1. Mullen, Jewel MD, MPH, MPA

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Introduction: Why Healthy Aging?

As the president of ASTHO, I have the honor of issuing a call to action to fellow state health officials and our public health colleagues. The 2014-2015 ASTHO President's Challenge, Healthy Aging: Living Longer Better, calls upon state health leaders to collaborate with key partners to implement policy and systems-level actions. Its goal is to improve the health of older adults and the communities in which they live. Although the direct authority for aging programs usually falls outside the domain of state public health agencies, health officials can, and I believe should, play a significant role in advancing the well-being of older adults in their jurisdictions. That is the principal reminder in this call to action. A simple starting point for many states, territories, and freely associated states is to identify at least one partner, a public or private organization, with whom they can combine forces. Together they can participate in the challenge by pledging to adopt a public health approach to elevate healthy aging. By using the National Prevention Strategy (NPS) as a framework, partners can elect to implement at least 1 of its 11 strategic directions or priorities. These include Tobacco-Free Living, Preventing Drug Abuse and Excessive Alcohol Use, Healthy Eating Active Living, Reproductive and Sexual Health, Injury and Violence Free Living, Healthy and Safe Community Environments, Clinical and Community Preventive Services, Elimination of Health Disparities, and Empowered People.1


The US Department of Health and Human Services (HHS) projects the older adult population will nearly double, reaching 79.7 million by 2040. Recognizing this important demographic shift, opportunities for older adults to maintain their health and vitality should advance as well. In addition to rising, the population of older adults will become more diverse. Racial and ethnic minority populations are projected to constitute 28% of the older adult population in 2030 compared with the 21% in 2011.2 Consistent with the NPS strategic direction to eliminate disparities, it is essential that public health leaders go beyond focusing on longevity to address disparities in healthy life expectancy years. We should consider the social determinants of healthy aging, paying particular attention to social support, economic resources, community environments, caregiving, and transportation access among older adults. Since the majority of older adults want to grow old in their homes and in their communities, attention to community livability is paramount.3 It is fundamental to recognize that the level of social support vastly differs by race/ethnicity, education, and income. Older adults with the lowest income and education feel they have less emotional support than those with higher income and more education. Alongside the social determinants loom the challenges of cognitive decline and multiple chronic conditions. As Americans are living longer, their risk of developing Alzheimer's disease and other dementias, as well as chronic conditions, increases. An estimated 5.3 million Americans of all ages have Alzheimer's disease in 2015, and by 2025 the number of people 65 years and older with Alzheimer's disease is estimated to reach 7.1 million and triple by 2050.4 More than a quarter of all Americans and 2 out of every 3 older Americans have multiple chronic conditions. In addition to the human cost of these conditions are costs to business. Employees' need to care for loved ones costs American businesses almost $34 billion each year.5


Public Health's Role in Healthy Aging

Healthy aging is defined by the National Association of Chronic Disease Directors as the development and maintenance of optimal physical, mental, and social well-being and function in older adults.6 A call to address healthy aging, however, evokes a range of reactions from health leaders, more often focused on the provision of medical care than on promoting well-being. An obvious reason for that focus is our ongoing national imperative to improve the efficiency and quality of health care through efforts such as care coordination for treatment of chronic conditions, reducing hospital readmissions, and improving palliative and end-of-life care. Public health has not been the de facto leader on those fronts. Moreover, since only 7 state health agencies have elder care services under their direct purview, health officials' leadership role in healthy aging might not be readily apparent to them. In many states, aging programs and initiatives are housed within the Health and Human Services Administration, Aging Regional Offices, State Units on Aging, Area Agencies on Aging, and a variety of local service providers. Rather than precluding the involvement of state health officials, this array of organizations and networks represents a broad group of collaborators with whom to advance healthy aging strategies.


As partners in healthy aging, state health officials contribute expertise in assessing the health of the public, developing policies to maintain and improve health, and implementing evidence-based and promising practices to improve population health. It is logical for us to be partners in this work because much of the capacity to advance healthy aging collaboratively, and within the NPS framework, already exists with public health agencies. Our health promotion and disease prevention programs already emphasize tobacco-free living, healthy eating, and physical activity, and our injury prevention initiatives often focus on falls. Public health emergency preparedness leaders design initiatives to build resilience, including plans to ensure safe and effective environments for community-dwelling elders. These examples are a reminder that advancing the NPS priorities to benefit older adults is what I consider the essence of public health. It also grounds our work in a life-course approach, one that supports the NPS vision of "Healthy Americans at Every Stage of Life."


Working across state agencies, health officials can improve older adult health by leveraging a number of national opportunities that also can be accomplished though the NPS framework. Many state public health and Medicaid agencies are collaborators in the CMMI State Innovation Model initiative. In addition to its explicit focus on population health, the State Innovation Model opportunity calls for health system transformation and resultant improved chronic disease outcomes, in addition to reduction of falls-related hospitalizations and decreased expenditures on care. Working together, public health, Medicaid, and other human services agencies can strengthen existing and create new, innovative models of clinical and community preventive services. Other national level opportunities to address healthy aging include state and local accreditation through the Public Health Accreditation Board and the implementation of State Health Improvement Plans. Both represent opportunities to strengthen the public health workforce, improve agency performance, and eliminate disparities while focusing on improving health across the life span.


State Examples of Cross-Sector Collaboration

A number of health officials are engaged in cross-sector collaboration to improve the health of older adults and the communities in which they live through the ASTHO President's Challenge and the ASTHO Healthy Aging/Public Health Learning Community. The following state examples highlight public health's role in collaborating across sectors to implement policy and systems-level interventions to promote healthy aging:


In the Connecticut Department of Health, we are leveraging our State Health Improvement Plan to enhance falls prevention and transportation access initiatives for older adults and establishing a life-course framework for family health in our Maternal and Child Health Section, starting with a focus on caregiving.


The Georgia Department of Public Health is focusing on increasing the capacity for data and surveillance to track Alzheimer's disease and related dementias through the development of an Alzheimer's Disease and Related Dementias Registry. In addition, they are promoting their "Roadmap for Cognitive Screening for Primary Care Doctors" toolkit/training to assist physicians in identifying and diagnosing Alzheimer's disease and related dementias. These efforts required partnerships across primary care, public health, the Division of Aging, academia, and the Alzheimer's Association, among others.


The Oregon Health Authority Public Health Division has incorporated healthy aging as a priority in its 2015-2019 Strategic Plan and is developing the Oregon Index for Healthy Aging. It will focus on identifying data sources and metrics to track progress on improving the quality of life and increasing the years of healthy life by promoting healthy aging. Some partners it has engaged with include the Department of Transportation, Department of Human Services, and the Alzheimer's Association. Furthermore, Oregon has emphasized the importance of identifying either common or complementary goals between partners and encourages public health to utilize a health equity and aging lens to examine existing data sets.


Michigan is addressing clinical and community preventive services and injury- and violence-free living. Using evidence-based practices and enhanced partnerships, it intends to increase participation in its Matter of Balance falls prevention program and the Personal Action Toward Health (PATH) diabetes management project for older adults. Its partners include the Area Agency on Aging and the Michigan Patient Centered Transformation Project and will be leveraging funding from the Michigan Blue Cross Endowment Fund.



Alignment With Federal Initiatives

Improving healthy aging through population-based strategies also is a priority for a number of ASTHO's partners in the federal government and national organizations. Along with many federal and state partners, leaders from groups including AARP, the National Council on Aging, and Leaders Engaged on Alzheimer's Disease (LEAD) coalition participated in the development of our healthy aging strategic map. In addition, earlier this year, ASTHO convened many of those groups, the Trust for America's Health, the Centers for Disease Control and Prevention, the National Park Services, the Administration on Aging, the Environmental Protection Agency, and the Centers for Medicare & Medicaid Services for a NPS healthy aging meeting. We were joined by the Deputy Surgeon General and the directors of the White House Conference on Aging and the HHS Office of Disease Prevention and Health Promotion. The engagement of those senior officials signifies the maturation of the federal interagency approach to healthy aging, and it creates new opportunities for federal-state collaboration. For example, the 2015 White House Conference on Aging enables states' participation through its regional formats. Moreover, the final day of the 2015 Healthy Aging Summit will convene state health officials and their teams, along with directors of states' aging agencies. The Office of Disease Prevention and Health Promotion's collaboration with ASTHO on this conference will support our development as leaders and conveners for sustainable healthy aging initiatives that are grounded in a "social determinants of health" framework. Our collective action will make it possible for more adults to live and age well in their communities.




1. National Prevention Council. National Prevention Strategy. Washington, DC: US Department of Health and Human Services, Office of the Surgeon General; 2011. Accessed April 1, 2015. [Context Link]


2. Administration on Aging, Administration on Community Living, Department of Health and Human Services. Profile of older Americans: 2012. Accessed February 21, 2014. [Context Link]


3. National Conference of State Legislatures and AARP. Aging in place: a state survey of livability policies and practices. Accessed April 3, 2015. [Context Link]


4. Alzheimer's Association. 2015 Alzheimer's disease facts and figures. Accessed April 1, 2015. [Context Link]


5. Metlife Mature Market Institute and the National Alliance for Caregiving. The Metlife caregiving cost study: productivity losses to U.S. business. Published 2006. Accessed April 1, 2015. [Context Link]


6. National Association of Chronic Disease Directors. Meeting the challenges of an aging society, the experience of state health departments. Published 2009. Accessed April 1, 2015. [Context Link]