Health Indicators

In the next two decades, New York will face an unprecedented increase in the number of persons aged 65 and older. The overwhelming majority intend to remain in their homes, but multiple chronic conditions pose a challenge to healthy aging in place.

Effective management of chronic conditions is complex and requires the integration of self-care, medical care, and the right mix of community supports. With partnerships of health and social services a hallmark of the NORC program model, these programs are an ideal laboratory for understanding effective strategies and interventions.

United Hospital Fund developed the Health Indicators in NORC Programs Initiative to help NORC programs improve the health status of older adults in their communities. Intended to provide programs with the information and tools they need to shift from reacting to crises to a systematic, proactive practice based on evidence and standardized guidelines, the initiative involved three steps:

1. Baseline data collection to identify key health risks in the community;
2. The design, implementation, and assessment of interventions targeted for a specific health issue; and
3. Follow-up data collection to measure interventions’ effectiveness and to identify new health risks.

Baseline Data Collection

All 54 NORC programs in New York completed the data collection step of Health Indicators, resulting in a database of 6,333 surveys on the health status and health risks of older adults living in communities with NORC programs. Drawn directly or modified from validated national and local surveys, the 75 survey questions were developed around the premise that, to advance successful aging in place, NORC programs must address three basic domains of healthy aging: access to health care; engagement in prevention, promotion, and wellness activities and services; and management of chronic conditions. 

From the baseline data, three major health issues emerged: heart disease, diabetes, and falls.  Other highlights of the baseline survey are available.

The Intervention Step

The Health Indicators’ intervention step was designed to help NORC programs improve the health of clients with heart disease or diabetes, or at risk for falls. As community-based organizations with both social workers and nurses on staff, NORC programs are uniquely positioned at the intersection of self-care, medical care, and community care, and can use this positioning to standardize practice and improve health in the community.

To guide participating programs, UHF developed NORC Program standards of practice and measures for the three focal health issues of heart disease, diabetes, and falls. These standards reflect best practices and clinical guidelines in self-care, medicine, and community supports that can be addressed by NORC programs, in five discrete areas:

  • Knowing and managing the relevant clinical measures;
  • Appropriate medication management;
  • Health care maintenance;
  • Diet and physical activity;
  • Education and information.

UHF also developed benchmarking tools to measure progress toward the standards and to identify gaps in practice. Using these tools and the accompanying process, NORC programs establish baseline measures for their selected health issue, set quality improvement goals and objectives, conduct targeted interventions, and measure progress at regular intervals. With the intervention process designed to be ongoing and sustainable, programs can apply it to a range of health issues.

Building on this first stage of Health Indicators, in 2016, with support from the Altman Foundation, UHF launched its Health Indicators–Performance Improvement project, to help senior-serving community-based organizations (CBOs) implement data-driven, results-oriented health and wellness programs for their clients, and improve their ability to partner effectively with health care providers. HI-PI helps CBOs use data to tailor interventions to their unique populations—to target the people most in need of support and education and produce measurable improvements in their health and well-being.

Contact: Deborah Halper


Family Caregiving

Resources for family caregivers and health care providers are available at our Next Step in Care website.

Support the Fund

The Fund's work is made possible by generous contributors like you. Your contribution helps us make a critical difference.