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Intervention Summary

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EnhanceWellness

EnhanceWellness is an outpatient intervention for older adults with chronic health conditions such as heart disease, high blood pressure, arthritis, and rheumatism. The program's goal is to help men and women better manage their illnesses and minimize related problems such as unnecessary use of prescription psychoactive medications, physical inactivity, depression, and social isolation. The individually tailored service is delivered through health care providers at senior centers and other community locations and is designed to complement medical intervention provided by the participant's primary medical team. Following a referral from their primary care physician or a community-based provider, participants meet with an EnhanceWellness provider, typically a registered nurse (RN) or social worker who has been trained in motivational interviewing and transtheoretical behavior change. The provider coaches the participant in developing a tailored health action plan that identifies risk factors the participant has chosen to work on as well as goals for making changes in those risk factors. Participants are encouraged to enroll in any or all of the three core offerings:

  • EnhanceFitness (formerly the Lifetime Fitness Program), an evidence-based exercise class provided at various community locations. (In the initial randomized trial reviewed in this summary, the class was provided at the senior center.) Alternatively, participants can opt to follow an exercise regimen at home or with another group.
  • The Chronic Illness Self-Management Course, a series of 2.5-hour classes offered weekly for 6 weeks. (In the initial trial, classes were 2 hours and held weekly for 7 weeks.) The course combines peer support with health promotion information and disease self-management concepts. As part of the course, participants use the accompanying self-management workbook, Living a Healthy Life With Chronic Conditions.
  • Peer support provided by a trained volunteer (health mentor).

After the initial meeting, the RN or social worker monitors the participant's progress toward health goals through follow-up visits and telephone calls and informs the primary care physician of the participant's progress. In the initial trial, the number of in-person visits ranged from 1 to 8, with an average of 3, and the number of phone contacts ranged from 1 to 22, with an average of 9. EnhanceWellness participants typically remain in the program for 6 months, graduating once they reach the goals outlined in their health action plan.

Descriptive Information

Areas of Interest Mental health promotion
Outcomes Review Date: August 2010
1: Use of prescription psychoactive medications
2: Physical function
3: Inpatient hospitalization
4: Physical activity
Outcome Categories Drugs
Ages 55+ (Older adult)
Genders Male
Female
Races/Ethnicities Data were not reported/available.
Settings Other community settings
Geographic Locations Urban
Suburban
Rural and/or frontier
Implementation History EnhanceWellness, formerly known as the Health Enhancement Program, was first implemented in 1997, 1 year after completion of the first formal evaluation. Since then, approximately 60 sites have implemented the intervention, reaching approximately 4,600 individuals. EnhanceWellness was implemented in Stockholm, Sweden, in 2002-03 using the same curriculum as is used in the United States. No known evaluations have been conducted outside the United States.
NIH Funding/CER Studies Partially/fully funded by National Institutes of Health: No
Evaluated in comparative effectiveness research studies: Yes
Adaptations No population- or culture-specific adaptations of the intervention were identified by the developer.
Adverse Effects No adverse effects, concerns, or unintended consequences were identified by the developer.
IOM Prevention Categories Indicated

Quality of Research
Review Date: August 2010

Documents Reviewed

The documents below were reviewed for Quality of Research. The research point of contact can provide information regarding the studies reviewed and the availability of additional materials, including those from more recent studies that may have been conducted.

Study 1

Leveille, S. G., Wagner, E. H., Davis, C., Grothaus, L., Wallace, J., LoGerfo, M., et al. (1998). Preventing disability and managing chronic illness in frail older adults: A randomized trial of a community-based partnership with primary care. Journal of the American Geriatrics Society, 46(10), 1191-1198.  Pub Med icon

Phelan, E. A., Williams, B., Penninx, B. W. J. H., LoGerfo, J. P., & Leveille, S. G. (2004). Activities of daily living function and disability in older adults in a randomized trial of the Health Enhancement Program. Journal of Gerontology: Medical Sciences, 59A(8), 838-843.  Pub Med icon

Supplementary Materials

Norris, S. L., Grothaus, L. C., Buchner, D. M., & Pratt, M. (2000). Effectiveness of physician-based assessment and counseling for exercise in a staff model HMO. Preventive Medicine, 30(6), 513-523.  Pub Med icon

Physician-based Assessment and Counseling for Exercise (PACE) Physical Activity Assessment Form

Scholes, D., LaCroix, A. Z., Wagner, E. H., Grothaus, L. C., & Hecht, J. A. (1991). Tracking progress toward national health objectives in the elderly: What do restricted activity days signify? American Journal of Public Health, 81(4), 485-488.  Pub Med icon

Outcomes

Outcome 1: Use of prescription psychoactive medications
Description of Measures Information on participants' currently prescribed medications were obtained from administrative databases maintained by the health management organizations (HMOs) involved in the study. The types of prescription psychoactive medications that were tracked included antidepressants, anxiolytics, antipsychotics, sedative-hypnotics, narcotics, and sedating antihistamines.
Key Findings Participants were randomized to the intervention group, which received the EnhanceWellness intervention, or to a comparison group. Those in the comparison group were given a tour of the senior center and a schedule of senior center activities. They did not meet with the RN but had access to all senior center activities that were available to the intervention group.

Prescription psychoactive medication use declined 36% among the intervention group from baseline to 12-month follow-up, compared with 20% among the comparison group (p = .039). This change was attributable to reductions in both the number of participants using psychoactive medications and the number of psychoactive medications used by individual participants.
Studies Measuring Outcome Study 1
Study Designs Experimental
Quality of Research Rating 2.0 (0.0-4.0 scale)
Outcome 2: Physical function
Description of Measures Two measures of physical function were used:
  • Self-reported number of bed disability days, or days spent in bed. Participants were asked, "In the past 12 months, did you ever stay in bed because of an illness or injury?" If participants responded "yes," they were asked, "How many days did you stay in bed at least half the day because of illness or injury?"
  • The Health Assessment Questionnaire (HAQ) Disability Index, which measures self-reported performance of activities of daily living (ADL) in eight categories of physical function: dressing, rising, eating, walking, hygiene, reach, grip, and usual activities. Participants were asked to rate whether they were able to perform particular tasks over the past week on a scale from 0 (without any difficulty) to 3 (unable to do).
Key Findings Participants were randomized to the intervention group, which received the EnhanceWellness intervention, or to a comparison group. Those in the comparison group were given a tour of the senior center and a schedule of senior center activities. They did not meet with the RN but had access to all senior center activities that were available to the intervention group.

The intervention group had significantly fewer self-reported bed disability days from baseline to 12-month follow-up than the comparison group (p = .019). After adjustment for age, gender, and baseline score, the intervention group also had significantly lower average HAQ Disability Index scores at follow-up relative to the comparison group, indicating better ability to perform everyday tasks (p = .014). Additionally, among participants who were ADL disabled at baseline, fewer than half of those in the comparison group (46.5%) reported improved ADL function between baseline and 6- or 12-month follow-up, whereas 63.4% of intervention group participants improved by 6-month follow-up, and 80.5% improved by 12-month follow-up (p = .026). After adjustment for sex and baseline ADL function, the intervention group also had greater likelihood for improvement in ADL function at 12-month follow-up relative to the comparison group (p = .02).
Studies Measuring Outcome Study 1
Study Designs Experimental
Quality of Research Rating 2.0 (0.0-4.0 scale)
Outcome 3: Inpatient hospitalization
Description of Measures The number of inpatient hospital days in the 12 months before and after randomization was obtained from administrative databases maintained by the HMOs involved in the study.
Key Findings Participants were randomized to the intervention group, which received the EnhanceWellness intervention, or to a comparison group. Those in the comparison group were given a tour of the senior center and a schedule of senior center activities. They did not meet with the RN but had access to all senior center activities that were available to the intervention group.

From baseline to 12-month follow-up, the total number of inpatient hospital days per year decreased 72% in the intervention group (from 116 to 33 days) while increasing 20% in the comparison group (from 96 to 116 days) (p = .049).
Studies Measuring Outcome Study 1
Study Designs Experimental
Quality of Research Rating 2.3 (0.0-4.0 scale)
Outcome 4: Physical activity
Description of Measures Physical activity was measured using two instruments:
  • The Physical Activity Scale for the Elderly (PASE), a self-report measure of physical activity engaged in over a 1-week period. The scale includes 12 items focusing on activities commonly performed by older adults, including occupational, household, and leisure activities. One example of items in this scale is "Over the past 7 days, how often did you participate in sitting activities such as reading, watching TV, or doing handcrafts?" Response options range from 0 (never) to 3 (often).
  • The Physician-based Assessment and Counseling for Exercise (PACE) Physical Activity Assessment Form, developed by the Centers for Disease Control and Prevention. The PACE is a 1-page questionnaire that measures level of physical activity and readiness to increase or maintain physical activity. This assessment provides a list of 11 statements about exercise and asks respondents to indicate the statement that best describes their current level of physical activity or interest in physical activity. Statements range from "I do not exercise or walk regularly now, and I do not intend to start in the near future" to "I do vigorous exercise 6 or more times per week."
Key Findings Participants were randomized to the intervention group, which received the EnhanceWellness intervention, or to a comparison group. Those in the comparison group were given a tour of the senior center and a schedule of senior center activities. They did not meet with the RN but had access to all senior center activities that were available to the intervention group.

At 12-month follow-up, intervention group participants reported significantly higher levels of physical activity and significantly more positive attitudes toward physical activity relative to the comparison group, as measured by the PASE (p = .031) and the PACE (p < .028).
Studies Measuring Outcome Study 1
Study Designs Experimental
Quality of Research Rating 2.5 (0.0-4.0 scale)

Study Populations

The following populations were identified in the studies reviewed for Quality of Research.

Study Age Gender Race/Ethnicity
Study 1 55+ (Older adult) 55.7% Female
44.3% Male
Data not reported/available

Quality of Research Ratings by Criteria (0.0-4.0 scale)

External reviewers independently evaluate the Quality of Research for an intervention's reported results using six criteria:

  1. Reliability of measures
  2. Validity of measures
  3. Intervention fidelity
  4. Missing data and attrition
  5. Potential confounding variables
  6. Appropriateness of analysis

For more information about these criteria and the meaning of the ratings, see Quality of Research.

Outcome Reliability
of Measures
Validity
of Measures
Fidelity Missing
Data/Attrition
Confounding
Variables
Data
Analysis
Overall
Rating
1: Use of prescription psychoactive medications 2.0 4.0 0.0 2.0 2.0 2.0 2.0
2: Physical function 2.5 3.0 0.0 2.5 2.0 2.0 2.0
3: Inpatient hospitalization 2.0 4.0 0.0 3.0 2.0 3.0 2.3
4: Physical activity 4.0 4.0 0.0 2.0 2.0 3.0 2.5

Study Strengths

A good range of outcome measures was used. Several of the measures are well established in the field and have been shown by independent investigators to have acceptable reliability and validity. All measures have face validity. The level of attrition is consistent with community research. Intent-to-treat analysis was performed. The data analyses were appropriate.

Study Weaknesses

One of the physical function measures relied on participants' recall of the number of days they spent in bed over the past year because of illness or injury. The ability to recall this kind of information varies with memory and cognitive status and can be unreliable, even among people without age-related cognitive impairment. The extent and duration of participants' involvement in the various program offerings were not adequately documented for either the intervention or comparison group, leaving significant concerns about implementation fidelity. Randomization was not effective, with the comparison group having lower socioeconomic status and income, less education, higher rates of smoking, worse self-perceived health, and less participation in social activities than the intervention group. Participants also had knowledge of their study condition assignment, which may limit the validity of the conclusions. The sample size was small.

Readiness for Dissemination
Review Date: August 2010

Materials Reviewed

The materials below were reviewed for Readiness for Dissemination. The implementation point of contact can provide information regarding implementation of the intervention and the availability of additional, updated, or new materials.

EnhanceWellness data entry system (WellWare), http://www.seniorhep.org

Holmes, C. A. (2005). From theory to practice: Testing an expert system for diffusing evidence-based health programs.

Phelan, E. A., Williams, B., Snyder, S. J., Fitts, S. S., & LoGerfo, J. P. (2006). A five state dissemination of a community-based disability prevention program for older adults. Clinical Interventions in Aging, 1(3), 267-274.  Pub Med icon

Program Web site, http://www.projectenhance.org

Sanchez, A. M. (n.d.). Motivational interviewing and behavior change [PowerPoint slides].

Sanchez, A. M. (n.d.). Motivational interviewing and behavior change: Day 1 [PowerPoint slides].

Senior Services. (2006). EnhanceWellness counselor manual. Seattle, WA: Author.

Senior Services. (n.d.). EnhanceWellness [DVD]. Seattle, WA: Author.

Other program materials:

  • Marketing package
  • EnhanceWellness PowerPoint slides
  • Training agenda (2006)
  • Training handouts

Readiness for Dissemination Ratings by Criteria (0.0-4.0 scale)

External reviewers independently evaluate the intervention's Readiness for Dissemination using three criteria:

  1. Availability of implementation materials
  2. Availability of training and support resources
  3. Availability of quality assurance procedures

For more information about these criteria and the meaning of the ratings, see Readiness for Dissemination.

Implementation
Materials
Training and Support
Resources
Quality Assurance
Procedures
Overall
Rating
4.0 4.0 4.0 4.0

Dissemination Strengths

The implementation materials are high quality, appropriate for a variety of audiences, and sequenced logically to simplify implementation planning. The materials provide helpful information on how to assess an organization's readiness for implementation. The program Web site is high quality and engaging. A variety of excellent training and support resources are available. On-site technical training and consultation are included with the program license, giving implementers the ability to share information with others using the program across the nation. Quality assurance procedures are provided and can be modified to meet site needs; the high-quality nature of the implementation materials and resources also supports quality assurance. The WellWare Web-based software application and data entry system provides implementers with detailed reports on participant outcomes and staff adherence to protocols as well as ideas for program improvement.

Dissemination Weaknesses

No dissemination weaknesses were noted by reviewers.

Costs

The cost information below was provided by the developer. Although this cost information may have been updated by the developer since the time of review, it may not reflect the current costs or availability of items (including newly developed or discontinued items). The implementation point of contact can provide current information and discuss implementation requirements.

Item Description Cost Required by Developer
EnhanceWellness license (first year) $6,000 Yes
Annual license renewal $300 Yes
Staff manuals for RN, social worker, and health mentor Included with license Yes
Administrative manual Included with license Yes
Marketing materials Included with license Yes
2.5-day on- or offsite training Included with license (up to 10 trainees per training) Yes
Technical assistance Included with license Yes
WellWare account and user guide Included with license Yes
Replications

Selected citations are presented below. An asterisk indicates that the document was reviewed for Quality of Research.

Fitts, S. S., Won, C. W., Williams, B., Snyder, S. J., Yukawa, M., Legner, V. J., et al. (2008). What is the optimal duration of participation in a community-based health promotion program for older adults? Journal of Applied Gerontology, 27(2), 201-214.  Pub Med icon

* Leveille, S. G., Wagner, E. H., Davis, C., Grothaus, L., Wallace, J., LoGerfo, M., et al. (1998). Preventing disability and managing chronic illness in frail older adults: A randomized trial of a community-based partnership with primary care. Journal of the American Geriatrics Society, 46(10), 1191-1198.  Pub Med icon

Phelan, E. A., Cheadle, A., Schwartz, S. J., Snyder, S., Williams, B., Wagner, E. H., et al. (2003). Promoting health and preventing disability in older adults: Lessons from intervention studies carried out through an academic-community partnership. Family and Community Health, 26(3), 214-220.  Pub Med icon

Phelan, E. A., Williams, B., Leveille, S., Snyder, S., Wagner, E. H., & LoGerfo, J. P. (2002). Outcomes of a community-based dissemination of the Health Enhancement Program. Journal of the American Geriatrics Society, 50(9), 1519-1524.  Pub Med icon

* Phelan, E. A., Williams, B., Penninx, B. W. J. H., LoGerfo, J. P., & Leveille, S. G. (2004). Activities of daily living function and disability in older adults in a randomized trial of the Health Enhancement Program. Journal of Gerontology: Medical Sciences, 59A(8), 838-843.  Pub Med icon

Phelan, E. A., Williams, B., Snyder, S. J., Fitts, S. S., & LoGerfo, J. P. (2006). A five state dissemination of a community-based disability prevention program for older adults. Clinical Interventions in Aging, 1(3), 267-274.  Pub Med icon

Contact Information

To learn more about implementation, contact:
Susan J. Snyder, M.S.
(206) 727-6297
susans@seniorservices.org

To learn more about research, contact:
Elizabeth Phelan, M.D., M.S.
(206) 744-9112
phelane@u.washington.edu

Consider these Questions to Ask (PDF, 54KB) as you explore the possible use of this intervention.

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