The Complexities and Connectedness of the Public Health and Aging Networks
With the United States on the brink of a longevity revolution, phrases such as "healthy aging" and "successful aging" represent the growing need for greater collaboration between the public health and aging networks. Since both public health and aging have a nationally coordinated state-based structure, it is especially relevant to look for collaboration at the state level. The field of vision rehabilitation must become part of this collaboration, but faces a challenge in this regard because public health has not been among the field's "natural" partners. This article will touch on both the problems and the opportunities presented by this challenge to the field of vision rehabilitation to interact and join forces with colleagues in public health.
According to a document produced in 2006 by the Administration on Aging of the Department of Health and Human Services, the gain in life expectancy in the United States during the 20th century poses a public health challenge to improve the quality of life for individuals who are living longer lives than ever before. The number of adults aged 65 years and older is expected to increase to over 70 million by 2030, which will place greater demands on the public health system and on medical and social services (Administration on Aging, 2006). Almost one-third of health care expenditures in the United States, or $300 billion each year, is currently spent on adults aged 65 years and older (Administration on Aging, 2006). Without greater emphasis on disease prevention, health care spending is expected to increase 25% by 2030 because of the growing number of older adults in the United States (Administration on Aging, 2006).
Two separate networks--public health and aging services--share similar goals in addressing the health needs of older Americans, but they reach the older population through different mechanisms. The Centers for Disease Control and Prevention has supported state health departments as counterparts to the aging network's state units on aging, but historically they have rarely collaborated.
The national aging network comprises the Administration on Aging, which supports a comprehensive network of state units and over 650 area agencies on aging at the local level. The area agencies exist in virtually every community in the United States. The state aging network implements health promotion and disease prevention programs and provides a range of nutrition and supportive services for older people--including congregate and home-delivered meals, transportation, counseling, adult day care, elder abuse prevention--that are designed to promote independent living in the community. Many older people experiencing vision loss participate in the services offered by the aging network.
In 2001, an Aging States Project was initiated to bring together the respective strengths of the public health and aging networks so as to better meet their shared responsibility for ensuring optimal health of older people and compiling information on health-related needs, activities, and partnerships serving older adults in the two systems. The project is a cooperative effort of the Association of State and Territorial Chronic Disease Program Directors and the National State Units on Aging, supported by the Centers for Disease Control and the Administration on Aging (<http://aoa.gov/prof/agingnet/healthyaging/
Although the project helped identify opportunities for collaboration between public health and aging, vision was not specifically mentioned. In an assessment conducted among state aging units and health departments, with responses analyzed separately, chronic disease, specifically cardiovascular disease, was identified as the greatest health concern, with prescription drug access and coverage a close second, followed by issues of mental and behavioral health. Most state units on aging were involved in promoting prescription drug access, but only 15% of state health departments have programs in that area. The two groups identified different barriers: The aging units focused on the individual, addressing issues such as inadequate transportation or concerns about quality of life; while the health departments identified barriers to providing programs and services, such as the lack of an organized approach to providing access to health care and fragmented services. Although state units on aging use funds provided by Title III-D of the Older Americans Act to carry out health promotion and disease prevention efforts, such as screenings and physical fitness and exercise programs, 50% of state health departments were unfamiliar with Title III-D.
The state units on aging and the state health departments both reported a need for best practices in health promotion and disease prevention among older people. Areas of risk reduction and behavior change were identified. Physical activity and nutrition were most frequently mentioned, followed by chronic disease control. The Aging States Project highlighted areas of mutual interest and potential collaboration of its participants. For example, the expertise of health departments in prevention and the strength of state aging units in community outreach might be brought together, and their differing perspectives and resources blended, to address a number of the needs arising from the fast-paced growth of the older population.
Although most aging units and health departments now collaborate to some extent by working together on committees and program activities, the lack of a designated lead unit or person for the older population remains a major barrier. Achieving a truly integrated system of health promotion and disease prevention will require a greater degree of cooperation between these two key networks. As steps are taken toward integration, it will be incumbent upon professionals in the vision rehabilitation field to make their voices heard. As things stand now, although vision loss is a major public health issue, vision rehabilitation programs are not recognized at the state level, and are rarely represented in either the public health or aging networks.
Opportunities for collaboration
Aging and Disability Resource Center
One program that holds promise for collaborative efforts by those in the aging and vision fields is the Aging and Disability Resource Center, which is jointly sponsored by the Administration on Aging and the Centers for Medicare and Medicaid Services. The program, part of President George W. Bush's Long Term Care Re-balancing Initiative and New Freedom Initiative (<www.cms.hhs.gov/newfreedominitiative/01_overview.asp?>), is intended to stimulate the development of state systems that integrate information and referral, benefits and options, counseling services, and access to publicly and privately financed long-term care services and benefits. The 43 projects funded since the 2003 inception of the resource center program serve older and disabled people, and each must serve a minimum of two target populations by the end of the grant period of three years. Nine of the funded projects have identified people with all disabilities as their targets. Although none of the projects has focused on visual impairment, the joint emphasis on aging and disability opens the door for professionals in the vision rehabilitation field to provide input and interact with these centers. In fact, information provided by the American Foundation for the Blind and Helen Keller National Center is already on the technical assistance section of the centers' web site, <www.adrc-tae.org>.
White House Conference on Aging
Delegates to the White House Conference on Aging, held in the fall of 2005, recognized the importance of aging and public health by including in their list of ten goals meriting the most immediate consideration: support for geriatric education and training for all health care professionals, paraprofessionals, health profession students, and direct care workers; and attainment of adequate numbers of health care personnel in all professions who are skilled, culturally competent, and specialized in geriatrics. Implementation of these objectives, both of which are likely to receive considerable attention in the coming decade, should provide valuable opportunities for collaboration among health professionals in the vision, aging, and public health fields, and result in more effective services for older people with vision loss.
While the objectives of the White House Conference on Aging focus on the role of trained professionals, attention must be paid as well to the mechanisms through which health care is provided in the United States. As the number of older people needing health care rises, as resources get tighter and medical costs increase, the use of "telehealth" is increasing dramatically in the health care arena. If telehealth is understood to mean the integration of telecommunications systems into the practice of protecting and promoting health while telemedicine is the incorporation of these systems into clinical practice, then it must be acknowledged that telehealth corresponds more closely to the international activities of the World Health Organization in the field of public health. Telehealth focuses on education in public and community health, health systems development, and epidemiology, whereas telemedicine is oriented more towards clinical issues (Charness, 2006). Telehealth is defined as the use of electronic information and communication technology to deliver medical information and services over distances through a standard telephone line. In most cases, an interactive monitor is placed in an individual's home--often accompanied by devices such as blood pressure machines or pulse oximeters--and daily information on health status, symptoms, and activities can be transmitted to and monitored by health care personnel. Telemedicine is defined as the incorporation of telehealth technologies into a physician, hospital, clinic, medical institution, or other health care organization's practice of medicine. The use of telecommunications technology assists such entities in transmitting images, such as x-rays or other diagnostic images, for examination at another site. Home health care providers are already using telemedicine to monitor blood pressure, heart rate, and other vital information. The Veterans Administration is also beginning to utilize telehealth practices.
However, for the most part, older people experiencing serious vision loss have not received adequate care. Most telehealth systems are not designed with vision loss in mind; they tend to be visually based through computer and camera systems, provide little audio feedback, and depend on availability of a sighted caregiver (Charness, 2006). These are, however, problems that can be overcome. Services for older adults with vision loss could be augmented through appropriate use of technology and research. This is an area in which the complementary knowledge bases of the vision rehabilitation and public health fields can be tapped in order to find ways to increase accessibility through Internet-based video camera technology, improved synthetic speech, enlarged screens with large print and good contrast, braille output, and "Smart Homes" that can interact with a consumer's computer. A Smart Home is defined as a highly automated home that uses a common electronic network infrastructure for lights, appliances, and other electronic devices. A security system and camera monitors in a smart house are designed to allow someone other than the home owner, such as a family member or health care provider, to monitor the older person's well being and safety. Automated products, such as those featured in Smart Homes, are designed to allow the older person to remain at home rather than moving to a higher level of care such as an assisted living facility.
Vision loss is an issue for both the fields of aging and public health. It must be recognized as such and receive the attention it deserves, as well as being given a commitment from the public health arena to address it. The vision rehabilitation field stands ready to join forces with the aging and public health systems to enhance the ability of older adults with vision loss to continue to live independent lives.
Alberta L. Orr, M.S.W., consultant, specialist in aging and vision loss; mailing address: 120 Garfield Place, Apartment D1, Brooklyn, NY 11215; e-mail: <firstname.lastname@example.org>. Priscilla Rogers, Ph.D., national independent living associate, Center on Vision Loss, American Foundation for the Blind, 11030 Ables Lane, Dallas, TX 75229; e-mail: <email@example.com>. Judy Scott, M.S., director, Center on Vision Loss, American Foundation for the Blind; e-mail: <firstname.lastname@example.org>.
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