Health Indicators

In the next 25 years, 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.

The 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 involves 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 is 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, the Fund 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.

The Fund 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.

The intervention process is designed to be ongoing and sustainable.  Programs will be able to use this process on a range of health issues in the future. The initiative’s goal is to foster proactive practices and improve the health status of seniors connected to NORC programs.


Contact: Deborah Halper


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