participating teams will be asked to share their experiences with each other and-in the long run-their lessons will be shared with stakeholders in other communities across the country.

Data and Evidence-Based Resources for Addressing Disparities and Improving Services

The project seeks to help local decisionmakers find and use the latest research-based information and methods in developing their strategies for addressing health disparities. Together, the five participating federal agencies have a wealth of data resources, reports, planning methods, guidelines, on-going projects, and expertise that can be tapped to assist participating teams. Examples of the kinds of resources that may be used include:

• AHRQ's 2006 National Healthcare Disparities Report, National Healthcare Quality Report, and materials related to cultural competency and health literacy;
• Lessons from AoA's Evidence-Based Disease Prevention Grants Program and the Center for Healthy Aging resources created to serve and support those program grantees;
• CDC's Behavioral Risk Factor Surveillance System (BRFSS) and Racial and Ethnic Approaches to Community Health across the U.S. program (REACH US);
• AoA, CMS, and HRSA's partnership to educate Spanish-speaking Medicare beneficiaries and their caregivers about Medicare's benefits and prevention services, including a newly released "Bienvenido a Medicare Telenovela" ("Welcome to Medicare") DVD;
• Stanford University's Chronic Disease Self-Management Program, including materials that have been used by Hispanic elderly in community settings such as senior centers, churches, libraries, and hospitals to address chronic health conditions.
• The Expanded Chronic Care Model (Barr, Robinson, Marin-Link, Underhill, Dotts, Ravensdale, & Salivaras, 2003), based on the Chronic Care Model developed by Ed Wagner, MD, MPH; and
• Prevention tools and resources for community and clinical programs from CDC and AHRQ.

The Workshop

The kickoff event for the initiative was a national workshop October 23-25, 2007, in Houston , TX . The purpose of this workshop was to bring together members of the eight community teams (Chicago, Houston, Los Angeles, Lower Rio Grande Valley/McAllen, Miami, New York, San Antonio, and San Diego), Federal Agency staff, researchers, and other experts involved with the HHS Hispanic Elders Project to support the development of local plans for reducing health disparities and improving the delivery of health care and related social services for Hispanic elders. It was a valuable opportunity for team members to work together, share ideas with their peers from other cities, identify their technical assistance needs, and help initiate a year-long learning network focused on shaping evidence-based solutions. Participants discussed the following at the workshop:

1. What health disparities exist between Hispanic elders and other populations? What factors contribute to these differences?
2. How can service providers assure that their services are culturally and linguistically appropriate for Hispanic elders?
3. To what extent are Hispanic Medicare beneficiaries obtaining the services they need under the Medicare program? What preventive services are now covered and how are they being promoted?
4. What kinds of evidence-based programs may be useful to consider, especially regarding healthy living, diabetes control, and chronic disease self-management?
5. What kinds of data, information, and organizational models can the community take advantage of when planning and implementing their interventions?
6. What approaches are the community teams currently considering and what are their perceived technical assistance needs?

The Learning Network

Following the workshop, the national learning network was formed. The learning network has served as a mechanism for local team members to stay in contact with each other as well as with peers and stakeholders from other teams and cities across the county, as well as with leading researchers and experts familiar with evidence-based disability and disease prevention programs. Members have been connected through an e-mail listserve, and periodic phone- and web-based conferences. A limited amount of technical assistance has also been available for teams as they complete and begin to implement their intervention plans. Such a learning network can be a powerful mechanism for discerning the relevance of the latest evidence, capturing tacit knowledge of colleagues, generating new ideas, and forming problem-solving partnerships.

The learning network members have shared their experiences with other network members, including lessons learned and innovative ideas, as well as their progress toward developing and implementing their projects, achieving their goals, and translating the research into action.

Composition of the Eight Selected Community Teams

To participate in the workshop, local community and agency leaders had to form a team or delegation of approximately six individuals representing critical stakeholder organizations and submit an application to participate in the project. These individuals were to be experienced in their field, understand the needs of local consumers, and hold significant responsibilities within their organizations (e.g., executive directors, senior managers, clinicians, board members). The following types of organizations were represented within the team:

• Area Agency on Aging,
• Hispanic community organization,
• Local public health agency,
• Aging services provider organization,
• Medical care provider organization (e.g., community health center, federally qualified health center, hospital, private medical group), or health plan, preferably registered as a Medicare provider; and
• Health services research organization (e.g., university, consulting group).

While any of the partner organizations could take the lead in organizing a delegation, the local Area Agency on Aging (AAA) submitted the application on behalf of the team. For the purpose of this initiative, the boundaries for these target communities correspond to the boundaries of the planning and service area of the AAA serving the major city in each of those areas. Area Agencies on Aging are the federally designated entities responsible for area-wide planning and coordination on matters that affect the elderly population.

Each team designated a Team Coordinator who serves as the point person for communications between the local project team and the sponsoring federal agencies. The eight community teams and corresponding AAAs are listed below; see Appendix A for each team's contact information.

Table 1. Eight community teams and Associated Area Agencies on Aging

This overview and other related information will be available at www.academyhealth.org/ahrq/elders. If you have questions, please contact Jennifer Tsai, Associate, at Jennifer.Tsai@academyhealth.org or call 202.292.6700 ext. 720.

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1. National Healthcare Disparities Report, 2005. Agency for Healthcare Research and Quality, Rockville, MD. http://www.ahrq.gov/qual/nhdr05/nhdr05.htm

2. This measure of falls in not from the NHDR, but from an analysis of the 2003 California Health Interview Survey, presented by Steven P. Wallace presented at a meeting titled, "Improving the Health and Wellbeing of Hispanic Elders," conducted by AcademyHealth on December 14, 2006 in Washington, DC.

3. "Nation's Population One-Third Minority" released on May 10, 2006. census.gov/Press-Release/www/releases/archives/population/006808.html Accessed March 17, 2007.

4. Older Americans Update 2006: Key Indicators of Well-Being. Federal Interagency Forum on Aging-Related Statistics (Forum); Accessed March 17, 2007.

5. U.S. Census Bureau, Annual Demographic Supplement to the March 2002 Current Population Survey.

6. 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. A Report to the Centers for Disease Control and Prevention & Administration on Aging, United States Department of Health and Human Services, January 2003. The report is available at:  http://www.chronicdisease.org/files/public/aging_states_project.pdf

7. AcademyHealth is providing substantive and logistical support for this project under the AHRQ Knowledge Transfer and Applications Support Contract # 290-04-0001.

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