Social Determinants of Health and Older Adults

Terry, a program manager at a local Area Agency on Aging (AAA) in a midsize rural town, is looking for ways to reduce food insecurity and promote healthy eating among older adults in the community. 

• Terry browses Healthy People 2030 objectives and finds Leading Health Indicator (LHI) NWS-01: Reduce household food insecurity and hunger. He reviews disparities data for this objective and sees that households in non-metropolitan areas have a higher rate of household food insecurity than those in metropolitan areas, and that unmarried people (who are more likely to live on their own) are particularly at risk of food insecurity. Terry knows from population surveys that many older adults in his community live alone.
• He looks up Healthy People evidence-based resources (EBRs) related to this LHI and sees the Community Preventive Services Task Force (CPSTF) recommendation about home-delivered and congregate meal services for older adults. He plans to draft a proposal about starting a congregate meal program in his area and involving community partners, like the local senior center. In his proposal, Terry includes the data he found to support his argument that the community needs a congregate meal program.
• To inform his proposal, Terry searches the Healthy People 2030 website for nutrition guidance and finds the Dietary Guidelines for Americans in the list of Healthy People EBRs. On dietaryguidelines.gov, he finds a slide deck with information to help health professionals support healthy eating for older adults. He includes it in his proposal as background information.
• Based on his proposal, Terry is given approval to start a workgroup to draft an implementation plan for a congregate meal program. A survey with older adults in the community shows that people are interested in congregate meal services but worry they’ll feel stigmatized if they go to the senior center or another community site for free food.
• To address this feedback, the workgroup partners with local restaurants to send meal coupons to people age 65 years and older. That way, people can get food from their favorite restaurants or eat out with friends instead of having to go to a congregate meal site.

Simone manages a residential care facility for older adults. She notices that certain residents don’t get visitors, and some rarely spend time with other residents. While staff members are doing their best to meet residents’ needs, their busy schedules often don’t allow time to interact with the residents socially. Simone knows that this social isolation is negatively affecting residents’ health.

• Simone searches the Healthy People 2030 website and finds objective HC/HIT‑04: Increase the proportion of adults who talk to friends or family members about their health, which captures whether people feel they have a social support system. She notices that the percentage of adults age 65 years and older with social support has dropped significantly in recent years.
• She also sees that the objective status is getting worse. And when she browses the Social and Community Context webpage, she notices objective AH-03: Increase the proportion of adolescents who have an adult they can talk to about serious problems. This sparks an idea.
• Simone reaches out to her local school district and proposes an intergenerational program. School administrators agree to a pilot program: Once a week, high school students volunteer to visit the residential facility to play board games, do crafts, and talk with residents.
• The program turns out to be a success. Residents report that they look forward to spending time with the students and that the activities keep them mentally engaged. Students report positive experiences from being able to talk about their lives with a caring adult outside of their immediate family or school.

Jenna works as a patient care coordinator at a large geriatric practice. She notices that many older patients call with questions about their health records, like what medicine their doctor prescribed last year or where to find test results. When she points them to their EHR, they say they don’t know how to access that information.

• Jenna searches “health records” on the Healthy People 2030 website and finds this evidence-based resource: The Guide to Getting and Using Your Health Records.
• Using the information in the guide, she puts together a short handout for patients that explains how to access their EHR. She gives the handout to administrative staff and asks them to include it in visit summaries.
• After a few weeks, Jenna checks in with staff to see how patients respond to the new EHR handout. They report that while patients seem interested, many still don’t know how to apply the information.
• Jenna explores the Health Communication topic webpage for strategies to increase patient understanding. She sees Healthy People objective HC/HIT-01: Increase the proportion of adults whose health care provider checked their understanding and starts thinking about ideas for how providers and staff can better support patients in understanding EHR information.
• While exploring the health.gov website, Jenna discovers the ODPHP Director’s blog post on enhancing organizational health literacy. Through the blog post, Jenna finds CDC’s health literacy hub and a toolkit for communicating effectively with older adults. She uses the toolkit to draft a memo with actionable tips to help doctors, nurses, and administrative staff talk with patients about the practice’s EHR system. Staff start setting aside a few minutes with each patient to go over the handout and make sure they understand the information.
• To evaluate this strategy’s success, the care coordinator team monitors how often patients age 65 years and older access their EHRs. After 6 months, the team finds that EHR use among this group has gone up 25 percent.

Alberto is the co-director of a rural public health department. In a district-wide meeting of health organizations, the director of the nearest hospital reports that many older adults come to the emergency department with problems due to untreated illnesses, like pneumonia caused by untreated respiratory viruses.

• Alberto starts exploring the Healthy People 2030 website and finds objective OA-06: Reduce the rate of hospital admissions for pneumonia among older adults. The objective summary notes that flu and pneumococcal vaccines can help reduce hospitalizations for pneumonia.
• On MyHealthfinder, Alberto finds more information about recommended vaccines to protect older adults’ health. He decides to survey older adults in the community to get insights into the barriers they face in getting recommended preventive care like vaccines. To get started, Alberto pulls questions from the National Institutes of Health’s All of Us Research Program health care access and utilization survey.
• The survey shows that many older adults have a hard time getting preventive care — or care for acute illnesses — because the nearest health clinic is at least a 30-minute drive and many older adults in the area don’t have reliable transportation. 
• On the Rural Health Information Hub, Alberto finds a Rural Transportation Toolkit. He downloads it to get ideas about how to help people in the community get to health appointments. Soon, Alberto and his team partner with the county’s transportation department to set up a shuttle service that residents can use to get to and from medical appointments.
• He also uses CDC’s guidance on planning vaccination clinics to set up a monthly clinic at the local school where residents of all ages can get recommended vaccines, including flu, pneumococcal, and Tdap vaccines.

Sam is a project coordinator at a nonprofit organization focused on improving the quality of housing for people in historically underserved neighborhoods. Their organization is in the early planning stage for an initiative to help people “age in place,” which means helping them stay in their homes safely as they age.

• To get started on writing a project plan, Sam checks out the Healthy People 2030 Older Adults webpage. They know that the risk of falling is a big factor that can make homes unsuitable for older adults, so they review objective IVP-08: Reduce fall-related deaths among older adults. They note that the objective’s status is getting worse — and that fall-related deaths are especially high for people age 85 years and older.
• Sam examines data from the United States Census Bureau and finds that their region is below the national average for homes that are aging-ready. They note this data in their project plan and decide to use it to apply for funding.
• To further develop their plan, Sam reviews a U.S. Department of Housing and Urban Development (HUD) publication about aging in place. They use it to map out the topics they need to address in their plan, like home modifications, age-friendly community environments, and cost.
• As they research information about home modifications to support aging in place, Sam remembers an ODPHP blog post they read a while ago. They search their email inbox and find “Wilmington Area Rebuilding Ministry and Healthy People: Repairing Homes to Help Ensure Safety and Independence.”
• Sam reaches out to the Healthy People 2030 Champion organization featured in the blog post. They explain their organization’s planned initiative and receive lots of valuable information to include in their project plan — as well as tips on where to apply for funding.