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107th Congress                   SENATE             Rept. 107-158
  2d Session                                             Volume 2
                  DEVELOPMENTS IN AGING: 1999 AND 2000-VOLUME 2


                                A REPORT

                                 of the

                       SPECIAL COMMITTEE ON AGING
                          UNITED STATES SENATE

                              pursuant to

                 S. RES. 54, SEC. 17(c), MARCH 8, 2001

  Resolution Authorizing a Study of the Problems of the Aged and Aging


                  June 4, 2002.--Ordered to be printed

             DEVELOPMENTS IN AGING: 1999 AND 2000--VOLUME 2
For Sale by the Superintendent of Documents, U.S. Government Printing Office
Internet:  Phone: toll free (866) 512-1800; (202) 512-1800  
Fax: (202) 512-2250 Mail: Stop SSOP, Washington, DC 20402-0001

                       SPECIAL COMMITTEE ON AGING

                  JOHN B. BREAUX, Louisiana, Chairman
PHARRY REID, Nevada                  LARRY CRAIG, Idaho, Ranking Member
HERB KOHL, Wisconsin                 CONRAD BURNS, Montana
JAMES M. JEFFORDS, Vermont           RICHARD SHELBY, Alabama
RUSSELL D. FEINGOLD, Wisconsin       RICK SANTORUM, Pennsylvania
RON WYDEN, Oregon                    SUSAN COLLINS, Maine
BLANCHE L. LINCOLN, Arkansas         MIKE ENZI, Wyoming
EVAN BAYH, Indiana                   TIM HUTCHINSON, Arkansas
THOMAS R. CARPER, Delaware           JOHN ENSIGN, Nevada
DEBBIE STABENOW, Michigan            CHUCK HAGEL, Nebraska
JEAN CARNAHAN, Missouri              GORDON SMITH, Oregon
                    Michelle Easton, Staff Director
               Lupe Wissel, Ranking Member Staff Director

                         LETTER OF TRANSMITTAL


                                       U.S. Senate,
                                 Special Committee on Aging
                                              Washington, DC, 2002.
Hon. Dick Cheney,
President, U.S. Senate,
Washington, DC.
    Dear Mr. President: Under authority of Senate Resolution 54 
agreed to March 8, 2001, I am submitting to you the annual 
report of the U.S. Senate Special Committee on Aging, 
Developments in Aging: 1999 and 2000, volume 2.
    Senate Resolution 4, the Committee Systems Reorganization 
Amendments of 1977, authorizes the Special Committee on Aging 
``to conduct a continuing study of any and all matters 
pertaining to problems and opportunities of older people, 
including but not limited to, problems and opportunities of 
maintaining health, of assuring adequate income, of finding 
employment, of engaging in productive and rewarding activity, 
of securing proper housing and, when necessary, of obtaining 
care and assistance.'' Senate Resolution 4 also requires that 
the results of these studies and recommendations be reported to 
the Senate annually.
    This report describes actions taken during 1999 and 2000 by 
the Congress, the administration, and the U.S. Senate Special 
Committee on Aging, which are significant to our Nation's older 
citizens. It also summarizes and analyzes the Federal policies 
and programs that are of the most continuing importance for 
older persons and their families.
    On behalf of the members of the committee and its staff, I 
am pleased to transmit this report to you.
                                          John B. Breaux, Chairman.

                            C O N T E N T S

Letter of Transmittal............................................   III
    Item 1. Department of Agriculture............................     1
        Cooperative Extension System.............................     1
        Agricultural Research Service............................     2
        Economic Research Service................................     3
        Food and Nutrition Service...............................     4
        Center for Nutrition Policy and Promotion................     7
        Food Safety and Inspection Service.......................     7
        Marketing and Regulatory Programs........................     8
    Item 2. Department of Commerce...............................     9
    Item 3. Department of Defense................................    17
    Item 4. Department of Education..............................    20
    Item 5. Department of Energy.................................    54
    Item 6. Department of Health and Human Services..............    60
        Administration for Children and Families.................    60
        Administration on Aging..................................    67
        Office of the Assistant Secretary for Planning and 
          Evaluation.............................................    92
        Centers for Disease Control and Prevention...............   102
        Food and Drug Administration.............................   129
        Health Care Financing Administration.....................   154
        National Institutes of Health............................   220
        Health Resources and Services Administration.............   275
        Office of Inspector General..............................   290
    Item  7. Department of Housing and Urban Development.........   295
    Item  8. Department of the Interior..........................   307
    Item  9. Department of Justice...............................   318
    Item 10. Department of Labor.................................   330
    Item 11. Department of State.................................   345
    Item 12. Department of Transportation........................   347
    Item 13. Department of the Treasury..........................   359
    Item 14. Commission on Civil Rights..........................   377
    Item 15. Consumer Product Safety Commission..................   379
    Item 16. Corporation for National Service....................   385
    Item 17. Environmental Protection Agency.....................   399
    Item 18. Equal Employment Opportunity Commission.............   400
    Item 19. Federal Communications Commission...................   430
    Item 20. Federal Trade Commission............................   445
    Item 21. General Accounting Office...........................   530
    Item 22. Legal Services Corporation..........................   628
    Item 23. National Endowment for the Arts.....................   629
    Item 24. National Endowment for the Humanities...............   648
    Item 25. Pension Benefit Guaranty Corporation................   654
    Item 26. Postal Service......................................   691
    Item 27. Railroad Retirement Board...........................   698
    Item 28. Small Business Administration.......................   704
    Item 29. Social Security Administration......................   705
    Item 30. Veterans' Affairs...................................   710

107th Congress                                            Rept. 107-158
 2d Session                      SENATE                        Volume 2

                  DEVELOPMENTS IN AGING: 1999 AND 2000

                                 VOLUME 2


                  June 4, 2002.--Ordered to be printed


    Mr. Breaux, from the Special Committee on Aging, submitted the 

                              R E P O R T

              Report from Federal Departments and Agencies

                          ITEM 1--AGRICULTURE



    Since early 1999, USDA's CSREES has been working with 
families with older Americans in small towns and rural areas to 
make improved health care decisions. One of the strategies 
focuses on how 4-H Youth Technology Teams can help other 
Americans to bridge the Digital Divide. The program is known as 
Teens Teaching Internet Skills (TTIS). In a partnership with 
the Health Care Finance Administration, 4-H Technology 
Leadership Teams are helping families with older Americans to 
learn how to use the internet to improve the quality of 
decisions they make in choosing health care, housing and 
transportation. As a result of collaboration between young 4H 
member volunteers and older Americans, seniors are increasingly 
accessing internet web sites such as, and
    In 1999, 4-H Youth Technology piloted Teens Teaching 
Seniors State Teams in Maryland, Virginia, Connecticut, 
Florida, Iowa and Washington to test approaches to help older 
adults to gain Internet skills. At the National Youth 
Technology Conference, held in July 2000 in College Park, 
Maryland, more than 250 youth leaders from 29 States met and 
learned from the six original teams, and, since then, twenty-
nine States have taken the initiative to develop State action 
plans and to identify state youth technology leadership

teams that, when provided with proper resources, will be able 
to implement efforts for their own TTIS program. Many of the 
individual State action plans call for the establishment of 
Community Technology Centers to serve as learning centers where 
youth can take the role of mentors to adults in helping them 
become technologically literate. Many States are planning 
public-private partnerships to establish technology learning 
places in their communities. Today, 4-H Youth Technology teams 
are converting the digital into digital opportunity across the 
generations. Communities are now seeking support to grow these 
efforts especially in under-served communities.
    CSREES provided key leadership in the framing of a new 
national extension initiative ``Financial Security in Later 
Life,'' which will be implemented in FY 2001. The purpose of 
the initiative is to focus new resources of the Land-grant 
University System on research, resident education, and 
extension/outreach programs related to an aging population. 
Particular attention will be paid to retirement planning 
especially the potential financial effects of long term care on 
family finances. A significant contribution of USDA-CSREES will 
be partnership building with other Federal agencies, the 
financial services sector, foundations, and non-profit 
organizations. Work already is underway on training for 
extension educators, research on retirement issues of farm 
families, and an interactive web site for consumers on long 
term care decisions. It is expected the initiative will span 5 


    The Department of Agriculture Research Service (ARS) 
conducts research at the Jean Mayer Human Nutrition Research 
Center on Aging (HNRCA) in Boston, Massachusetts, on behalf of 
older Americans. Center scientists are determining the ways in 
which diet and nutritional status influence the onset and 
progression of aging, employing experimental animals, tissue 
cultures, and human subjects for such studies. They are 
exploring the ways in which diet, alone and in association with 
other factors, can delay or prevent the onset of degenerative 
conditions commonly associated with the aging process. This 
research will determine nutrient requirements during aging and 
the ways in which an optimal diet, in combination with 
exercise, genetic, physiological, psychological, sociological 
and environmental factors, may provide health and vigor over 
the life span of man.
    Scientists at the HNRCA are addressing three general 
questions of central importance to this mission:
           How does nutrition influence the progressive 
        loss of tissue functions with aging?
           What is the role of nutrition in the genesis 
        of major chronic degenerative conditions associated 
        with the aging process?
           What are the nutrient requirements necessary 
        to maintain the optimal functional well-being of older 
    ARS is strengthening its integrated multidisciplinary human 
nutrition research program to develop means for promoting 
optimum human health and well-being through improved nutrition. 
ARS research is also seeking to improve understanding of the 
functional roles dietary patterns play in human health 
maintenance. The goals of the ARS Human Nutrition Initiative 
are to:
           Reduce health care costs and enhance the 
        quality of life.
           Improve the scientific basis for more 
        effective Federal food assistance programs.
           Generate a more nutritious food supply.
           Improve the resistance to acute infections 
        and immune disorder.
           Enhance the capacity to promote changes in 
        diet habits.
           Individualize dietary guidance for 
        nutritionally vulnerable groups within the United 
    The ARS Human Nutrition Initiative Focuses on Five Vital 
           Food, Phytonutrients, and Health
           Health Body Weight
           Brain Function/Resistance to Mental Decline
           Bone Growth and Protection from Osteoporosis
           Foods to Fight Infectious Disease
    Recent accomplishments include findings that fortification 
or folate has reduced the prevalence of low circulating folate 
and high homocysteine concentrations. The implementation of the 
FDA-mandated folic acid fortification of enriched grain 
products was completed by early 1998. Researchers at HNRCA 
assessed the impact of fortifi-cation on the folate status of 
adult Americans. They have conducted a long-term follow-up of 
folate and homocysteine concentrations in the population-based 
Framingham Heart Studies. This work indicated that the current 
levels of fortification were able to reduce the prevalence of 
low circulating folate and high homocysteine concentrations to 
levels seen in multivitamin supplement users. This was the 
first demonstration of the effectiveness of this important 
national program.
    Researchers at HNRCA in collaboration with Framingham 
Osteoporosis Study researchers evaluated associations between 
dietary vitamin K intake, apoE genotype, bone mineral density 
and rate of hip fracture among elderly men and women 
participating in the original cohort of the Framingham Health 
Study. Low vitamin K intakes were significantly associated with 
increased incidence of hip fractures in men and women. In 
contrasts, neither low intakes of vitamin K nor apoE4 allele 
were associated with low bone mineral density.


    The Economic Research Service identifies research and 
policy issues relevant to the elderly population from the 
perspective of rural development. Ongoing research looks at 
demographic and socioeconomic characteristics of the older 
population by rural-urban residence. Current research examines 
rural-urban differences in health and access to health care for 
the elderly, based on data from the Current Population Survey 
and National Health Interview Survey. In the past year, we 
participated in the Interagency Forum on Aging-Related 
Statistics, reviewed proposals for the Office of Rural Health 
Policy's Rural Health Analytic Research Center Cooperative 
Agreement Program, and contributed to the Conference Report 
from the National Rural Health Research Agenda Setting 
    The following publications on the rural elderly have been 
prepared by ERS staff in the past year:
    Rogers, Carolyn C., ``Growth of the Oldest Old Population 
and Future Implications for Rural America,'' Rural Development 
Perspectives, Vol. 14, No. 3, October 1999.
    Rogers, Carolyn C., ``Changes in the Older Population and 
Implications for Rural Areas, RDRR-90, December 1999 (released 
Feb. 2000).
    Rogers, Carolyn C., ``The Graying of Rural America,'' Forum 
for Applied Research and Public Policy, December 2000.

                    FOOD AND NUTRITION SERVICE (FNS)

Title and purpose statement of each program or activity which affects 
        older Americans

    The Food Stamp Program (FSP) provides monthly benefits to 
help low-income families and individuals purchase a more 
nutritious diet. In fiscal year 1999, $18 billion in food 
stamps were provided to a monthly average of 18 million 
    Households with elderly members accounted for approximately 
20 percent of the total food stamp caseload. However, sinced 
these households were smaller on average and had relatively 
higher net income, they received only 8 percent of all benefits 

Brief description of accomplishments

    The FSP has been at the forefront of efforts to reduce 
hunger and food insecurity among the elderly. The initiatives 
           Development of a guide titled ``Help for the 
        Elderly and Disabled: A Primer for Enhancing the 
        Nutrition Safety Net for the Elderly and Disabled'' 
        that was distributed to appropriate agencies and 
        organizations. The purpose of this guide is to: 1) 
        assist State policy makers and others in understanding 
        the special rules embedded in the Food Stamp Act of 
        1977 (as amended) and the FSP regulations for elderly 
        and disabled individuals, 2) assist States and others 
        in identifying participation barriers the elderly and 
        disabled face when seeking nutrition assistance through 
        the FSP, and 3) assist States and others in identifying 
        possible outreach activities to increase participation 
        among the elderly and disabled.
           Development of easily reproducible posters 
        and fliers as part of a public information campaign to 
        increase awareness of the FSP among target audiences, 
        including the elderly.
           Announcing the availability of $3 million 
        dollars in research grants to be awarded in January 
        2001 to improve FSP access through partnerships and new 
        technology. The purpose of the grants is to explore 
        various strategies to reach potentially eligible 
        households and to educate food stamp eligible persons 
        not currently participating in FSP about the benefits 
        of the Program and how to apply for these benefits. One 
        of the target populations for these grants is the 
    The Food and Nutrition Service (FNS) continues to work 
closely with the Social Security Administration (SSA) in order 
to meet the legislative objectives of joint application 
processing for Supplemental Security Income (SSI) households.
    In response to recommendations for joint processing 
improvements, FNS and SSA have stepped up efforts to ensure 
that SSI applicants are counseled on their potential 
eligibility to receive food stamps. Additionally, a joint 
Supplemental Security Income/Food Stamp processing 
demonstration--the South Carolina Combined Application Project 
(SCCAP)--was begun in the fall of 1995. An independent 
evaluation of SCCAP was completed in January 2000 and showed 
that the rate of food stamp participation among SSI recipients 
in South Carolina increased from 38 percent in 1994 to 50 
percent in 1998 while the national rate decreased from 42 
percent to 38 percent during the same period. Net potential 
savings at the South Carolina Department of Social Services are 
estimated at $575,000 per year. Based on the success of the 
project, FNS agreed to extend SCCAP for a maximum of three 
additional years (through September 2000). During this time, 
Congress will have a chance to review the findings of the 
evaluation and determine whether the results warrant amending 
the Food Stamp Act so that South Carolina may continue to use 
the special provisions of SCCAP as part of its normal FSP 

               Commodity Supplemental Food Program (CSFP)

Title and purpose statement of each program or activity which affects 
        older Americans

    The Commodity Supplemental Food Program provides 
supplemental foods, in the form of commodities, and nutrition 
education to infants and children up to age 6, pregnant, 
postpartum or breastfeeding women, and the elderly (at least 60 
years of age) who have low incomes and reside in approved 
project areas.
    Service to the elderly began in 1982 with pilot projects. 
In 1985, allowed the participation of older Americans outside 
the pilot sites if available resources exceed those needed to 
serve women, infants and children. In fiscal year 1999, 
approximately $45 million was spent on the elderly component.

Brief description of accomplishments

    About 65 percent of total program spending provides 
supplemental food to approximately 270,000 elderly participants 
a month. Older Americans are served by 23 eligible State 

        Food Distribution Program on Indian Reservations (FDPIR)

Title and purpose statement of each program or activity which affects 
        older Americans

    The Food Distribution Program on Indian Reservations 
provides commodity packages to eligible households, including 
households with elderly persons, living on or near Indian 
reservations. Under this program, commodity assistance is 
provided in lieu of food stamps.
    Approximately $27 million of total costs went to households 
with a lease one elderly person. (This figure was estimated 
using a 1990 study that found that approximately 39 percent of 
FDPIR households had at least one elderly individual).

Brief description of accomplishments

    This program serves approximately 15,000 households with 
elderly participants per month.

               Child and Adult Care Food Program (CACFP)

Title and purpose statement of each program or activity which affects 
        older Americans

    The Child and Adult Care Food Program provides Federal 
funds to initiate, maintain, and expand nonprofit food service 
for children, the elderly, or impaired adults in nonresidential 
institutions which provide child or adult care. The program 
enables child and adult care institutions to integrate a 
nutritious food service with organized care services.
    The adult day care component permits adult day care centers 
to receive reimbursement of meals and supplements served to 
functionally impaired adults and to persons 60 years or older. 
An adult day care center is any public or private nonprofit 
organization or any proprietary Title XIX or Title XX center 
licensed or approved by Federal, State, or local authorities to 
provide nonresidential adult day care services to functionally 
impaired adults and persons 60 years or older. In fiscal year 
1999, $36 million was spent on the adult day care component.

Brief description of accomplishments

    The adult day care component of CACFP served approximately 
32 million meals and supplements to over 62,000 participants a 
day in fiscal year 1999.
    In 1993, the National Study of the Adult Component of CACFP 
was completed. Some of the major findings of the study include: 
overall, about 31 percent of all adult day care centers 
participate in CACFP; about 43 percent of centers eligible for 
the program participate. CACFP adult day care clients have low 
incomes; 84 percent have incomes of less than 130 percent of 
poverty. Many participants consume more than one reimbursable 
meal daily; CACFP meals contribute just under 50 percent of a 
typical participant's total daily intake of most nutrients.

             The Emergency Food Assistance Program (TEFAP)

Title and purpose statement of each program or activity which affects 
        older Americans

    The Emergency Food Assistance Program (TEFAP) provides 
nutrition assistance in the form of commodities to emergency 
feeding organizations for distribution to low-income households 
for household consumption or for use in soup kitchens.
    Approximately $17 million in commodities were distributed 
to households including an elderly person. (This figure is 
estimated using a 1986 survey indicating that about 38 percent 
of TEFAP households have members 60 years of age or older.)

Brief description of accomplishments

    About 38 percent of the households receiving commodities 
under this program had at least one elderly individual.

                Nutrition Program for the Elderly (NPE)

Title and purpose statement of each program or activity which affects 
        older Americans

    The Nutrition Program for the Elderly provides cash and 
commodities to States for distribution to local organizations 
that prepare meals served to elderly persons in congregate 
settings or delivered to their homes. The program addresses 
dietary inadequacy and social isolation among older 
individuals. USDA currently supplements the Department of 
Health and Human Services' Administration on Aging with 
approximately $141 million worth of cash and commodities.

Brief description of accomplishments

    In fiscal year 1999, over 247 million meals were reimbursed 
at a cost of almost $150 million. On a average day 
approximately 932,000 meals were provided.


    On September 28, 2000, CNPP hosted a symposium titled 
``Nutrition and Aging: Leading a Healthy, Active Life.'' This 
is the fifth in a series of symposiums hosted by CNPP that has 
included topics such as Childhood Obesity, Breakfast and 
Learning in Children, and Dietary Behavior. The purpose of the 
symposiums is to provide participants with the latest available 
scientific information, to increase the awareness of important 
nutritional issues, and to examine how these issues influence 
nutrition policy.
    The following publication on the elderly have been prepared 
by CNPP staff in calendar years 1999-2000:
    Sahyoun, Nadine and Basiotis, P. Peter, ``Food 
Insufficiency and the Nutritional Status of the Elderly 
Population,'' Nutrition Insights, Insight #18, May 2000.
    Gaston, Nancy W., Mardis, Anne, Gerrior, Shirley, Sahyoun, 
Nadine, and Anand, Rajen S, ``A Focus on Nutrition for the 
Elderly: It's Time to Take a Closer Look,'' `Nutrition 
Insights, Insight #14, July 1999.


                   New Education Program for Seniors:

    With input from experts on aging, the Food Safety and 
Inspection Service has worked cooperatively with the Food and 
Drug Administration to produce a new educational program for 
seniors: a 14 minute video and accompanying publication both 
titled To Your Health, Food for Seniors.
    In developing this educational program, FSIS staff drew on 
the expertise of varied groups including the Administration on 
Aging, the National Institutes of Health, AARP and the State 
Units on Aging. As a result of those consultations, the program 
materials are targeted to address unique behaviors that can 
contribute to the risks of foodborne illness for seniors. They 
are also presented in formats designed to be ``senior 
friendly.'' The 17-page publication is printed in 14 point type 
to make reading easier to older eyes. The publication is 
presented in a large format--8\1/2\ by 11 inches--to make it 
easy to hold and use. The video presents information in a clear 
and concise manner with key points highlighted and repeated for 
emphasis. The video is broken into two segments, one addressing 
safe food handling at home and the other, food safety when 
eating out.
    The key food safety messages in the campaign--clean, 
separate, cook and chill--are drawn from the national food 
safety education campaign called Fight BAC! 
Support of these four key food safety messages is a goal of 
Healthy People 2010 and the new Dietary Guidelines for 
    The educational program will be distributed early in 2001 
and will include distribution to the Administration on Aging's 
area offices and direct mail to more than 10,000 senior 
centers. The publication will also be available through the 
Consumer Information Center in Pueblo, CO. In all, more than a 
half a million copies of the publication and nearly 50,000 
copies of the video will be distributed.

                On-going Food Safety Advice for Seniors:

    To help communicate the importance of safe food handling 
for seniors--and their special risks--all press releases issued 
by FSIS include a box with safe food handling advice for at-
risk audiences. This advice is also routinely featured in video 
news releases as well as feature stories. The Food Safety 
Education staff also develops special features and fact sheets 
designed to help educate seniors about safe food handling--
available through the FSIS web site:


    The Agricultural Marketing Service facilitates the 
accessibility of agricultural products to older Americans by 
promoting and developing wholesale, collection, farmers, and 
direct markets. The support provided for these markets has made 
fresh, nutritious foods available in communities where older 
Americans have previously not had access to such products. The 
number of farmers markets has increased from 1,755 in 1994 to 
over 2,800 in 2000.

                     ITEM 2--DEPARTMENT OF COMMERCE



    This report provides short descriptions and listings of 
products that contain demographic and socioeconomic information 
on the elderly population, 65 years of age and older, in the 
United States and abroad. All of the items included in this 
report were released by the U.S. Census Bureau during calendar 
years 1999 and 2000.
    The items listed are available to the public in a variety 
of formats including print, electronic data bases, 
microcomputer diskettes, and CD-ROM. Many of these products can 
be found on the Internet at the Census Bureau's Web site at: 
    1. Population, Housing, and International Reports.--Three 
of the Census Bureau's major report series (Current Population 
Reports, Current Housing Reports, and International Population 
Reports) are important sources of demographic information on a 
wide variety of population-related topics. This includes 
information on the United States' elderly population, ranging 
from their numbers in the total population to socioeconomic 
characteristics, such as income, health insurance coverage, 
need for assistance with activities of daily living, and 
housing situation. Data on the elderly around the world also 
are found in these series of reports.
    Much of the data used in Current Population Reports are 
derived from the Current Population Survey (CPS) and the Survey 
of Income and Program Participation (SIPP). The Current Housing 
Report series presents housing data primarily from the American 
Housing Survey, a biennial national survey of approximately 
55,000 housing units. The International Population Report 
series includes demographic and socioeconomic data reported by 
various national statistical offices, such as the National 
Institute on Aging, agencies of the United Nations, and the 
Organization for Economic Cooperation and Development.
    Additionally, the Census Bureau's population projection 
program and Special Studies Report series contain information 
about the future estimated size of the elderly population and 
information pertaining to statistical methods, concepts, and 
specialized data.
    2. Decennial Products.--A large number of printed reports, 
computer tape files, CD-ROMs, and summary tape files are 
produced after each decennial census. Included in these 
materials are information and data on the numbers and 
characteristics of persons 65 years of age and older.
    3. Data Base on Aging/National Institute on Aging 
Products.--The data provide a summary of analytical studies and 
other ongoing international aging products. Reports are based 
on compilations of data obtained from statistical offices of 
individual countries, various international organizations, and 
estimates and projections prepared at the Census Bureau. This 
work is funded by the National Institute on Aging.
    4. Federal Interagency Forum on Aging-Related Statistics 
Summary.--The Forum, for which the Census Bureau is one of the 
lead agencies, encourages cooperation, analysis, and 
dissemination of data pertaining to the older population. A 
summary of the activities of the Forum lists a number of aging-
related statistics.
    5. Other Products.--In addition to the major products 
listed separately, we include a list of other data products 
that contain demographic and socioeconomic information on the 
elderly population.



                                                           Report Number
Series P-20 (Population Characteristics):
    Regularly recurring reports in this series contain data from 
      the Current Population Survey. Topics include geographical 
      mobility, fertility, school enrollment, educational 
      attainment, marital status and living arrangements, 
      households and families, the Black and Asian and Pacific 
      Islander populations, persons of Hispanic origin, voter 
      registration and participation, and various other topics for 
      the general population, as well as the elderly population 65 
      years and older.
    School Enrollment--Social and Economic Characteristics of 
      Students: October 1997......................................   516
    The Foreign-Born Population in the United States: March 1999..   519
    Geographical Mobility 1997 to 1998............................   520
    School Enrollment--Social and Economic Characteristics of 
      Students: (Update) October 1998.............................   521
    Computer Use in the United States: October 1997...............   522
    Voting and Registration in the Election of November 1998...... 523RV
    The Hispanic Population in the United States: March 1998......   525
    Fertility of American Women: June 1998........................   526
    The Hispanic Population in the United States: March 1999......   527
    Educational Attainment in the United States: March 1999.......   528
    The Asian and Pacific Islander Population in the United 
      States: March 1999..........................................   529
    The Black Population in the United States: March 1999.........   530
    Geographical Mobility (Update): March 1998 to March 1999......   531
    The Older Population in the United States: March 1999.........   532
Series P-23 (Special Studies):
    Information pertaining to methods, concepts, or specialized 
      data is furnished in these publications. Reports in this 
      series contain data on mobility rates, home ownership rates, 
      and the Hispanic population for both the general and older 
    Profile of the Foreign--Born Population in the United States..   195
    Trends in Premarital Childbearing.............................   197
    Coresident Grandparents and Grandchildren.....................   198
    Centenarians in the United States............................. 199RV
    Geographical Mobility: 1990-1995..............................   200
    Poverty Among Working Families: Findings From Experimental 
      Poverty Measures 1998.......................................   203
Series P-25 (Population Estimates and Projections):
    Population estimates data include monthly estimates of the 
      total U.S. population; annual midyear estimates of the U.S. 
      population by age, sex, race, Hispanic origin (nativity was 
      added for the 1998 series of estimates); States by age and 
      sex; and population totals for counties, metropolitan areas, 
      and approximately 36,000 cities and other local governments. 
      The estimates for counties appeared in Series P-26 during 
      the 1970s and 1980, as did estimates for the approximately 
      36,000 local governments during the 1980s. Estimates for 
      Puerto Rico and the outlying areas were published in Series 
      P-25 through the 1980s. Estimates of the population for 
      Puerto Rico, outlying areas, and United States and state 
      housing unit estimates are available in the P-25 series and 
      more recently in press releases mentioned in this 
      publication. At present, most estimates formerly published 
      in the P-25 series are released only through the Internet, 
      with future plans to archive annual estimates data on CD-
    Projections of the United States and state populations are 
      also included in the P-25 series. Beginning in the 1980's, 
      projections are available not only by age and sex, but also 
      by race and Hispanic origin. There also can be occasional 
      research/developmental reports in this series. The Census 
      Bureau's plan for releasing projections include CD-ROM and 
      the Internet.
    Population Trends in Metropolitan Areas and Central Cities....  1133

     Population Estimates available on the Census Bureau's Web site

National Population Estimates:
    Annual Population Estimates--Median and Mean Age; 5-year Age 
      Groups; Sex; and Special Age Categories for Selected Years 
      from 1990 to 2000. July 1 dates, plus the most recent month 
      for which data are available.
    Annual Population Estimates by Age, Sex, Race and Hispanic 
      Origin; Median Age; Sex; Race (White; Black; American 
      Indian, Eskimo, and Aleut; and Asian and Pacific Islander); 
      Hispanic (of any race) and Non-Hispanic by Race for Selected 
      Years 1990 to 2000. July 1 dates, plus the most recent month 
      for which data is available.
    Population by Nativity--National Population Estimates by 
      Nativity from 1990-1999 (Includes age).
State Population Estimates (Includes: U.S. Regions, Divisions, and 
    1990 to 1999 Annual Time Series of State Population Estimates 
      by Age and Sex; By 5-Year Age Groups and Sex, Selected Age 
      Groups and Sec, and Single Year of Age and Sex, Median Ages: 
      1990 and 1999.
    1990 to 1999 Annual Time Series of State Population Estimates 
      by Race and Hispanic Origin: By Age, Sex, Race, and Hispanic 
County Population Estimates:
    1990 to 1999 Annual Time Series of County Population Estimates 
      by Age, Sex, Race and Hispanic Origin: By Age, Sex, Race, 
      Hispanic Origin, and Selected Age Groups.
Household and Housing Unit Population Estimates:
    Housing Units, Households, Households by Age of Householder, 
      and Persons per Household for States: 1998 Estimates, 1990 
      Census, 1990 to 1998 Percent Change, 1990 to 1998 Numeric 
      and Percent Change, 1998 Percent Distribution of Households 
      by Age of Householder, 1990 to 1998 Annual Time Series.

                         Population Projections

National Population Projections:
    The Population Projections Program produces projections of the 
      United States resident population by age, sex, race, 
      Hispanic origin, and nativity. The projections are based on 
      assumptions about future births, deaths, and international 
      migration. Although alternative series are produced, the 
      preferred, or middle series, is most commonly used. The 
      Census Bureau releases new national population projections 
Press Releases Available on Population Projections:
    (NP-T3) Projections of the Total Resident Population by 5-Year 
      Age Groups and Sex with Special Age categories: Middle 
      Series, 1999 to 2100.
    (NP-T4) Projections of the Total Resident Population by 5-Year 
      Age Groups, Race, and Hispanic Origin with Special Age 
      categories: Middle Series, 1999 to 2100.
    (NP-D1-A) Annual Projections of the Resident Population by 
      Age, Sex, Race, and Hispanic Origin: Lowest, Middle, 
      Highest, and Zero International Migration Series, 1999 to 
    (NP-D1-B) Quarterly Projections of the Resident Population by 
      Age, Sex, Race, and Hispanic Origin: Middle Series, January 
      1, 1999 to January 1, 2101.
    (NP-D2) Projections of the Foreign-Born Population by Age, 
      Sex, Race, and Hispanic Origin: Lowest, Middle, Highest 
      Series, 1999 to 2100.
    (NP-D5) Components of Change: Component Assumptions of the 
      Resident Population by Age, Sex, Race, and Hispanic Origin: 
      Lowest, Middle, Highest Series, 1999 to 2100.
    Population Pyramids: Total Population by 5-Year Age Groups: 
      1990, 2000, 2025, 2050, 2100.
Series PPL (Population Paper Listings):
    This series of reports contains estimates of population and 
      projections of the population by age, sex, and origin. Other 
      topics appear as well some of which address issues related 
      to aging.
    The Asian and Pacific Islander Population in the United 
      States: March 1998 (Update).................................   113
    Computer Use in the United States: October 1997...............   114
    Profiles of the Foreign-Born Population in the United States: 
      1997........................................................   115
    Fertility of American Women: June 1998........................   116
    The Foreign-Born Population in the United States: March 1998..   117
    Geographical Mobility: March 1997 to March 1998...............   118
    School Enrollment--Social and Economic Characteristic of 
      Students: October 1998 (Update).............................   119
    Voting and Registration in the Election of November 1998......   120
    Foreign-Born Population in the United States: March 1999......   123
    The Hispanic Population in the United States: March 1999......   124
    Educational Attainment in the United States: March 1999.......   125
    Foreign-Born People in the United States: March 1995..........   127
    Foreign-Born People in the United States: March 1996..........   128
    Foreign-Born People in the United States: March 1997..........   129
    The Black Population in the United States: March 1999 (Update)   130
    The Asian and Pacific Islander Population in the United 
      States: March 1999 (Update).................................   131
    Geographical Mobility: March 1998 to March 1999...............   132
    The Older Population in the United States: March 1999.........   133
    Geographical Mobility: 1990-1995..............................   137
    Who is Minding the Kids? Child Care Arrangements Fall 1995....   138
Technical Working Papers Series:
    This series contains papers of a technical nature on various 
      topics, which have been written by staff of the Population 
      Division of the Census Bureau. Evaluation of population 
      projections, estimates and 1990 Census results, examination 
      of immigration issues, race and ethnic considerations, and 
      fertility patterns are some of those topics.
    ``Are There Differences in Voting Behavior Between Naturalized 
      and Native-born Americans?'' by Loretta E. Bass and Lynn M. 
      Casper, Issued 1999.........................................    28
    ``Historical Census Statistics on the Foreign-born Population 
      of the United States: 1850-1990 by Campbell J. Gibson, 
      Issued February 1999........................................    29
    Women's Labor Force Attachment Patterns and Maternity Leave: A 
      Review of the Literature by Kristen E. Smith and Amara 
      Bachu, Issues January 1999..................................    32
    Evaluation of Relationship, Marital Status, and Grandparents 
      Items on the Census 2000 Dress Rehearsal by Charles Clark 
      and Jason Fields, Issued April 1999.........................    33
    Unbinding the Ties: Edit Effects of Marital Status on Same 
      Gender Couples by Jason Fields and Charles Clark, Issued 
      April 1999..................................................    34
    Racial-Ethnic and Gender Differences in Returns to 
      Cohabitation and Marriage: Evidence from the Current 
      Population Survey by Philip N. Cohen, Issued May 1999.......    35
    How Does POSSLQ Measure Up? Historical Estimates of 
      Cohanitation  by Lynne M. Casper, Philip N. Cohen, and Tavia 
      Simmons, Issued May 1999....................................    36
    Is Childlessness Among American Women on the Rise? by Amara 
      Bachu, Issued May 1999......................................    37
    Population Projections of the United States, 1999 to 2100: 
      Methodology and Assumptions by Frederick Hollmann, Tammany 
      Mulder, and Jeffrey Kallan, Issued January 2000.............    38
    What Do We Know About the Undercount of Children? by Kristin 
      K. West and J. Gregory Robinson, Issued August 1999.........    39
    Measures of Help Available to Households in Need: Their 
      Relation to Well-being, Welfare, and Work by Kurt J. Bauman 
      and Barbara Downs, Issued May 2000..........................    42
    Have We Reached the Top? Educational Attainment Projections of 
      the U.S. Population by Jennifer Cheeseman Day and Kurt J. 
      Bauman, Issued May 2000.....................................    43
    The Effects of Work and Welfare on Living Conditions in Single 
      Parent Households, by Kurt J. Barman, Issued August 2000....    46
Series SB/CENBR (Statistical Briefs):
    These are succinct reports that are issued occasionally and 
      provide timely data on specific issues of public policy. 
      Presented in narrative style with charts, the reports 
      summarize data from economic and demographic censuses and 
      surveys. In December 1996, the Statistical Brief series 
      format was revised and became known as Census Briefs.
    Women in the United State: A Profile..........................  00-1
    Coming to America: A Profile of the Nation's Foreign-Born.....  00-2
    From the Mideast to the Pacific: A Profile of the Nation's 
      Asian Foreign-Born Population...............................  00-4
Series P-60 (Consumer Income):
    This series of reports presents data on the income, poverty 
      and health insurance status of households, families, and 
      people in the United States.
    Child Support for the Custodial Mothers and Fathers: 1995.....   196
    The Changing Shape of the Nation's Income Distribution: 1947-
      1998........................................................   204
    Experimental Poverty Measures.................................   205
    Money Income in the United States: 1998.......................   206
    Poverty in the United States: 1998............................   207
    Health Insurance Coverage: 1998...............................   208
    Money Income in the United States: 1999.......................   209
    Poverty in the United States: 1999............................   210
    Health Insurance Coverage: 1999...............................   211
    Child Support for the Custodial Mothers and Fathers: 1997.....   212
Series P-70 (Household Economic Studies):
    These data are from the Survey of Income and Program 
      Participation (SIPP), a national survey conducted by the 
      Census Bureau. Its principal purpose is to provide better 
      estimates of the economic situation of families and 
      individuals. These reports include data on the elderly 
      population 65 years and older.
    Financing the Future: Postsecondary Students, Cost, and 
      Financial Aid...............................................    60
    Extended Measures of Well-Being: Meeting Basic Needs..........    67
    Dynamics of Economic Well-Being: Program Participation, Who 
      Gets Assistance?............................................    69


These data are from the American Housing Survey. The survey 
    presents data on apartments; single-family homes; mobile 
    homes; vacant housing units; age, sex, and race of 
    householders; housing and neighborhood quality; housing 
    costs; equipment and fuels; and size of housing units. 
    Reports are present data on homeowner's repairs and 
    mortgages, rent control, rent subsidies, previous units of 
    recent movers, and reasons for moving. A wall chart 
    accompanies each report.
Series H-170 (Housing Characteristics for Selected Metropolitan 
    A separate report present data for individual metropolitan 
      areas for the same characteristics shown in Series H-150. 
      Eleven to 13 metropolitan areas are interviewed each year. 
      They are surveyed on a rotating basis, with a total of 48 
      metropolitan areas being surveyed within a 6-year period.

                         2. DECENNIAL PRODUCTS

    Centenarians in the United States: 1990, Connie Krach and 
Victoria A. Velkoff, Current Population Reports, Series P-23-
199, Washington, DC 1999.
    State Chartbook on Aging, forthcoming. This report presents 
state-level data for the population aged 65 and older for 
several key indicators; population, race and ethnic group, 
marital status, living arrangements, and poverty. Most of the 
data are from the 1990 Census of Population and Housing for the 
United States.


    The following reports, articles, and book chapters are 
based on information contained in the International DataBase on 
Aging and other related holdings of the International Programs 
Center, Population Division, Census Bureau. This work is 
carried out with the support of the National Institute on Aging 
and is intended to highlight the present and future worldwide 
dimensions of aging and portray the diversity among nations.
    ``Gender Stereotypes: Data Needs for Aging Research.'' 
Victoria A. Velkoff and Kevin Kinsella. International Aging, 
Spring 1998, Vol. 24, No. 4, pp. 18-38.
    ``Russia's Aging Population'' Victoria A. Velkoff and Kevin 
Kinsella. In Russia's Torn Safety Nets, Mark G. Field and 
Judyth L. Twigg, eds. St. Martin's Press, New York, 2000.

                            Work in Progress

    An Aging World 2000, forthcoming. This report gives a 
cross-national comparison of aging in 52 study countries. It 
focuses on both the demographic aspect of aging in these 
countries and the socioeconomic impact of aging. The report 
highlight projected trends into the 21st century for the 
world's older population.
    Aging in Africa, forthcoming. This report examines the 
demographic and socioeconomic characteristics of the older 
population in Sub-Saharan Africa and will highlight the impact 
of HIV/AIDS on the older populations in these countries.
    World Population Profile: 2000, forthcoming. This report 
provides comprehensive demographic data for all countries and 
regions of the world. There are two special focus sections in 
the report, ``Child Mortality in the Developing World'' and 
``Focus of the AIDS Pandemic in the 21st Century.''


    The Census Bureau is one of the convening agencies in the 
Federal Interagency Forum on Aging-Related Statistics. The 
Forum, begun in the mid-1980s, was the first-of-its-kind effort 
to coordinate data and efforts of different government 
agencies. The Forum currently is being managed by staff of the 
National Center for Health Statistics, with the support of the 
National Institute on Aging.
    The Forum encourages cooperation among federal agencies in 
the development, collection, analysis, and dissemination of 
data pertaining to the older population. Through coordinated 
approaches, the Forum extends the use of limited resources 
among agencies through joint problem-solving, identification of 
data gaps, and improvement of statistical information bases on 
the older population, which are used to set project priorities 
of individual agencies.
    The Forum goals include widening access to information on 
the older population, promoting communication between data 
producers and public policymakers, coordinating the development 
and use of statistical databases among relevant federal 
agencies, identifying information gaps/data inconsistencies, 
and evaluating data quality. The work of the Forum facilitates 
the exchange of information about needs at the time new data 
are being developed or changes are being made in existing data 
systems. It also promotes communication between data producers 
and policymakers.
    As part of the Forum's work to improve access to data on 
the older population, in 1999, the Census Bureau published a 
report entitled DataBase News in Aging, which includes 
developments in databases of interest to researchers and others 
in the field of aging. Much of the information comes from 
government-sponsored surveys and products. All federal agencies 
are invited to contribute to the report, which is produced in 
hard copy and is available on the Census Bureau's Internet 
    In 2000 the Forum produced the report, Older Americans 
2000: Key Indicators of Well-Being. This report described the 
overall status of the U.S. population 65 and over. It compiled 
data to focus on several important areas in the lives of older 
people--including economic status, health status, health risks 
and behaviors, and health care.

                           5. OTHER PRODUCTS

    Profile on Racial and Ethnic Diversity Among Older 
Americans, forthcoming. This report focuses on racial and 
ethnic differences in America's older population using data 
from the Current Population Survey (CPS).

                        American Housing Survey

    Computer data tapes and CD-ROM are available for the 1997 
survey efforts. The survey is designed to provide information 
on the housing situation in the United States. Information is 
available by age.

           CPS and Survey of Income and Program Participation

    Data for both surveys are available in electronic media.

Statistical Abstract of the United States: 1999

    As the National Data Book, these annually released products 
contain an enormous collection of statistics on social and 
economic conditions in the United States. Selected 
international data also are included. The abstract appears in 
both print and CD-ROM versions.

International DataBase

    The International Data Base (IDB) is a computerized data 
bank containing statistical tables of demographic and 
socioeconomic data for all countries of the world. Most 
demographic information comes from country-specific estimates 
and projections made by the Census Bureau's International 
Programs Center. Country-specific data on social and economic 
characteristics are obtained from censuses and surveys or from 
administrative records. Country files are regularly updated as 
new information becomes available. Selected information from 
the IDB is highlighted in the Census Bureau's various 
international reports and publications mentioned previously.

                     ITEM 3--DEPARTMENT OF DEFENSE


                           Eldercare Support

    Military members and their families face unique challenges 
when facing Eldercare issues. Military members and families are 
often stationed far away from elderly relatives who may need 
their assistance. These demands seem to be increasing as life 
expectancies increase. Military families often find themselves 
trying to deal long-distance, even from overseas, with finding 
quality, affordable care for elderly family members. The 
situation is often further complicated by military family 
separations that are the norm of military life.
    In the 1999 Department of Defense Survey of active duty 
members, of those responding to the survey, we estimate that 
4.1 percent of the force has caregiver responsibilities for 
elderly loved ones. Of the 4.1 percent, 72 percent of those 
indicated that they have responsibility for one elder person, 
23.5 percent indicated responsibility for 2 elderly persons, 
and 4.5 percent indicated responsibilities for 3 or more.
    The Information and Referral (I&R;) function of the 
Department of Defense Family Support programs is a critical 
source of information to families struggling to balance the 
demands of military life with the need to ensure the well-being 
and safety of elderly parents and loved-ones. Internet 
resources have proved to be a valuable tool for family support 
specialists who can research information and help military 
families start on the right path in sifting through this 
mountain of information. The I&R; specialists often use the 
Eldercare Locator which directs them to appropriate local 
resources. The I&R; specialists will filter a quantity of 
information in order to assist the inquiring service member 
with the appropriate resource and advice. While the assistance 
family support I&R; specialists can provide is limited, they 
make every effort to connect military families with the best 
and most reliable resources for making informed choices.
    The I&R; specialists often receive inquiries about making an 
elderly loved one a legal dependent of the service member. The 
specialists will caution the member to carefully consider this 
option since the elderly loved one may lose state benefits if 
they relocate with the service member. In addition, if they 
become a legal dependent of the military person, they are not 
eligible for TRICARE.
    The Family Centers also have a number of useful pamphlets 
and handouts on eldercare which they provide to military family 
members seeking assistance for a particular eldercare issue. 
The Family Centers often work with the local Retired Affairs 
Offices across the country in sponsoring Retired Affairs 
Seminars which draw thousands of military retirees and their 
families. For these seminars, staff bring in experts to present 
eldercare topics such as: long-term care insurance, respite 
care, medical information, social security benefits and 
eldercare legal issues. These seminars are an important vehicle 
to update the military retiree community on current eldercare 

                              Health Care

    TRICARE is the health plan for uniformed services 
beneficiaries. It is a regionally organized managed care 
program that integrates the military health facilities of the 
Army, Navy and Air Force and supplements the care these 
facilities offer with civilian networks of providers. TRICARE 
offers three choices for health care delivery: TRICARE Prime, 
TRICARE Extra, and TRICARE Standard. TRICARE Prime, a voluntary 
enrollment option, offers patients the advantage of primary 
care management, assistance in making specialty appointments, 
and additional preventive and primary care services. For 
eligible beneficiaries, TRICARE Prime generally is the least 
expensive option.
    TRICARE Extra allows eligible beneficiaries to receive an 
out-of-pocket discount when using preferred network providers. 
Eligible beneficiaries who do not enroll in TRICARE Prime may 
participate in Extra on a case-by-case basis just by using 
network providers. Beneficiaries selecting TRICARE Extra do 
incur deductibles and co-payments. TRICARE Standard offers 
comprehensive healthcare coverage from any authorized provider. 
Beneficiaries selecting this option incur deductibles and co-
payments at a slightly higher rate than those selecting TRICARE 
    All active duty members enroll in TRICARE Prime without 
cost to the member. Family members, survivors and retirees 
under the age of 65 may enroll in TRICARE Prime. Retirees and 
their family members pay a small enrollment fee and all 
eligible beneficiaries except active duty members incur nominal 
co-payments for care received from network providers. Care 
received in military medical facilities is without cost to 
beneficiaries; for those not enrolled in TRICARE Prime, care in 
military medical facilities is received on a space available 
    During this reporting period, the law stipulated that 
military retirees and their families up to age 65 are eligible 
for the three TRICARE options. Military retirees and their 
dependents over the age of 65 may not participate in TRICARE, 
but they are eligible for care in military medical facilities 
on a space available basis. Included in this space available 
coverage are prescription drugs provided the needed medications 
are on the facility's formulary. Additionally, the Department 
of Defense sought ways to enhance its services to its over-65 
beneficiaries through a number of demonstration programs. 
Specifically, the Department tested alternatives to expand 
healthcare coverage to Medicare-eligible beneficiaries through 
Medicare reimbursement of military medical facilities, opening 
access to the Federal Employee Health Benefit Program, 
expanding pharmacy options, and offering supplemental coverage 
to Medicare.
    Implemention of the Floyd D. Spence National Defense 
Authorization Act of fiscal year 01 will directly impact these 
demonstration programs and significantly change the healthcare 
coverage offered by the Department of Defense to its Medicare 
eligible beneficiaries. This new legislation is the most 
dramatic modification to military health care coverage since 
the establishment of the Civilian Health and Medical Program of 
the Uniformed Services in 1965. By April 2001, the Department 
of Defense will offer these senior beneficiaries the same 
prescription drug benefit enjoyed by other uniformed services 
beneficiaries. They will continue to use the military 
pharmacies with no cost for medications; and on April 1, 2001, 
they will be entitled to use the mail order pharmacy program, 
network retail and non-network retail pharmacies. Medications 
through these sources will require a nominal copayment of $3 
for generic and $9 for branded medications; by mail order 
patients may receive up to a 90-day supply for this amount, and 
in the network retail pharmacies they may receive up to a 30-
day supply for this amount. The non-network retail pharmacies 
will cost a bit more. Also in the next year, senior 
beneficiaries will become eligible for TRICARE for Life 
benefits, the most significant of which is the secondary pay 
program. Beginning October 1, 2001, TRICARE will supplement 
Medicare benefits of these uniformed services beneficiaries, 
and, in most cases, with no additional claims processing 
required by the patient. To participate, these beneficiaries 
must be eligible for Medicare Part A and enrolled in Medicare 
Part B. They may continue to seek care from their Medicare 
providers and have TRICARE pick up the cost of their 
deductible, co-payments and other costs not paid by Medicare. 
TRICARE will also cover any TRICARE benefit that Medicare does 
not offer. Out-of-pocket expenses for these dual eligible 
beneficiaries will be a nominal co-payment for medications and 
Medicare Part B fees. This legislation brings to the senior 
military retirees and their dependents a health benefit that is 
unparalleled. It provides low-cost access to an extraordinary 
range of healthcare benefits, and offers choice in selection of 
providers. This legislation brings healthcare coverage by the 
Department of Defense as an entitlement to our senior 

                      ITEM 5--DEPARTMENT OF ENERGY



    The Department of Energy (DOE) is a leading science and 
technology agency whose research supports our nation's energy 
security, national security, and environmental quality and 
contributes to a better quality of life for all Americans. DOE 
owns and manages more than 50 major installations located in 35 
states, employing approximately 10,000 federal workers and 
100,000 contract workers.
    Science is at the center of DOE's work, performed in its 27 
laboratories and other scientific user facilities and in the 
nation's universities. DOE supports breakthrough research in 
energy sciencesand technology, high energy physics, global 
climate change, genome mapping and the bio-sciences, 
superconducting materials, accelerator technologies, 
environmental sciences, and super-computing. DOE also supports 
science and mathematics education from the K-12 level through 
post-doctoral work.
    In support of the nation's energy security, DOE promotes 
development of clean, secure, sustainable energy resources, 
works to increase the diversity of energy supplies and fuel 
choices, and maintains the Strategic Petroleum Reserve.
    In fulfilling its national security mission, DOE assures 
the safety and reliability of the U.S. nuclear weapons 
stockpile without underground testing and supports U.S. non-
proliferation, arms control, and nuclear safety objectives 
    In meeting its environmental quality mission, DOE is 
responsible for cleaning up the environmental legacy left at 
sites where, for some 50 years, the nation's nuclear weapons 
were designed and manufactured.

                       Energy Efficiency Programs

    Weatherization Assistance Program--The program's mission is 
to make energy more affordable and improve health and safety in 
homes occupied by low-income families, particularly those with 
elderly residents, children, or persons with disabilities. 
Elderly residents make up approximately 40 percent of the low-
income households served by this program. As of September 30, 
2000 about 4.9 million homes had been weatherized with federal, 
state, and utility funds; of these, an estimated 2.0 million 
were occupied by elderly persons.
    Low-income households spend an average 15 percent of income 
for residential energy more than four times the proportion 
spent by higher income households. The weatherization program 
allows low-income citizens to benefit from energy efficiency 
technologies that are otherwise inaccessible to them. 
Alleviating the high energy cost burden faced by low-income 
Americans helps them increase their financial independence and 
their flexibility to spend household income on other needs.
    The program has become increasingly effective due to 
improvements in air-leakage control, insulation, water heater 
systems, windows and doors, and space heating systems. At 
current prices, a weatherized low-income household now saves 
approximately $250 per year, about one-third of its space 
heating costs. Program benefits are further described in the 
Progress Report of the National Weatherization Assistance 
Program, available through the National Technical Information 
Service, 703/487-4650, 5285 Port Royal Road, Springfield, VA 
    States implement the program through community-based 
organizations. DOE and its state and community partners 
weatherize approximately 70,000 single- and multi-family 
dwellings each year. The program awarded $133 million in Fiscal 
Year 1999 and $135 million in Fiscal Year 2000 for grants to 
the 50 states, the District of Columbia, and six Native 
American tribal organizations. In addition to DOE 
appropriations, state and local programs receive funding from 
the Department of Health and Human Services' Low Income Home 
Energy Assistance Program, from utilities, and from states.
    State Energy Program--The program provides grants to State 
Energy Offices to encourage the use of energy efficiency and 
renewable energy technologies and practices in states and 
communities through technical and financial assistance. In 
Fiscal Year 1999, $32 million wasappropriated for the program 
and in Fiscal Year 2000, $33 million. States have broad 
discretion in designing their projects. Typical project 
activities include: public education to promote energy 
efficiency; transportation efficiency and accelerated use of 
alternative transportation fuels for vehicles; financial 
incentives for energy conservation/renewable projects including 
loans, rebates, and grants; energy audits of buildings and 
industrial processes; development and adoption of integrated 
energy plans; promotion of energy efficient residences; and 
deployment of newly developed energy efficiency and renewable 
energy technologies.
    Some projects target the elderly specifically, such as 
Louisiana's low-income/handicapped/elderly/Native American 
outreach program which provides energy related assistance 
through a joint venture with utilities. The elderly also 
benefit from broader programs that provide energy audits, 
hands-on energy conservation workshops, and low-interest loans 
for homeowners. These can result in significant personal energy 
savings. Energy efficiency improvements in local and state 
buildings and services also indirectly benefit the elderly by 
freeing up state and local government tax revenues for non-
energy needs, as do energy efficient schools which place less 
of a burden on property taxes.

                Information Collection and Distribution

    The Energy Information Administration collects and 
publishes comprehensive data on energy consumption through the 
Residential Energy Consumption Survey (RECS). The RECS is 
conducted in households quadrennially and collects data from 
individual households throughout the country, including those 
headed by elderly individuals. Along with household and housing 
unit characteristics data, the RECS also collects the actual 
billing data from the households' fuel suppliers for a 12-month 
    The results of the RECS are analyzed and published by the 
Energy Information Administration. The most recent survey data 
are from the 1997 RECS and are published on the Internet at The 1997 RECS public use data 
files are also available at this site. These files will include 
demographic characteristics of the elderly such as age, marital 
status and household income, as well as estimates of 
consumption and expenditures for electricity, natural gas, fuel 
oil, kerosene, and liquefied petroleum gas used in elderly 
    In the 1997 RECS, 28.5 million, or 28 percent of all U.S. 
households, were headed by a person 60 years of age or older. 
Of these elderly households, 44 percent were one-member 
households (12.4 million people living alone) and 44 percent 
contained two people. In 19 percent of the two-member elderly 
households both members were under the age of 65; in 21 percent 
of these households, only one member was younger than 65; and 
in 60 percent, both members were over the age of 65. 
Comparisons of elderly versus non-elderly households reveal 
           The 1997 household income of elderly 
        households was generally lower than that of non-elderly 
        households. Nearly a quarter, 23 percent, of elderly 
        households had incomes of less than $10,000, compared 
        to 9 percent of the non-elderly households. Only 12 
        percent of the elderly households had incomes of 
        $50,000 or more, compared to 34 percent of the non-
        elderly households. Of the 14.7 million U.S. households 
        whose income was below the poverty line, 37 percent 
        were headed by a person 60 years of age or older.
           Despite having lower household incomes, the 
        elderly households were more likely to own their 
        housing unit, 80 percent, than were non-elderly 
        households, 63 percent. The elderly were also more 
        likely to live in a single-family house, 76 percent, 
        than were non-elderly households, 71 percent.
           Elderly households are less likely to have a 
        personal computer or a modem connecting that computer 
        to the Internet or e-mail networks than are households 
        headed by persons less than 60 years of age. Among 
        elderly households, 14 percent have a personal computer 
        compared to 43 percent of the non-elderly households. 
        Only 7 percent of elderly households have a modem 
        connection compared to 26 percent of the non-elderly 
           Elderly households are only marginally less 
        likely to have a microwave oven, 79 percent, than are 
        non-elderly households, 85 percent.
    Analysis of the 1997 RECS data shows that consumption 
patterns differed between the elderly and non-elderly for some 
uses of energy. The elderly used more energy to heat their 
homes but used less energy for air conditioning, water heating, 
and appliances. Expenditures followed the same pattern. 
           The average expenditures per household 
        member in elderly households in 1997 was $708. This 
        amount was higher than the comparable amount for all 
        other households, due to the fact that households 
        headed by persons 60 years or more of age tend to be 
        smaller than those headed by persons under 60 years of 
           About 58 percent of total energy consumption 
        and about 37 percent of total energy expenditures in 
        elderly households were for space heating. On the other 
        hand, appliances accounted for 23 percent of 
        consumption and 45 percent of total expenditures in 
        elderly households. Energy costs for appliances are 
        much higher relative to consumption than are energy 
        costs for space heating because virtually all 
        appliances are powered by electricity, the most 
        expensive energy source, whereas space heating is 
        largely provided by other, less expensive, energy 

                       Research Related to Aging

    Through fiscal year (FY) 2000, the Office of Environment, 
Safety and Health (EH) sponsored research to further 
understanding of the human health effects of radiation. As part 
of this research program, DOE sponsored epidemiologic studies 
concerned with understanding health changes over time. Lifetime 
studies of humans constitute a significant part of EH's 
research; and because the risks of various health effects vary 
with age, these studies take age into consideration. EH 
supports research to characterize late-appearing effects 
induced by chronic exposure to low levels of physical agents, 
as well as some basic research on certain diseases that occur 
more frequently with increasing age.
    Because health effects resulting from chronic low-level 
exposure to energy-related toxic agents may develop over a 
lifetime, they must be distinguished from normal aging 
processes. To distinguish between induced and spontaneous 
changes, information is collected from both exposed and non-
exposed groups on changes that occur throughout the life span. 
These data help characterize normal aging processes and 
distinguish them from the toxicity of energy-related agents. 
Summarized below are specific research projects that the 
Department sponsored in FY 2000.
    Long Term Studies of Human Populations--Through EH, DOE 
supports epidemiologic studies of health effects in humans who 
may have been exposed to chemicals and radiation associated 
with energy production or national defense activities. 
Information on life span in human populations is obtained as 
part of these studies. Because long-term studies of human 
populations are difficult and expensive, they are initiated on 
a highly selective basis.
    The Radiation Effects Research Foundation, sponsored 
jointly by the United States and Japan, continues to work on a 
lifetime follow up of survivors of atomic bombings that were 
carried out in Hiroshima and Nagasaki in 1945. Over 100,000 
persons are under observation in this study. An important 
feature of this study is the acquisition of valuable 
quantitative data on dose-response relationships. Studies 
specifically concerned with age-related changes are also 
conducted. No evidence of radiation-induced premature aging has 
been observed.
    Multiple epidemiologic studies involving about 400,000 
contract employees at DOE facilities are being managed by the 
Department of Health and Human Services through a Memorandum of 
Understanding between the two agencies. These studies include 
assessments of health effects at older ages due to ionizing 
radiation and other industrial toxicants. Several of the 
studies will look closely at workers who were first exposed at 
age 45 or older, assessing the impact of these late exposures 
in relation to the burden of chronic diseases that are common 
among older people. The average age of workers included in 
these studies is greater than 50 years.
    A recent study indicated that workers who were 
occupationally exposed to radiation for the first time at age 
45 or older might be more sensitive to health effects than 
workers who were exposed at younger ages. However, very few 
workers at DOE fit this profile. This finding is very 
preliminary and further research and analyses are being 
conducted to see if these results can be duplicated.
    The United States Uranium/Transuranium Registry, currently 
operated by Washington State University, collects occupational 
data including work, medical, and radiation exposure histories 
and information on mortality among workers exposed internally 
to plutonium or other transuranic elements. Most of the workers 
participating in this voluntary program are retirees.
    In response to the Defense Authorization Act of 1993, EH 
has established a program involving a number of ongoing 
projects across the DOE weapons complex to identify former 
workers whose health may have been placed at risk as a result 
of occupational exposures that occurred from the 1940's through 
the 1960's. The projects provide medical screening and 
monitoring for former workers to identify those at high risk 
for occupationally related diseases and to identify workers 
with diseases that may be reduced in severity by timely 
    In addition to its epidemiologic research and health 
monitoring programs, EH has established the Comprehensive 
Epidemiologic Data Resource, a growing archive of data sets 
from the many epidemiologic studies sponsored by DOE. This 
public archive provides the research community with data that 
continue to be used to gain additional insights into the 
relationships between occupational exposures and a variety of 
health outcomes including diseases of aging like cancer.

               Other Doe-Funded Research Related to Aging

    Since the inception of the Atomic Energy Commission, the 
Department and its predecessor agencies have carried out a 
broad range of research and technology development activities 
which have impacted health care and medical research. The 
Medical Sciences Division within the Office of Biological and 
Environmental Research, Office of Science, carries out a 
Congressional mandate to develop beneficial applications of 
nuclear and other energy related technologies, including 
research on aging.
    The Aging Research involves study of a brain chemical, 
dopamine (DA), and its function in humans as they age. It has 
long been recognized that age brings a significant decline in 
the function of the brain DA system, but the functional 
significance of this loss is not known. Medical imaging 
studies, using radiotracers and positron emission tomography, 
are designed to investigate the consequences of age-related 
losses in brain DA activity in cerebral function and to 
investigate mechanisms involved with the loss of DA function in 
normal aging. The results of these studies to date have shown 
that healthy volunteers with no evidence of neurological 
dysfunction do experience a decline in parameters of DA 
function, which are associated with a decline in performance of 
motor and cognitive functions. The results of these studies 
also indicate that changes in life style, such as exercise, may 
be beneficial in promoting the health of the dopamine system in 
the elderly.




              Title XX Social Service Block Grant Program

    The major source of Federal funding for social services 
programs in the States is Title XX of the Social Security Act, 
the Social Services Block Grant (SSBG) program. The Omnibus 
Budget Reconciliation Act of 1981 (Public Law 97-35) amended 
Title XX to establish the SSBG program under which formula 
grants are made directly to the 50 States, the District of 
Columbia, and the eligible jurisdictions (Puerto Rico, Guam, 
the Virgin Islands, American Samoa, and the Commonwealth of the 
Northern Mariana Islands) for use in funding a variety of 
social services best suited to the needs of individuals and 
families residing within the State. Public Law 97-35 also 
permits States to transfer up to ten (10) percent of their 
block grant funds to other block grant programs for support of 
health services, health promotions and disease prevention 
activities, and low-income home energy assistance. In the 
welfare reform legislation, Section 103 of Title I of Public 
Law 104-193 gives states the authority to transfer up to 30 
percent of their Temporary Assistance to Needy Families (TANF) 
grant to SSBG and the Child Care Development Block Grant 
programs. The Balanced Budget Act of 1997 (Public Law 105-33) 
provided that the TANF transfer to SSBG would be up to 10 
percent of a State's TANF grant. The Transportation Equity Act 
of 1998 (Public Law 105-178) reduced the amount available for 
transfer from TANF to SSBG to 4.25 percent beginning in Fiscal 
Year 2001.
    Under the SSBG, Federal funds are available without a 
matching requirement. In fiscal year 2000, a total of $1.775 
billion was allotted to States. Of that amount, $425 million 
was delayed for funding until September 29, 2000. $1.909 
billion was appropriated for these activities in fiscal year 
1998. Within the specific limitations in the law, each State 
has the flexibility to determine what services will be 
provided, who is eligible to receive services, and how funds 
are distributed among the various services within the State. 
State and/or local Title XX agencies (i.e., county, city, 
regional offices) may provide these services directly or 
purchase them from qualified agencies and individuals.
    A variety of social services directed at assisting aged 
persons to obtain or maintain a maximum level of self-care and 
independence may be provided under the SSBG. Such services 
include, but are not limited to adult day care, adult foster 
care, protective services, health-related services, homemaker 
services, housing and home maintenance services, 
transportation, preparation and delivery of meals, senior 
centers, and other services that assist elderly persons to 
remain in their own homes or in community living situations. 
Services may also be offered which facilitate admission for 
institutional care when other forms of care are not 
appropriate. Under the SSBG, States are not required to submit 
data that indicate the number of elderly recipients or the 
amount of expenditures provided to support specific services 
for the elderly. States are required, prior to the expenditures 
of funds under the SSBG, to prepare a report on the intended 
use of the funds including information on the type of 
activities to be supported and the categories or 
characteristics of individuals to be served. States also are 
required to report annually on activities carried out under the 
SSBG. Beginning with fiscal year 1989, the annual report must 
include specific information on the numbers of children and 
adults receiving services, the amount spent in providing each 
service, the method by which services were provided, i.e., 
public or private agencies, and the criteria used in 
determining eligibility for each service.
    Based on an analysis of post-expenditure reports submitted 
by the States for fiscal year 1998, the list below indicates 
the number of States providing certain types of services to the 
aged under the SSBG.

Services:                                           Number of States \1\
    Home-Based Services \2\.............................              36
    Adult Protective Services...........................              31
    Transportation Services.............................              19
    Adult Day Care......................................              25
    Health Related Services.............................              14
    Information and Referral............................              16
    Home Delivered......................................              17
    Congregate Meals....................................               9
    Adult Foster Care...................................              13
    Housing.............................................               9
\1\ Includes 50 States, the District of Columbia, and the five eligible 
territories and insular areas.
\2\ Includes homemaker, chore, home health, companionship, and home 
maintenance services.

    In enabling the elderly to maintain independent living, 
most States provide Home-Based Services which frequently 
includes homemaker services, companion and/or chore services. 
Homemaker services may include assisting with food shopping, 
light housekeeping, and personal laundry. Companion services 
can be personal aid to, and/or supervision of aged persons who 
are unable to care for themselves without assistance. Chore 
services frequently involve performing home maintenance tasks 
and heavy housecleaning for the aged person who cannot perform 
these tasks. States also provide Adult Protective Services to 
persons generally sixty years of age and over. These services 
may consist of the identification, receipt, and investigation 
of complaints and reports of adult abuse. In addition, this 
service may involve providing counseling and assistance to 
stabilize a living arrangement. If appropriate, Adult 
Protective Services may include the provision of, or arranging 
for, home based care, day care, meal service, legal assistance, 
and other activities to protect the elderly.

               Low Income Home Energy Assistance Program

    The Low Income Home Energy Assistance Program (LIHEAP) is a 
Department of Health and Human Services block grant program 
administered by the Office of Community Services (OCS) in the 
Administration for Children and Families (ACF).
    LIHEAP helps low-income households meet the cost of home 
energy. The program is authorized by the Omnibus Budget 
Reconciliation Act of 1981, as amended most recently by the 
Community Opportunities, Accountability, and Training and 
Educational Services Act of 1998, the NIH Revitalization Act of 
1993 (P.L. 103-43), and the Human Services Amendments of 1994 
(P.L. 103-252). In fiscal year 1999, all 50 states, the 
District of Columbia, five territories, and 130 tribes and 
tribal organizations received grants amounting to approximately 
$1.2775 billion, including $175 million in emergency 
contingency funds, and $2.2 million in re-allotted funds from 
FY 1998.
    In FY 2000, $1.1 billion is available. In addition, $300 
million in emergency contingency funds are available if the 
President decides to release some or all of the funds because 
of weather, supply shortages, or other energy emergencies. 
Federally-recognized and state-recognized Indian tribes, 
including Alaska native villages, may apply for direct LIHEAP 
funding. The amount to be reserved from a state's allotment for 
a direct grant to a tribe will be based on the ratio of 
eligible tribal households to total eligible households in the 
state, or a larger allotment amount agreed on by the tribe and 
state. Of the $1.1 billion appropriated for FY 2000, $27.5 
million is earmarked for leveraging incentive awards, to reward 
grantees that add non-Federal resources to help low income 
households meet their home heating and cooling needs. Up to 25 
percent of the leveraging incentive awards, or $6,875,000, will 
be used to fund grants to LIHEAP grantees under the Residential 
Energy Assistance Challenge Option Program (REACH) to develop 
innovative programs to reduce the energy vulnerability of 
LIHEAP-eligible households.
    LIHEAP block grants are made to States, territories, and 
eligible applicant Indian Tribes. Grantees may provide heating 
assistance, cooling assistance, energy crisis interventions, 
and low-cost residential weatherization or other energy-related 
home repair to eligible households. Grantees can make payments 
to households with incomes not exceeding the greater of 150 
percent of the poverty level or 60 percent of the State's 
median income.\3\ Most households in which one or more persons 
are receiving benefits from the Temporary Assistance to Needy 
Families (TANF) block grant, Supplemental Security Income, Food 
Stamps or need-tested veterans' benefits, may be regarded as 
categorically eligible for LIHEAP.
    \3\ Beginning with fiscal year 1986, States are prohibited from 
setting income eligibility levels lower than 110 percent of the poverty 
    Low-income elderly households are a major target group for 
energy assistance. They spend, on average, a greater portion of 
their income for heating costs than other low-income 
households. Grantees are required to target outreach activities 
to elderly or handicapped households eligible for energy 
assistance. In their crisis intervention programs, grantees 
must provide physically infirm individuals the means to apply 
for assistance without leaving their homes, or the means to 
travel to sites where applications are accepted.
    In fiscal year 1998, about 34 percent of households 
receiving assistance with heating costs included at least one 
person age 60 or over, as estimated by the March 1998 Current 
Population Survey.
    OCS is a member of the National Energy and Aging 
Consortium, which focuses on helping older Americans cope with 
the impact of high energy costs and related energy concerns.
    The 1998 reauthorization retains legislation from the 1994 
reauthorization that specifically allows grantees to target 
funds to vulnerable populations, mentioning by name ``frail 
older individuals'' and ``individual with disabilities''. No 
new initiatives commenced in 1999 or 2000 that impacted on the 
status of older Americans.

       The Community Services Block Grant (CSBG) and the Elderly

    I. Community Service Block Grant--The Community Service 
Block Grant Act (Title VI, Subtitle B, Public Law 97-35 as 
amended; and the Coats Human Services Reauthorization Act of 
1998 105-285) is authorized through fiscal year 2003. The Act 
authorizes the Secretary, through the Office of Community 
Services (OCS), an office within the Administration for 
Children and Families in the Department of Health and Human 
Services, to make grants to States and Indian tribes or tribal 
organizations. States and tribes have the authority and the 
flexibility to make decisions about the kinds of local projects 
to be supported by the State or tribe, using CSBG funds. The 
purposes of the CSBG program are:
          (A) to provide a range of services and activities 
        having a measurable and potentially major impact on 
        causes of poverty in the community or those areas of 
        the community where poverty is a particularly acute 
          (B) to provide activities designed to assist low 
        income participants including the elderly poor--
                  (i) to secure and retain meaningful 
                  (ii) to attain an adequate education;
                  (iii) to make better use of available income;
                  (iv) to obtain and maintain adequate housing 
                and a suitable living environment;
                  (v) to obtain emergency assistance through 
                loans or grants to meet immediate and urgent 
                individual and family needs, including the need 
                for health services, nutritious food, housing, 
                and employment-related assistance;
                  (vi) to remove obstacles and solve problems 
                which block the achievement of self-
                  (vii) to achieve greater participation in the 
                affairs of the community; and
                  (viii) to make more effective use of other 
                programs related to the purposes of the 
          (C) to provide on an emergency basis for the 
        provision of such supplies and services, nutritious 
        foodstuffs and related services, as may be necessary to 
        counteract conditions of starvation and malnutrition 
        among the poor;
          (D) to coordinate and establish linkages between 
        governmental and other social services programs to 
        assure the effective delivery of such services to low-
        income individuals; and
          (E) to encourage the use of entities in the private 
        sector of the community in efforts to ameliorate 
        poverty in the community; (Reference Section 675(c)(1) 
        of Public Law 97-35, as amended).
    It should be noted that although there is a specific 
reference to ``elderly poor'' in (B) above, there is no 
requirement that the States or tribes place emphasis on the 
elderly or set aside funds to be specifically targeted on the 
elderly. Neither the statute nor implementing regulations 
include a requirement that grant recipients report on the kinds 
of activities paid for from CSBG funds or the types of indigent 
clients served. Hence, it is not possible for OCS to provide 
complete information on the amount of CSBG funds spent on the 
elderly, or the number elderly, or the numbers of elderly 
persons served.
    II. Major Activities or Research Projects Related to Older 
Citizens in 1997 and 1998--The Human Services Reauthorization 
Act of 1986 contained the following language: ``each such 
evaluation shall include identifying the impact that assistance 
. . . has on . . . the elderly poor.'' The reauthorization act 
of 1998 requires that states assure a portion of the grant 
funds will be used to support activities for elderly low-income 
individuals as part of their State Application and Plan 
submitted to OCS. Following the 1994 reauthorization, local 
community action agencies began to include a description of how 
linkages will be developed to fill identified gaps in services 
through information, referral, case management, and follow-up 
consultations as well as a description of outcome measures to 
be used to monitor success in promoting self sufficiency, 
family stability and community revitalization. As a result, the 
CSBG Task Force on Monitoring and Assessment, a representative 
body of eligible entities, established a goal which states, 
``Low-income people, especially vulnerable populations, achieve 
their potential by strengthening family and other support 
systems''. This goal assists local, state and federal agencies 
to focus jointly on vulnerable populations, particularly the 
frail elderly.
    III. Funding Levels--Funding levels under the CSBG program 
for States and Indian Tribes or tribal organizations amounted 
to $491.9 million in fiscal year 1999. For fiscal year 2000, 
$521.5 million was appropriated. Of this amount, $3.3 million 
is available for federally and state-recognized tribes. A total 
of $8.4 million is available for training and technical 

              Aging and Developmental Disabilities Program

                       CRITICAL AUDIENCES PROJECT

    Grantee: Institute for the Study of Developmental 
Disabilities, Indiana University
    Project Director: Barbara Hawkins, Ph.D., (812) 855-6506; 
Fax (812) 855-9630
    Project Period: 7/97-6/30/2002; FY '97--$82,680
    The project provides training in a late-life functional- 
developmental model for audiences that are critical to 
effective planning and care of older persons. Activities 
include developing training modules and instructional videos 
for interdisciplinary university credit courses, and 
illustrating the model by demonstration projects in community 
retirement settings.


    Grantee: University of Miami/CADD, Miami, FL
    Project Director: John Stokesberry, Ph.D., (305) 325-1043
    Project Period: 7/97-6/30/2002; FY '97--$82,680
    CADD is providing education and training to service 
providers, parents and families; advocacy and outreach for 
consumers, information to the public on aging and developmental 
disabilities; networking, policy direction and community-based 
research. Materials will include a manual for parents/
caregivers, a resource guide and a handbook on developing a 
peer companion project.


    Grantee: UAP--Institute for Human Development, University 
of Missouri-Kansas City
    Project Director: Gerald J. Cohen, J.D., M.P.A., (816) 235-
1770; Fax (816) 235-1762
    Project Period: 7/97-6/30/2002; FY '97--$82,680.
    The Center addresses personnel preparation needs with a 
focus on administration, interdisciplinary training, exemplary 
services, information/technical assistance/research; and 
evaluation. Materials include training guide for aging, 
infusion models, inservice fellowship curriculum, resource 
bibliography, guide for training volunteers, and course 


    Grantee: UAP--University of Rochester Medical Center, 
Rochester, NY
    Project Director: Jenny C. Overeynder, ACSW, (716) 275-
2986; Fax (716) 256-2009
    Project Period: 7/97-6/30/2002; FY '97--$82,680.
    An inter-university interdisciplinary consortium of 
educational resources in gerontology and developmental 
disabilities is being established in western New York, to be 
linked to local and state networks. The project will develop 
and implement preservice and inservice education curriculum for 
direct care and nursing home staff.


    Grantee: Eunice Kennedy Shriver Center, Inc. Shriver Center 
    Project Director: Karen E. Gould, Ph.D., (617) 642-0238
    Project Period: 7/92-6/30/1999; FY '97--$82,680
    The Center has two primary goals which are: 1) to implement 
a service delivery model that creates a new vision for 
individuals who are labeled ``old'' and ``developmentally 
disabled'' in Massachusetts, one in which entry into valued 
adult roles is expected and capacities and interests form the 
basis for structuring support; and 2) to provide training to 
persons with developmental disabilities, family members and 
friends, graduate students, professionals and community members 
so that they can develop the skills necessary to support 
community entry and inclusion in valued roles and relationships 
for older adults with developmental disabilities, and learn to 
use these skills in other settings.


    Grantee: North Dakota Center for Disabilities, Minot State 
    Project Director: Dr. Rita Curl and Dr. Demetrios 
Vassiliou, (701) 857-3580
    Project Period: 7/97-6/30/2002; FY '97--$82,680
    The project seeks to upgrade the training opportunities 
available to North Dakotans; 1) project staff works with pre-
service geriatric programs to develop strong DD components; 2) 
project staff expands on an existing inservice training program 
to provide information on aging DD service provision; and 3) 
the project supports the development of training opportunities 
for secondary consumers and advocates.


    Grantee: Graduate School of Public Health, University of 
Puerto Rico - Medical Sciences
    Project Director: Dr. Margarita Miranda, (809) 758-2525, 
ext. 1453, (809) 754-4377
    Project Period: 7/97-6/30/2002; FY '97-$82,680
    The project provides pre-service training including 
practical experience on best practices in serving the older 
population with developmental disabilities to three (3) 
graduate and to three (3) undergraduate students from different 
disciplines per year (from the second funding year on); 
provides culturally adapted in-service training to the Catano 
Family Health Center's interdisciplinary team and to at least 
40 professionals in the aging service per year through the 
Graduate School and implementation of five regional Seminars on 
Aging and Developmental Disabilities throughout Puerto Rico.


    Grantee: University-Affiliated Program Department of 
Pediatrics, Univ. of Arkansas for Medical Sciences.
    Project Director: Judith Holt, Ph.D ((501) 682-9900
    Project Period: 7-97-6/30/2002, FY '97--$82,680
    The UAP of Arkansas' Training Initiative Project, Creative 
Choices for Healthy Living, will focus on persons who are aging 
with developmental disabilities, their access to appropriate 
services and supports within the community. Specifically, it 
will enhance the health and well-being of older persons with 
developmental disabilities and other members of the aging 
community; enhance the skill and competencies of community 
trainers to provide the training identified by the community 
action plan; expand the project into new communities; develop 
and disseminate preserve training modules for undergraduate and 
graduate courses; disseminate project training modules for use 
in other settings state- and nation-wide; and evaluate the 
project's effects.


    Grantee: Department of Pediatrics, Children's Hospital Los 
    Project Director: Irma Castaneda, Ph.D (213) 669-2300-9900
    Project Period: 7/1/97-6/30/2002, FY '97--$82,680
    Develop and implement an interdisciplinary training program 
with a special emphasis on the multicultural aspects of aging 
and developmental disabilities which is integrated into 
Department's curriculum for a minimum of one primary or 
secondary consumer, and two graduate students per year. Will 
integrate material on multicultural aging and developmental 
disabilities into existing gerontology certificate programs. 
Provide training and consultation on the integration of content 
related to multicultural aging and developmental disabilities 
to four university departments. Provide training to a total of 
100 health care providers, community support personnel, and 
family members on the changing health and social needs of aging 
individuals with developmental disabilities from ethnic 
minority groups.

                        ADMINISTRATION ON AGING

                               Section I.

                           1. Reauthorization

    On November 13, 2000, President Clinton signed into law 
legislation (P.L. 106-501) to reauthorize the Older Americans 
Act. The amended Act, last reauthorized in 1992, will provide 
essential home and community-based services to millions of 
older Americans across the United States. In addition, for the 
first time ever, it will provide under the National Family 
Caregiver Support Program much needed support to families who 
are caring for their loved ones who are ill or who have 

              2. National Family Caregiver Support Program

    In 1999, President Clinton announced the Administration on 
Aging proposal to create the National Family Caregiver Support 
Program (NFCSP). The NFCSP is one of four LTC initiatives 
proposed in the FY 2000 Administration budget to help families 
sustain their efforts to care for an older relative who has 
serious chronic illness or disability. Under this Older 
Americans Act program, State Units or Offices on Aging, working 
in partnership with local Area Agencies on Aging, community 
service providers, and consumer organizations, will be expected 
to put in place at least five program components:
           Individualized information on available 
        resources to support caregivers;
           Assistance to families in locating services 
        from a variety of private and voluntary agencies;
           Caregiver counseling, training, and peer 
        support to help them better cope with the emotional and 
        physical stress of dealing with the disabling effects 
        of a family member's chronic condition;
           Respite care provided in the home, at an 
        adult day care center, or over a weekend in a nursing 
        home or residential setting such as an assisted living 
        facility; and
           Limited supplemental services to fill a 
        service gap that cannot be filled in any other manner.
    The NFSCP program was enacted as part of the Older 
Americans Act Amendments of 2000 (P.L. 106-501) signed into law 
on November 13, 2000. Full start-up funding for the program, as 
proposed at $125 million, has been provided for FY 2001.
    The basis underlying the program is simple: family 
caregivers need help. Families, not social service agencies or 
government programs, are the mainstay underpinning long term 
care (LTC) for older persons in the United States. According to 
the most recent National Long Term Care Survey (1994), more 
than seven million persons are informal caregivers providing 
unpaid help to older persons who live in the community and have 
at least one limitation in their activities of daily living. 
These caregivers include spouses, adult children, and other 
relatives and friends. Of the older persons receiving paid and 
unpaid assistance, 95 percent have family and friends involved 
in their care. Paid home care is the exception, not the rule, 
for the great majority of older persons with disabilities.
    The degree of caregiver involvement has remained fairly 
constant for more than a decade, bearing witness to the 
remarkable resilience of the American family in taking care of 
its older persons. This is despite increased geographic 
separation, greater numbers of women in the workforce, and 
other changes in family life. Thus, family caregiving has been 
a blessing in many respects. It has been a budget-saver to 
governments faced annually with the challenge of covering the 
health and LTC expenses of persons who are ill and have chronic 
disabilities. If the work of caregivers had to be replaced by 
paid home care staff, the estimated cost would be $45-95 
billion per year.

                         3. Longevity Symposium

    The 21st century presents many opportunities and challenges 
for the Aging Network--medical and technological advances, home 
and community-based care options, the need to prepare for a 
long life, and the need to implement evidence-based and 
culturally-responsive services to ensure that American elders 
receive the most effective assistance. The Administration on 
Aging convened a symposia series which highlighted the agency's 
commitment to helping the Aging Network prepare for the myriad 
of issues that come along with the gift of longevity.
    The first symposium, Longevity in the New American Century, 
convened in March 1999, was designed to identify the most 
potent, most promising research findings on issues important to 
older Americans and their families. Based upon these research 
findings, the Administration on Aging and other agencies and 
organizations will be able to make strategic decisions and 
build outcome-oriented programs for older Americans. The 
speakers invited to share information at this symposium were 
asked to provide specific ideas for an evidence-based, outcomes 
agenda in relation to the issues of caregiving, information and 
technology, diversity, consumer protection, economic security, 
and health.
    The second symposium, Building the Network on Aging 
Toolkit, convened in May 2000, focused on the presentation of 
evidence-based, outcomes-oriented strategies that can directly 
be used to develop and strengthen policies, programs and 
services. The primary purpose of this second symposium was to 
bridge the gap between research and practice. The speakers 
presented tools and methods that are essential components of 
programs for family caregiver support, cultural competent 
service delivery, the elimination of health disparities, life 
course planning, the application of new technologies, and for 
the measurement of program outcomes.

                        4. Priority Initiatives

                          Cultural Competence

    The Administration on Aging (AoA) recognizes that minority 
Americans often are at greater risk of poor health, social 
isolation, and poverty. Currently, minority elders comprise 
over 16.1 percent of all older Americans (65 years of age and 
older). In the future, this number is expected to increase 
dramatically. As a result, AoA has focused on educating the 
public and the aging network on cultural competence.
    Cultural competence is a set of congruent behaviors, 
attitudes, knowledge, and policies that come together in a 
practice and a service system that enables professionals to 
serve diverse clients. During calendar years 1999 and 2000, AoA 
has initiated the following activities to increase culturally 
competent practice:
           AoA's Longevity Symposia series, entitled 
        Longevity in the New American Century included a few 
        workshops focusing on cultural competence and the 
        minority aging experience. Included in the workshops 
        were new research, policy development ideas, and 
        suggestions for programs that promote equality in the 
        aging experience for minority elders;
           Collaboration with the Office of Minority 
        Health (OMH) on the May 2000 edition of Closing the 
        Gap, which focused on health issues and concerns for 
        minority older Americans;
           A Guide for Culturally Competent Practice 
        was developed for dissemination to providers of aging 
           Grants for applied research and 
        demonstration projects seeking to provide culturally 
        and linguistically competent services to Alzheimer's 
        Disease patients and their families in New York City, 
        Los Angeles, and San Francisco;
           Grants for a legal services hotline project 
        serving northern California;
           Grants for a resource center that 
        disseminates educational and best practice materials to 
        better equip minority and non-English speaking 
        consumers to combat waste and fraud in the Medicare and 
        Medicaid programs;
           Presentations by AoA staff at national 
        conferences and meetings on how to develop culturally 
        appropriate services to serve minority elders;
           AoA's website addition ``The Many Faces of 
        Aging: Resources to Effectively Serve Minority Older 
        Persons'' provides information on cultural competence.

             Eldertech--Technologies for Successful Aging:

    The number of older persons in the U.S. is estimated to 
increase from over 33 million today to 53 million in 2020. By 
2030, the demographic profile for the whole nation will be 
similar to the profile in the state of Florida today. 
Technologies that help to meet the challenges of aging, both 
for individual Americans as well as for the entire nation, will 
be increasingly valuable as the shift in demographics continue 
this century.
    In October 2000, the White House Office of Science and 
Technology Policy held a Forum on Technologies for Successful 
Aging. The Administration on Aging, as part of the cross-
Cabinet Steering Committee for this forum, played a key role in 
developing the agenda for the forum whose goal was to identify 
collaborative, technology transfer, and technology development 
and deployment opportunities for government, industry and 
academic communities that help to improve the independence, 
mobility, security, and health of aging Americans.
    In support of this goal, the 100 participants of the 
Conference began work to identify current and prospective 
barriers to those opportunities, mechanisms of support, and 
areas where additional research is needed. Specific topic areas 
included Health care and Assistive Devices, Regulatory and 
Technology transfer, Information and Technology, Mobility, 
Housing and the Workplace, and Consumer Protection, Security 
and Privacy issues. The Forum's overarching mission was to 
identify and prioritize recommendations that can be articulated 
as a set of near-term opportunities as well as long-term 
challenges to federal policymakers. The Intergovernmental 
Steering Committee continues to meet to follow up and formalize 
the steps that need to be taken in the coming months and years, 
and recommendations will be made to the incoming Administration 
to continue the work that has begun.

                       Mental Health Initiatives

    Companion Report to Surgeon General's Report on Mental 
    AoA has authored a report that expands on the discussion of 
older adults and mental health contained in the 1999 Surgeon 
General's report. The AoA report focuses on challenges in the 
delivery of mental health services to older Americans, and 
highlights a number of supportive services that can provide 
vital assistance to older adults with mental health problems 
and their families. Release of this report is planned for 
January 2001.
    The report includes background information about the 
demographic characteristics of older Americans, the common 
stressors and adaptations that older persons face, and a brief 
summary of the findings from the Surgeon General's report. The 
report describes community mental health services, delivery of 
mental health services in primary and long-term care, and 
Medicare and Medicaid financing of mental health care. 
Supportive services discussed in the report include respite 
care, adult day services, support groups and peer counseling 
programs, wellness and health promotion programs, mental health 
outreach services, and caregiver programs. The discussion of 
each service includes its purpose, implementation models and 
examples, and research regarding effectiveness.
    Lastly, the report sets forth the challenges that must be 
addressed in order to provide effective community-based care to 
older persons with mental illnesses. Identified needs include: 
expanding prevention and early intervention services; 
increasing the number of professionals and paraprofessionals 
trained in geriatric mental health; providing adequate 
financing for mental health services; enhancing collaboration 
among delivery systems; improving access to mental health care; 
educating the public about mental illness and mental health 
treatment; expanding research on mental health issues in older 
adults; addressing the mental health needs of special 
populations; and encouraging consumer involvement.

           Alzheimer's Disease Demonstration Grants to States

    The Alzheimer's Disease Demonstration Grants to States 
Program (ADDGS) was established under Section 398 of the Public 
Health Service Act (P.L. 78-410) as amended by Public Law 101-
157 and by Public Law 105-379, the Health Professions Education 
Partnerships Act of 1998. Beginning in fiscal year (FY) 1999, 
the program was transferred within the Department of Health and 
Human Services from the Health Resources and Services 
Administration (HRSA) to the Administration on Aging (AoA).
    The ADDGS program's mission is to expand the availability 
of diagnostic and support services for persons with Alzheimer's 
disease, their families, and their caregivers. The 
Administration on Aging provides an added focus of reaching 
hard-to-serve and underserved people with Alzheimer's disease 
or related disorders (ADRDs).
    In general, the ADDGS projects demonstrate how existing 
public and private resources within States may be more 
effectively identified, utilized, and coordinated to enhance 
the educational and service delivery systems for persons with 
Alzheimer's disease, their families and caregivers. Under the 
Program, state grantees:
    Link public and non-profit agencies that develop and 
operate respite care, and other support, educational, and 
diagnostic services within the State to people who need 
    Deliver services such as primary health care physician 
education and support services including respite care, home 
health care, personal care, day care, companion services, 
short-term respite care, and other forms of respite and 
supportive services to persons with ADRDs (at least 50 percent 
of the total grant must be spent on these activities);
    Improve access to home and community-based long-term care 
services for persons with Alzheimer's disease & their families;
    Provide individualized and public information, education, 
and referrals about 1) diagnostic, treatment and related 
services that are available; 2) sources of assistance to obtain 
such services, including entitlement programs; 3) legal rights 
of individuals and families affected by ADRD.
    In FY2000, AoA held a competitive grant award process, 
resulting in the issuance of grants to 16 states. Each grant 
has a 3-year project period and requires local match in the 
amounts of 25 percent (year 1), 35 percent (year 2), and 45 
percent (year 3). The general programmatic foci of the program 
are to:
           develop models of care for persons with 
        Alzheimer's disease, and
           improve the responsiveness of the home and 
        community based care system for persons with dementia.
    Projects are targeted to hard-to-reach populations 
including ethnic minorities, low income and rural families with 
Alzheimer's disease. The 16 states with ADDGS grants are 
Alaska, Arizona, Arkansas, California, Iowa, Maine, Minnesota, 
Nebraska, Nevada, New Hampshire, New Mexico, Rhode Island, 
Texas, Vermont, Virginia, and Wisconsin.

                        Managed Care Initiative

    In addition to the 16 new projects, 5 states have grants of 
$80,000 to fund services provided under the ADDGS Managed Care 
Initiative, an effort started in 1997 by HRSA. The Managed Care 
Initiative is designed to test the impact of community-based 
service interventions on primary care physician utilization 
rates by persons with Alzheimer's disease in a managed care 
    Organizations with FY 2000 ADDGS Managed Care Initiative 
Grants are:
           DC Office on Aging
           Florida Department of Elder Affairs
           Michigan Department of Community Health
           Ohio Department on Aging
           Oregon Senior and Disabled Services Division

               5. Reinventing the Administration on Aging

                        Performance Measurement

    AoA and the Aging Network have forged a partnership to 
utilize the tools provided by the Government Performance and 
Results Act (GPRA) to demonstrate to the Congress and the 
public the value of the programs administered under the Older 
Americans Act (OAA). GPRA has provided the Network the 
opportunity to use performance measurement to continuously 
document the results that service providers, Area agencies on 
Aging, State agencies on Aging, and AoA produce for older 
Americans. The reauthorized Older Americans Act reinforces the 
importance of measuring results, and directs AoA to develop 
performance outcome measures for Older Americans Act programs 
by December 2001. AoA and the Network have launched the 
Performance Outcomes Measures Project (POMP) to serve as a 
mechanism to identify and institutionalize indicators of 
results that will serve the long-term program improvement needs 
of the Network and Older Americans Act programs.
    Early in its second year of operation, the POMP is building 
on the consensus achieved by AoA's initiative to pull together 
selected network participants to identify a set of core areas 
and methods of performance measurement that can serve the aging 
community. With the assistance of accomplished researchers in 
the fields of gerontology and statistics, State and area 
partners from 16 States developed and tested performance 
measurement instruments that center on the needs and 
characteristics of the people they serve. Consistent with the 
best quality management practices in the field, POMP focuses 
primarily on customer assessment measures for core service 
areas, such as home care, transportation, and caregiver 
services. Pilot test users have found a high degree of 
satisfaction with services, and have also identified customer-
based recommendations for service improvement. For example, 
test findings for pilot areas indicate that transportation 
services are used most for doctor's appointments, and that 
expanded hours of service would be the most helpful change. 
State and area partners also tested nutrition assessment 
instruments for new clients and found that the nutritional risk 
of these individuals was very high. This indicates for test 
locations that nutrition services are targeted to the elderly 
who need the service most. Follow-up surveys of these same 
individuals will provide an indicator of the effects of Aging 
Network nutrition services on the nutritional status of these 
high-risk individuals after six months of program 
    Statistical methodologies that are useful to program 
administrators in the field are an added and promising feature 
of the AoA sponsored performance outcome measurement effort. 
The POMP survey methods and instruments have been designed to 
allow real people, working area agency staff and others, to 
conduct valid sample surveys of clients across an assortment of 
service areas. The materials and experiences of pilot agencies 
are being documented and have been proven to be replicable for 
a variety of agencies and programs.
    To support and enhance the indicators of program results 
that the performance outcome measurement partners are working 
to define, AoA is making use of ongoing administrative data to 
more fully illustrate and define the success of the Network in 
the service of elderly Americans. Ongoing administrative data 
from State and area agencies will be useful for demonstrating 
the effectiveness of these program entities in targeting 
services to those most vulnerable and in need. Existing 
administrative data will be useful for demonstrating the 
effectiveness of the Network in coordinating services and 
leveraging resources in support of the program objectives of 
the Older Americans Act.
    AoA and its program partners are committed to use 
performance measures to inform decision making that improves 
programs for older Americans. As AoA's performance measures 
mature, and trends in program performance emerge, AoA and the 
Network believe that these indicators of results, along with 
program evaluation and other management assessment tools, will 
be critical to program development in support of older 

                            Policy Analysis

    For the first 30 years after enactment of the Older 
Americans Act (OAA) the major thrust of efforts undertaken by 
the Administration on Aging (AoA) was to support the 
development of a nationwide infrastructure with a capability to 
promote more comprehensive and coordinated home and community-
based services to vulnerable older individuals. A network of 
State and Area Agencies on Aging, as well as providers of 
supportive and nutrition services, has developed which 
leverages other sources of funds and coordinates with other 
agencies in addressing the needs of older individuals in 
greatest economic or social need, including older individuals 
with physical or mental impairments, living alone, with low 
income, minority status, or rural residence. The statutory 
basis for these efforts may be found in Titles III, VI, and VII 
of the OAA.
    More recently the focus has shifted to the responsibilities 
of the AoA to ``serve as the effective and visible advocate for 
older individuals within the Department of Health and Human 
Services and with other departments, agencies, and 
instrumentalities of the Federal Government by maintaining 
active review and commenting responsibilities over all Federal 
policies affecting older individuals'' (OAA Section 202(a)(1)). 
The OAA requires that the Assistant Secretary for Aging ``shall 
coordinate, advise, consult with, and cooperate with the head 
of each department, agency, or instrumentality of the Federal 
Government proposing or administering programs or services 
substantially related to the objectives of this Act, with 
respect to such programs or services'' (OAA Section 203(a)(1)). 
Additionally the OAA provides that ``The head of each 
department, agency, or instrumentality of the Federal 
Government proposing to establish programs and services 
substantially related to the objectives of this Act shall 
consult with the Assistant Secretary prior to the establishment 
of such programs and services.'' (OAA Section 203(a)(2)).
    To implement these statutory requirements, recently a 
policy unit has been established in areas defined in the 
Declaration of Objectives for Older Americans (OAA Section 101 
(1) ``An adequate income...''.), (2) ``The best possible 
physical and mental health.....''), (3) ``Obtaining and 
maintaining suitable housing......''). In the Economic Security 
policy area there will be review and analysis of legislation 
and regulations covering programs administered by the Social 
Security Administration, the U.S. Department of Labor, and 
other agencies; in the Housing policy area of programs 
administered by the U.S. Department of Housing and Urban 
Development and other agencies; in the Health policy area of 
programs administered by the Health Care Financing 
Administration, the Veterans Administration, the Substance 
Abuse and Mental Health Services Administration and other 
agencies. The policy analysts represent AoA at meetings with 
representatives of these departments and agencies and 
participate actively on work groups. They prepare analyses of 
reports, develop policy briefs, and advise senior officials on 
developments in their policy areas.

                        International Activities

    The AoA responds to requests for information from 
international organizations such as the United Nations, foreign 
governments, and agencies. It hosts international scholars, 
officials and practitioners who come to the U. S. to learn 
firsthand about America's response to population aging. In 1999 
and 2000, AoA staff briefed delegations from over 25 countries.
    The AoA participates in a number of collaborative efforts 
with other countries and with international organizations, such 
as the World Health Organization, to enhance aging programs and 
policies worldwide. The AoA has a signed agreement with the 
China National Committee on Aging of the People's Republic of 
China to share information and to develop collaborative 
    The Aging Core Group of the Health Working Group, U.S.-
Mexico Binational Commission.--The Commission promotes 
exchanges at the Cabinet level on a wide range of issues 
critical to U.S.-Mexico relations. The Aging Core Group is one 
of five areas of collaboration between the U.S. Department of 
Health and Human Services and the Mexican Ministry of Health. 
The U.S. side of the Core Group is led by the Assistant 
Secretary for Aging. A number of on-going exchanges of 
information, training and technical assistance have taken place 
to help both countries better address the special health needs 
of older people. In 1999 and 2000, in collaboration with the 
AoA, the Mexican Ministry of Health hosted invitational 
conferences to share models of care for the elderly; nutrition 
and the elderly; and prevention and control of chronic disease 
in the elderly.
    The International Year of Older Persons 1999.--The AoA 
coordinated the U.S. government's activities for the 
International Year of Older Persons (IYOP). A Federal Committee 
for the IYOP (the ``Committee'') was created and chaired by the 
Assistant Secretary for Aging. The Committee consisted of over 
40 governmental agencies and departments.
    The IYOP was formally launched by the reading of a message 
from President Clinton by HHS Secretary Donna E. Shalala on 
October 19, 1999, at a gathering at the U.S. Department of 
Agriculture. Guests included Cabinet heads and representatives, 
international delegates and senior advocates in Washington, 
D.C. A special video message was delivered from US Senator John 
Glenn (D-OH) upon his return to space on October 29 as a NASA 
researcher. Gubernatorial proclamations of the IYOP within 
their states were displayed.
           In June 1999, the AoA and the Committee 
        convened the invitational symposium Coming of Age: 
        Federal Agencies and the Longevity Revolution. The 
        symposium brought together some 300 senior 
        administrators from across the Executive Branch to 
        examine and address the policy and program implications 
        of our rapidly aging American society. The goal of the 
        symposium was to establish a foundation for the 
        advancement of the federal policy and program agenda 
        related to older Americans and their families in the 
        21st century. Discussions were organized around the 
        major themes of economic security, aging in place, 
        older people as a resource, health promotion and care, 
        and disability and long-term care.
           An IYOP website was established on the AoA 
        home page and became a major international source of 
        information on the IYOP.
           The IYOP culminated with an event entitled 
        ``Positive Aging: A Goal for the Next Millennium''--A 
        Day Celebrating the Culmination of The United Nations 
        International Year of Older Persons. The event was 
        hosted by the Committee and the US Committee 
        (representing non-governmental aging associations). The 
        program included a federal and a business panel and an 
        award ceremony for communities that have celebrated the 
    The Federal Committee on Aging Issues.--With the close of 
the IYOP, the Committee continues its work as the Federal 
Committee on Aging Issues. The Assistant Secretary for Aging 
continues to chair the Committee. The Committee continues to 
share information among members and to examine ways of 
implementing recommendations from the 1999 symposium, Coming of 
Age: Federal Agencies and the Longevity Revolution.
    International Plan of Action on Aging, 2nd World Assembly 
on Aging.--Working together with the Committee, AoA is 
coordinating the federal government's input to the revised 
International Plan of Action. The revised Plan will be 
presented for discussion at the 2nd World Assembly on Aging, to 
be held under the UN auspices in 2002.
    International Conference on Rural Aging.--Under Title IV of 
the Older Americans Act, the Administration on Aging funded 
West Virginia University to put on the first international 
conference on rural aging: Rural Aging: A Global Challenge. The 
West Virginia University Center on Aging is now a UN Programme 
on Aging Advisory Site on Rural Aging. Representatives of 40 
nations attended the five-day conference held in June 2000 in 
Charleston, West Virginia. Policy recommendations on worldwide 
rural aging were adopted. They will become the basis of a Rural 
Aging Plan of Action to be included in the revised UN 
International Plan of Action on Aging.

             Work Force Plan of the Administration on Aging

    AoA's workforce planning initiative was completed here at 
headquarters in December, 1999 and in our regional offices in 
November, 2000. The plan highlights the Administration on 
Aging's vision of itself to be actualized by the year 2005, 
identifies competencies of its present workforce and areas for 
staff development, and focuses on organizational competency 
gaps to be addressed in the recruitment of staff in the future.
    In the last few months AoA has recruited approximately 
twenty new employees, following the indicators, conclusions, 
and recommendations contained in our workforce plan, and we 
will continue to use the workforce plan as the basis for our 
recruitment and staff development efforts in the future. The 
workforce plan indicates that the agency's present allocation 
of staff to the organizations support functions or 
infrastructures (i.e. grants, budget and finance, personnel, 
and training, IRM, and general administrative functions) are 
adequate for the size of the agency. The staffs performing 
these functions also are younger, with less seniority within 
the agency, and tend to have received technical training 
specific to their particular jobs. On the other hand AoA's 
workforce plan highlights the fact that an overwhelming number 
of the almost one hundred employees the agency has lost since 
1993 have been program staff. That trend will continue unabated 
over the next five years, when a 60 percent turnover in staff 
is anticipated because of retirements.
    AoA has recently filled a vacant management position which 
oversees our regional operations and a planning and evaluation 
officer position, but the vast majority of the new recruits are 
policy analysts and program analysts with extensive experience 
in applying research methodologies, evidence-based principles 
and qualitative and quantitative approaches to policy 
formulation and development and to the design, implementation, 
and evaluation of programs and services. AoA has recruited 
policy analysts with a thorough, in-depth knowledge of the 
following public policy areas, as they relate to older people: 
home and community based long term care, healthcare, housing, 
economic security, and mental health. The newly hired program 
analysts will concentrate on program design, technical 
assistance, and implementation in the following program areas: 
home and community based long term care/housing, elder rights/
legal services, public health promotion, and consumer 
    A few of these analysts have been assigned the task of 
serving as mentors to the two Presidential Management Interns 
(PMI) recruited by the agency this summer. Next year and in 
subsequent years, AoA will be in a position to concentrate on 
recruitment of staff at the GS 9 entry level of the PMI 
program, the Outstanding Student program, and the Student Co-op 
program and anticipate being able to employ each year at least 
four to six staff from these programs to replace program staff 

                             Regional Teams

    As part of the new vision for the Administration on Aging, 
The Assistant Secretary on Aging directed the Regional Offices 
in 1999 to establish teams, including multi-regional teams, to 
help advance AoA's priorities in the areas of public/private 
partnerships, diversity, customer service and financial 
management. The teams made significant progress during 1999 and 
    The Boston (Region I) and New York (Region II) Offices 
worked together on a team to foster public/private 
partnerships. As it's first project, the team established a 
partnership with the Federal Deposit Insurance Corporation 
(FDIC) and the Women's Institute for a Secure Retirement 
(WISER) to help mid-life and elderly women, especially low-
income and minorities, understand and prepare to meet their 
everyday economic and financial needs at progressive states of 
aging. The partnership has produced a financial literacy 
program known as Power 2000 Take Control of Your Financial 
Future. The program includes a training manual with a suggested 
curriculum, materials that can be duplicated, resource guides 
and information on how to conduct a local workshop. To promote 
the program, AoA, FDIC and WISER identify and stimulate 
opportunities for presentations to the Aging Network, the 
banking network and other community-based groups, all of whom 
are asked to serve as catalysts in promoting the financial 
literacy program in their localities. Local partnerships are 
then formed among the partners and other federal, state and 
local organizations to serve as facilitators, resources and/or 
faculty in conducting Power 2000 presentations locally. The 
program was successfully piloted during 2000 in New York City 
and in one rural community in Upstate New York. Based on the 
results of the pilot, the partnership plans to roll out the 
program in 2001 to AoA regions nationwide.
    The San Francisco Office (Region IX) team is focused on 
policy issues related to diversity and aging. The team has 
developed a new section of the AoA web site,, ``The 
Many Faces of Aging: Resources to Effectively Serve Minority 
Older Persons,'' to help increase access to programs and 
services for older minority Americans and their caregivers. The 
site was launched in December, 2000 and includes a range of 
health and aging resources for and about minorities and diverse 
aging populations; demographic snapshots and statistics; and 
laws and executive orders related to ensuring improved access 
and culturally appropriate services. The site highlights 
various approaches to develop culturally and linguistically 
responsive services for minority older persons. The Dallas-
Atlanta (Regions IV and VI) team has been building a diversity 
website that will offer state-specific data on minority 
populations. These two initiatives were developed response to 
the growing diversity of the aging population. Currently, 
minority elders comprise over 16.1 percent of all older 
Americans (65 years of age and older). In the future, their 
numbers are expected to increase dramatically. Between 1999 and 
2030, the older minority population 65+ is projected to 
increase by 217 percent, compared with 81 percent for older 
white population.
    The Denver Office (Region VIII) team is focused on customer 
service, including the establishment of internal performance 
outcome measures for employee participation and performance. 
The Denver team has developed a comprehensive orientation 
manual for all new AoA employees. The manual provides 
background information on the Department of Health and Human 
Services, AoA, the Older Americans Act and the Aging Network, 
as well as information on internal operating policies and 
procedures. The manual will be issued in January 2001.
    The Denver team also has developed several tools for AoA's 
external customers. The ``Compendium of Grant Resources for 
Native American Elders Programs'' was developed in partnership 
with the Community Resource Center in Denver and the National 
Committee to Preserve Social Security and Medicare. The 
Compendium contains resources on funding, publications, 
resource agencies, profiles of funders and internet resources 
targeted to Native Americans. The Compendium project was 
initiated in Region VIII when Tribal Elders Programs requested 
additional funding information from the regional office to 
augment moneys received under Titles VI and III of the Older 
Americans Act. ``Cyberspace Resources on Retirement'' is a 
publication that identifies internet links on retirement and 
financial planning, health, quality of life and other baby 
boomer issues. The publication was a result of a creative 
partnership among the Develop Denver Office, the Community 
College of Denver, American Association for Retired Persons, 
and the National Committee to Preserve Social Security and 
    The Chicago (Region V) and Kansas City (Region VII) Offices 
have collaborated on establishing a fiscal management team 
comprised of representatives from all the regional offices and 
the AoA central office in Washington. The team serves as the 
focal point within AoA on all grantee related fiscal matters. 
The team ensures the provision of timely, consistent, uniform 
and accurate fiscal policy and technical assistance to the 
state units on aging, Native American programs, and the area 
agencies on aging. During 2000, the team developed a manual for 
AoA project officers, and drafted several technical assistance 
documents that will be used to implement the 2000 Amendments to 
the Older Americans Act, including the National Family 
Caregiver Support Program.
    The Seattle (Region X) Office team is looking at the issue 
of active aging, including the opportunities and challenges 
associated with creating meaningful roles for older people. 
There is a growing body of research which suggests that both 
the individual and the nation as a whole can benefit from older 
people being actively engaged in activities which allow them to 
make meaningful contributions to their families, their 
communities and the larger society. This issue will take on 
great significance as the baby boom generation ages. As a first 
step in exploring this issue, the Seattle team is reviewing the 
literature to identify what we know about the key factors and 
dynamics associated with active aging.

                               Section II

                         1. Summary of Reports

                          State Program Report

    Each year, the Administration on Aging (AoA) awards Older 
Americans Act (OAA) funds to every state based primarily on the 
relative size of the state's elderly population.
    Each State Unit on Aging (SUA), in turn, relies upon Area 
Agencies on Aging (AAAs)to partner with a diverse set of home 
and community service providers in getting supportive, 
nutrition, and related services to older persons. (Several 
states with relatively small populations combine the SUA and 
AAA functions into a single agency). The following is summary 
information on the clients, services, expenditures and staffing 
of OAA programs for fiscal year 1998 (most recent data 


    Older Americans Act programs served nearly 6.5 million 
persons 60 years of age and older in FY 1998. While services 
are open to all older Americans, efforts are made to focus on 
those with the greatest economic and social need. Thus, OAA 
program participants have incomes below the poverty level at a 
rate nearly four times that of the total population in this age 
group. Nearly one-third of these individuals live in rural 
areas, compared to less than one-quarter of the total 
population age 60 and above. Participants in OAA service 
programs were members of racial or ethnic minority groups at a 
level nearly one-third higher than the total elderly 
population. OAA minority clients had incomes below the poverty 
level at a rate more than twice that of the minority elderly 
population overall.


    Older Americans Act programs provided nearly 20 million 
units of personal care, homemaker and chore services in FY 
1998. During the same period, OAA programs provided almost 130 
million home delivered meals and 114 million congregate meals. 
Older persons received over 45.7 million trips to medical 
services, grocery stores, and other community services through 
OAA transportation programs. Over 13 million units of 
information and assistance services were provided to older 
persons and those acting on their behalf.

Expenditures and Staffing

    State Units on Aging and Area Agencies on Aging generated 
nearly $2 billion in state and local funds to supplement the 
$678 million in OAA dollars they received from AoA in FY 1998. 
Many SUAs also administered other programs for the elderly such 
as Medicaid home and community based waivers and state funded 
support services. There were 3,285 SUA staff and another 37,174 
staff at the AAA level working together to administer the much 
needed services provided through OAA funds. These figures 
include over 16,000 volunteers.

                        Ombudsman Program Report

    State Long Term Care Ombudsmen are advocates for residents 
of nursing homes, board and care homes, assisted living 
facilities and similar adult care facilities. They work to 
resolve problems of individual residents and to bring about 
changes at the local, state and national levels to improve 
care. While most residents receive good care in long-term care 
facilities, far too many are neglected, and other unfortunate 
incidents of psychological, physical and other kinds of abuse 
do occur. Thus, thousands of trained volunteer ombudsmen 
regularly visit long-term care facilities, monitor conditions 
and care, and provide a voice for those unable to speak for 
    Begun in 1972 as a demonstration program, the Ombudsman 
Program today is established in all states under the Older 
Americans Act, which is administered by the Administration on 
Aging (AoA). Local ombudsmen work on behalf of residents in 
hundreds of communities throughout the country. Detailed 
information on the program for 1998 (the latest year for which 
reports are available) follows.

Cases and Complaints

    In FY 1998, ombudsmen nationwide opened 136,424 cases and 
closed 121,686 cases involving 201,053 individual complaints, 
most of which were filed by residents or friends and relatives 
of residents. Eighty-two percent of cases were in nursing home 
settings; 17 percent involved board and care, assisted living 
and similar facilities; and one percent were in non-facility 
settings. The top five nursing home complaints were in 
categories involving poor resident care, lack of respect for 
residents and physical abuse. Seventy-two percent of nursing 
home complaints and 67 percent of board and care complaints 
were resolved or partially resolved to the resident's or 
complainant's satisfaction.

Program Funding

    FY 1998 program funding totaled $47,404,557, $4.35 million 
more than in FY 1997. While program funding rose in FY 1998, it 
was relatively level for the period FY 1995 to 1998. Resources 
are still inadequate to meet the need for ombudsman services 
and volunteer coverage in all facilities covered by the 
program. About 58 percent of the program funding was from 
federal sources, especially Title III of the OAA; states 
provided about 28 percent of funding; 14 percent was from 
private sources.

Local Programs, Staffing and Volunteers

    There were 587 local and regional ombudsman programs in FY 
1998, essentially the same as in FY 1997; most of these 
programs were located in area agencies on aging. The number of 
paid ombudsman staff increased from 887 full-time equivalents 
(FTEs) in FY 1997 to 927 FTEs in FY 1998, with 679 paid staff 
working full-time on the program. The number of volunteers who 
are trained and certified to investigate complaints increased 
from 6,795 in FY 1997 to 7,359 in FY 1998. Most state ombudsman 
programs are located in state agencies on aging, but programs 
in 15 states are located in other types of organizational 
settings, a slight increase since FY 1997.

   Report on the American Indian, Alaskan Native and Native Hawaiian 

    The Office for American Indian, Alaskan Native and Native 
Hawaiian programs serves as the focal point within the AoA for 
the operation and assessment of Native American programs 
authorized under Title VI and oversight of the Native American 
Elders Resource Centers authorized under Title IV. The Office 
Director continues to serve as the effective and visible 
advocate on behalf of older Native Americans, coordinates 
activities with other Federal departments and agencies, 
collects and disseminates information related to the problems 
of older Native Americans, and promotes coordination between 
the administration of Title III and Title VI.

Title VI--Grants for Native Americans

    Under Title VI of the OAA, the AoA annually awards grants 
to provide supportive and nutritional services for older 
American Indians, Alaska Natives and Native Hawaiians.
    Title VI, Grants to Indian Tribes, was added to the OAA in 
the 1978 amendments and was expanded by the 1987 Amendments to 
include Native Hawaiians.
    In Fiscal Year 2000 grants totaling $18,457,000 were 
awarded to 225 American Indian and Alaska Native Tribal 
Organizations, and two organizations serving Native Hawaiians, 
to provide congregate and home-delivered meals and a variety of 
supportive services. As required by the OAA, 90 percent of the 
funds went to the Tribal organizations and 10 percent went to 
the Native Hawaiian organizations.
    Nutrition services are a major component of Tribal Title VI 
programs. Native elders receive nearly three million congregate 
and home-delivered meals annually. Most program sites provide 
hot congregate meals four to five times a week. Home-delivered 
meals are delivered five times a week for elders who generally 
are in poorer health, are more functionally impaired, get out 
of their homes less often, and need in-home supportive 
services. Most programs provide modified diets for diabetics, 
or others who might be on low-fat, low-cholesterol, and low-
sodium diets. Several programs provide special nutrition 
services such as meals for homeless older persons an evening 
meal option for home-delivered meal participants, and weekend 
home-delivered meals.
    In addition to providing meals, nutrition education, 
screening, and counseling, Title VI programs are important 
resources for social interaction and supportive services. For 
example, congregate meal programs provide Native elders with 
important opportunities to meet with friends, participate in 
recreation and other activities, and take trips to other elder 
programs or state and national meetings. Other vital supportive 
services can include outreach, family support, legal 
assistance, and transportation to meal sites, doctor's 
appointments, and grocery shopping. Most programs offer health-
related services, such as podiatry screening and blood pressure 

Tribal Listening Session

    President Clinton signed an Executive Memorandum on April 
29, 1994 affirming that the United States government maintains 
the unique relationship with Indian Tribes founded on the 
principle of government-to-government relations. Consistent 
with this relationship, the AoA hosted a Tribal Listening 
Session on August 8, 2000 in Washington, DC with Tribal leaders 
throughout the country. The Session focused on issues affecting 
the lives of Indian elders. There were over 100 participants 
representing Tribes nationally. The Listening Session allowed 
for an open dialogue addressing four priority areas: 1) policy 
directions; 2) capacity building; 3) health care; and 4) long-
term care. Recommendations were made by the participants in 
these four areas and are currently being reviewed and 

National Resource Centers

    Since 1994, AoA has awarded grants to two universities to 
establish National Resource Centers for Older American Indians, 
Alaska Natives, and Native Hawaiians. The University of 
Colorado at Denver and the University of North Dakota at Grand 
Forks provide culturally competent health care resources, 
community-based long term care information, and related 
services. They serve as the focal points for developing and 
sharing technical information and expertise for American Indian 
organizations, Native American communities, educational 
institutions, and professionals and others working with Native 

Interagency Task Force on Older Indians

    The 1987 Amendments in Section 134(d) directed the 
Commissioner on Aging to establish a permanent Interagency Task 
Force on Older Indians, with representative of federal 
departments and agencies who work to improve services to older 
American Indians. This Task Force was established in Fiscal 
Year 1990. Task Force members focus on three areas of concern: 
health, transportation, and data. The Task Force recommends 
ways to improve interagency collaboration, enhance services, 
and identify problems or barriers that prevent or diminish 

                      Discretionary Grants Program

    The Administration on Aging supports a number of 
demonstration programs, national resource centers, and related 
discretionary grant projects under the authority of Title IV of 
the Older Americans Act, the Health Insurance Portability and 
Accountability Act, and the Public Health Services Act. The 
principal AoA discretionary grants program efforts are 
summarized below:

Health Care Fraud and Abuse Control Program Activities

    The General Accounting Office estimates that billions of 
Medicare and Medicaid dollars are lost each year to waste, 
fraud and abuse. The AoA has played an active role in the 
ongoing effort to address this serious national problem through 
the enactment of P.L. 104-209, the Omnibus Consolidated 
Appropriations Act of 1997. Language contained in Title IV of 
the Older Americans Act directs the AoA to establish community-
based projects that utilize the skills and expertise of retired 
professionals in identifying and reporting waste, fraud and 
abuse. The projects are designed to recruit and train retired 
professionals, such as doctors, nurses, teachers, lawyers, 
accountants, and others to work in their communities and in 
local senior centers to help identify deceptive health care 
practices, such as over billing, overcharging, or providing 
unnecessary or inappropriate services. These senior volunteers 
undergo several days of training reviewing health care benefit 
statements and outlining steps individuals can take to protect 
    AoA also receives funding under the Health Insurance 
Portability and Accountability Act of 1996 to work in 
partnership with the Health Care Financing Administration, the 
Office of Inspector General, the Department of Justice, and 
others in a coordinated effort to combat and prevent waste, 
fraud, and abuse in Medicare and Medicaid. The AoA's efforts 
under this initiative have been to: 1) train professionals who 
provide services to older Americans about how to recognize and 
report potential instances of waste, fraud, and abuse; 2) 
support the work of four technical assistance resource centers 
which provide outreach activities to rural, isolated, or 
limited English-speaking individuals; 3) develop consumer 
education materials in English, Spanish, and Chinese; and 4) 
convene annual national and regional conferences which bring 
together government officials, health care professionals, aging 
service providers, and older Americans to share common 
strategies and practices.
    Working in partnership with partners at the federal, state, 
and local levels, the Medicare error rate has been reduced by 
more than 40 percent over the past three years, and billions of 
dollars of improper payments have been returned to the Medicare 
and Medicaid programs.
    Over the past three years, the AoA's projects supported by 
Title IV of the Older Americans Act and the Health Insurance 
Portability and Accountability Act have a commendable track 
           They have trained more than 40,000 
        volunteers and aging service professionals to serve as 
        community resources and educators.
           These volunteers and professionals in turn 
        have conducted more than 25,000 community education 
        events and one-on-one counseling sessions, directly 
        educating more than one million beneficiaries.
           The projects also held more than 2,500 media 
        events, reaching more than an estimated 45 million 
           During this time period, more than 2,300 
        complaints have been referred to health care providers, 
        Medicare contractors, the Office of Inspector General, 
        or other appropriate entities for follow-up 
        investigation and correction.
           While it has not been possible to document 
        the results of all the cases referred by the AoA's 
        grantees, nearly $58 million in savings have been 
        documented as being directly related to the efforts of 
        the projects.
           The heightened awareness of beneficiaries 
        checking their Medicare Summary Notices and Explanation 
        of Medicare Benefit statements has contributed to a 42 
        percent reduction in the Medicare error rate since the 
        projects have been in operation.

Pension Information and Counseling Program

    Now located in 14 states (Arizona; California; Connecticut; 
Illinois; Maine; Massachusetts; Michigan; Minnesota, Missouri; 
New Hampshire; New York; Rhode Island; Vermont; and Virginia), 
the pension counseling demonstration projects supported by AoA 
since 1993 have assisted over 10,000 older Americans with 
pension problems. The projects have been instrumental in 
recouping over $30 million in pension claims. Each of the 
pension counseling projects brings its own unique model to the 
program. Some projects operate with full-time lawyers, others 
rely on highly trained volunteers to provide assistance. The 
projects provide a range of services, from answering pension 
questions to providing legal assistance to obtain promised 
pension benefits.
    Each of the demonstration projects offers several basic 
           Counseling and assistance to older 
        individuals and their families who need help in 
        determining their rights and in following the process 
        for filing claims or complaints related to pension and 
        other retirement benefits;
           Information on sources of pension and other 
        retirement benefits;
           Referrals to attorneys, actuaries, legal 
        services and other advocacy programs;
           Outreach programs to provide information, 
        counseling, assistance and referral regarding pension 
        and other retirement benefits with special emphasis on 
        outreach to women; minority; rural, and low-income 
    The Pension Rights Center in Washington, DC, with financial 
assistance from the Administration on Aging, provides technical 
assistance to individual pension projects, state and area 
agencies on aging, and legal services providers on pension 
issues, and encourages these groups to coordinate their 
activities with other federal agencies. The Center also 
provides training for staff and volunteers working in pension 
demonstration projects.

Elder Rights and Legal Assistance Program

    AoA support for model projects and resource centers under 
its Elder Rights and Legal Assistance Program is summarized 

                  (1) Statewide Senior Legal Hotlines

    Model legal hotlines, utilizing paid, specially-trained, 
and experienced lawyers, are designed to provide unlimited free 
legal advise to all state residents age 60 and older, 
regardless of their level of income or resources. The hotlines 
also provide legal briefs and related assistance such as 
document reviews and calls/letters to third parties, but only 
when there is a likelihood that this would resolve the problem. 
Services are provided statewide by means of toll-free telephone 
lines. Currently, AoA is supporting senior legal hotlines in 
northern California, Georgia, Hawaii, Indiana, Iowa, Kentucky, 
Maine, Maryland, Michigan, New Hampshire, Tennessee, 
Washington, and West Virginia.

             (2) National Legal Assistance Support Projects

    The Older Americans Act mandates the support, under Title 
IV, of a national system of legal assistance support activities 
to State and Area Agencies on Aging which will assist them in 
developing an elder rights system and in providing, developing 
and supporting legal assistance for older people. In the 1992 
amendments to the Older Americans Act, legal assistance was 
made an integral part of the new Title VII, Vulnerable Elder 
Rights Protection program. As a result, AoA expanded the role 
of the national system to encompass elder rights systems 
development. Five (5) national level providers of legal support 
and assistance are now being funded by AoA through 2001.

         (3) National Resource Centers to Protect Elder Rights

    Two centers active nationwide (the National Center on Elder 
Abuse and the National Long Term Care Ombudsman Resource 
Center) have been funded by AoA since 1993 to provide findings, 
products, information, training, and technical assistance that 
would help to safeguard the rights of older persons living in 
residential and institutional settings.

Reach 2010 for the Elderly

    In FY 2000, the AoA joined with the Centers for Disease 
Control and Prevention to strengthen the scope of the 
departmental initiative to eliminate health disparities among 
racial and ethnic minority populations by mounting REACH 2010 
for the Elderly. This major collaborative effort has the goal 
of improving the health status of older racial and/or ethnic 
minority persons. Four projects were funded to support 
community coalitions in their groundbreaking initiatives to 
reduce health care disparities in the areas of heart disease, 
diabetes, and immunization. The Reach 2010 grantees are as 
           Boston Public Health Commission
           The Latino Education Project
           Special Services for Groups
           National Indian Council on Aging

Other Significant Discretionary Program Efforts

    Other noteworthy AoA-supported discretionary programs and 
projects include the Alzheimer's Disease Demonstration Grants 
to States Program, the Family Friends/Volunteer Senior Aides 
program, the National Eldercare Locator, minority aging model 
projects, and home and community based long term care 
demonstration projects.

                          2. Program Direction

                                                              FY 1999            FY 2000            FY 2001
Supportive Services & Centers..........................       $309,957,000       $310,020,000       $325,082,000
Congregate Meals.......................................        374,261,000        374,336,000        378,412,000
Home-Delivered Meals...................................        112,000,000        146,970,000        152,000,000
Preventive Health Services.............................         16,123,000         16,120,000         21,123,000
State and Local Innovations/Projects of National                18,000,000         31,156,000         37,678,000
Grants to Native Americans.............................         18,457,000         18,457,000         23,457,000
Vulnerable Older Americans.............................         12,181,000         13,179,000         14,181,000
Alzheimer's Disease....................................          5,970,000          5,968,000          8,970,000
Program Administration.................................         14,781,000         16,458,000         17,232,000
TOTAL, Budget Authority................................       $881,730,000       $932,664,000     $1,103,135,000

                                FY 1999

    In FY 1999, AoA programs were funded at a total of $881.7 
million, an increase of almost $11 million over FY 1998. The 
majority of this money was allotted by statutory formula to 
states and territories. Funding for the major supportive 
services and nutrition programs remained unchanged; increases 
were provided for several smaller AoA programs. Vulnerable 
Older Americans did receive an additional $3 million (+33%) to 
increase Ombudsman activities. AoA's sole discretionary grant 
program, State and Local Innovations and Projects of National 
Significance received $18 million, the largest increase, +$8 
million (+80%). In FY 1999 the number of projects funded under 
this discretionary authority increased from approximately 61 to 
105 and included the Eldercare Locator, Senior legal hotlines, 
pension counseling, and evaluation activities.

                                FY 2000

    In FY 2000, AoA programs were funded at a total of $932.7 
million, an increase of $51 million. Home-Delivered meals, one 
of AoA's two formula grant nutrition programs, received an 
additional $35 million, a +31 percent increase. Funding for 
AoA's other formula grant programs again remained static. The 
increase for Home-Delivered meals allowed grantees to provide 
nearly 166,000,000 meals to frail, home-bound elders. 
Vulnerable Older Americans also received a $1 million increase, 
again for the Ombudsman program. And once again, State and 
Local Innovations and Projects of National Significance 
received a large increase (73%) bringing the program level to 
over $31 million and funding approximately 70 new projects, 120 
projects total. Program Administration also received a nearly 
$2 million increase to fund staff increases and increased costs 
of facilities rental, automated systems support, travel, 
supplies and equipment.

                               THE FUTURE

    In FY 2001, the start of which covers the final three 
months in calendar year 2000, funding for Aging programs has 
increased significantly, to a total of $1.1 billion or $169 
million over the FY 2000 level. This includes $125 million for 
a new National Family Caregiver Support Program to provide 
support to the 7 million informal caregivers of older 
Americans. In addition, the FY 2001 budget includes increases 
for each of its core services and programs, including home-
delivered and congregate meals; preventive health; grants to 
Native Americans, programs which protect the rights of the 
vulnerable, as well as an increase for the Alzheimers Disease 
Demonstration Project Grants to States.

       Accomplishments of the Administration on Aging: 1999-2000

                Administration/Departmental Initiatives

    Since 1995, the Administration on Aging has been a partner 
in the Administration's Operation Restore Trust initiative, 
along with HCFA, the Office of the Inspector General, and the 
Department of Justice to combat waste, fraud and abuse in 
Medicare and Medicaid. AoA has trained state and local 
ombudsmen and volunteers, aging network personnel, including 
staff and volunteers of State and Area Agencies on Aging, 
health insurance counselors and other service providers to 
identify and report suspected fraud and abuse. In FY 2000, $10 
million in grants was awarded to 48 ``Senior Medicare Patrol 
Projects'' operating in 43 states plus the District of Columbia 
and Puerto Rico. These projects have trained approximately 
30,000 senior volunteers and aging network staff and educated 
650,000 beneficiaries to identify and report suspected cases of 
fraud and abuse.
    Reauthorization of the Older Americans Act (OAA) with 
inclusion of the National Family Caregiver Support Program, 
part of the Administration's Long Term Care Initiative unveiled 
in 1999, which will help hundreds of thousands of family 
members care for their older family members by providing 
respite care and supplemental services, information, 
assistance, training, support and counseling. FY 2001 funding 
for the National Family Caregiver Support Program is $125 

                  Public Information/Customer Service

    Launching of AoA's web site in 1995, a major source of 
timely and useful information to older people, the national 
aging network, policymakers. AoA's web site has been expanded 
to include limited access web sites for the Federal 
Coordinating Committee of the International Year of Older 
Persons (1999); a limited Spanish web site containing resource 
and referral information to those interested in Hispanic aging 
and health issues, and an independent web site dedicated to 
providing and sharing information about the Administration on 
Aging's role in the Administration's effort to fight fraud, 
waste and abuse in Medicare and Medicaid. In FY 2000, a 
minority/aging issues limited access web site and an on-line 
caregivers guide called ``Because We Care'' was added.
    Institution in 1999 of a limited access list serve 
specifically devoted to national aging network of state and 
area agencies on aging responsible for the collection and 
reporting program performance data to the Administration on 
Aging. Through NAPISNEWS, customized information and technical 
assistance can be quickly disseminated and provided to 
appropriate staff throughout the country.
    Creation of a Congressional mandated National Aging 
Information Center to provide convenient access to a wide range 
of resources for those interested in aging issues and 
information. The Center serves the aging network, educators, 
researchers, practitioners and the general public.
    Establishment of AoA's national disaster assistance program 
to assist older persons and representatives of the aging 
network in recovery efforts from Presidentially declared 
disasters. Since 1993, the Administration on Aging in 
collaboration with its state and area agencies on aging, FEMA, 
and the Red Cross has provided approximately $17.5 million in 
disaster relief to thousands of older persons in immediate need 
of assistance.


    Since 1998, AoA has worked in partnership with the Health 
Care Financing Administration (HCFA) to support Medicare+Choice 
(M+C) implementation. Through the Information and Referral for 
Medicare Beneficiaries Projects, AoA was able to provide funds 
to State Units on Aging (SUAs) to strengthen the capability of 
information and referral providers at the State, Area Agency 
and local levels to respond to inquiries regarding M+C. In 
addition, AoA worked in collaboration with it's National 
Information and Referral Support Center and HCFA to develop the 
Medicare+Choice Training Manual for Older Americans Act 
Information Referral & Assistance Programs. The manual was 
provided to State Units on Aging and Area Agencies on Aging to 
assist them in developing Medicare+Choice training and outreach 
activities. Over 15,000 information and referral specialists 
and other Aging Network staff have received training as a 
result of this collaborative effort.

                     National Symposia on Longevity

    The Administration on Aging convened two symposia during 
1999 and 2000 which focused on the implications of a long 
living society. The symposia were designed to increase public 
awareness of longevity, provide a forum for dialogue about the 
implications for research, policy, programs and services, and 
foster the development of partnerships and collaborations 
between a variety of organizations. The first symposium focused 
on the most potent and promising research findings related to 
caregiving, economic security, health, population diversity, 
consumer protection, information and technology and media 
relations. The second symposium bridged the gap between 
research and practice by providing the participants evidenced-
based, outcomes-oriented methods and tools that could be used 
to plan, develop and modernize services and programs for 
America's diverse and growing older population.

               Programs and Services for Older Americans

    The Older Americans Act continues to provide essential home 
and community services for older persons, and their family 
members such as nutrition, transportation, and legal 
assistance, through a national aging network of 57 State 
offices on aging, 655 area agencies on aging, 225 Tribal 
Organizations, service providers and volunteers.


    Release of a Congressionally mandated evaluation of the 
Elderly Nutrition Program under the Older Americans Act (OAA) 
to determine the effectiveness of the Elderly Nutrition Program 
in meeting the nutritional needs of older persons as well as 
meeting unmet needs. Key findings include determination that 
the highly successful OAA Elderly Nutrition program provides an 
average of one million meals per day to older Americans; 
between 80 and 90 percent of participants have incomes below 
200 percent of the DHHS poverty level, and more twice as many 
of the participants live alone.
    Establishment of the National Policy and Resource Center on 
Nutrition and Aging which focuses on providing information 
dissemination, training and technical assistance and policy 
analysis on issues related to nutrition and older persons.
    The Morning Meals on Wheels Program Initiative was launched 
in 20 communities across the United States. This is a 
partnership with General Mills Food service and the 
Administration on Aging to provide at-risk older Americans with 
additional food and nutrition security. Morning Meals on Wheels 
provides home elders with a morning meal delivered to their 
door in addition to their regularly scheduled noon meal.
    Alzheimer's Disease Demonstration Grants program was 
transferred from HRSA to AoA. Sixteen new ADDGS grants were 
funded in 2000, to expand support efforts for persons with 
Alzheimer's Disease and their caregivers.The program emphasizes 
outreach to under served populations and regions, program 
development, service delivery systems and information 
    AoA convened its first Tribal Listening Session to Native 
American elder issues. The session gave American Indians, 
Alaska Natives, and Native Hawaiian representatives the 
opportunity to discuss policy directions and capacity building 
in areas such as long term care, health promotion, and support 
services needed in the future. Greater numbers of Native 
Americans are living well into their 80's and 90's. AoA funds 
225 tribal organizations representing more than 300 American 
Indian and Alaska Native tribes and two organizations serving 
Native Hawaiians, through Title VI of the Older Americans Act.

                          Consumer Protection

    Release of the National Elder Abuse Incidence Study which 
found that more than one half million older Americans, mostly 
older women, suffered some form of abuse and neglect in 1996, 
most at the hands of their family members.
    Entered into Interagency Agreement with the Department of 
Justice to address the public safety and security needs of 
older Americans. Activities have included promotion of local 
and state TRIAD programs, which are efforts to increase 
cooperation between law enforcement and aging and social 
services providers to reduce criminal victimization.
    Funding a new National Center on Elder Abuse to be operated 
by the National Association of State Units on Aging in 
partnership with the other advocacy organizations to facilitate 
training and technical assistance between state and local 
service providers, including older Americans, working to 
prevent elder abuse.
    Establishment of Pension Counseling and Counseling program 
including 10 AoA-funded pension demonstration projects serving 
14 states and one technical assistance Project for a total of 
$3.3 million dollars. These projects have assisted 30,000 
retirees, older employees and their spouses or widows/widowers 
to determine whether or not they are receiving the amount of 
retirement benefits to which they are entitled. The project has 
recouped at least $21 million in pension benefits on behalf of 
their clients returning $7 for every $1 spent to older 
Americans. AoA also released results of a two-year 
Congressional study of the Pension Counseling Program, which 
found that basic pension counseling for older workers and 
retirees is needed, can be easily provided at a moderate cost 
by training volunteers, and can yield substantial individual 
and collective savings.
    Design and Implementation of the National Ombudsman 
Reporting System (NORS) to obtain needed detailed ombudsman 
complaint and program information in an effort to design policy 
and serve as a baseline against which to measure program 
outcomes in future years. Funding of the National Long Term 
Care Ombudsman Resource Center, which provides training and 
technical assistance to state and local ombudsmen across the 
    Partnership with the Federal Deposit Insurance Corporation 
in the Financial Literacy, Y2K and Banking Campaign, a public 
awareness campaign to promote financial literacy in particular 
between women and low income and minority populations.

                  Promoting Health and Quality of Care

    AoA has awarded four demonstration grants to expand the 
Centers for Disease Control's Reach 2010 (Racial and Ethnic 
Approaches to Community Health 2010) initiative. This grants 
will permit four communities to develop science based, 
community demonstration projects to address health disparities 
in older, racial and ethnic minority populations.
    AoA and HCFA joined forces to improve the quality of care 
in nursing homes. Nearly one half million dollars has been 
dedicated to support 4 demonstration projects to educate and 
empower communities and families to improve nutrition and 
hydration, and prevent abuse of nursing home residents.


    To develop the national core set of performance outcome 
measures for aging services required by the Government Results 
and Performance Act, AoA is building on performance outcome 
measures currently in use by state and area agencies. Seventeen 
State and Area Agency partners are working to address the 
elements of data collection; analysis and recommendations; 
pilot testing, and dissemination, utilization and mentoring 
    The Administration on Aging was one of the first in HHS to 
undertake a workforce planning process. In early 1999, it 
completed a workforce plan to identify requisite knowledge, 
skills, and abilities for management and staff to be able to 
formulate, implement and assess programs and policies related 
to older persons and their families. The workforce plan serves 
as a guide for the recruitment and hiring of new managers and 
    The Administration on Aging embarked upon the reorientation 
of its Central and Regional Office program and policy foci in 
order to respond more effectively to the growing numbers and 
the increasing diversity of older Americans and their families, 
baby boomers anticipating their older years, and of populations 
at greater risk of chronic illness, disability and economic 

                        International Activities

    AoA chaired and led national federal activities for the 
International Year of Older Persons, designated by the UN for 
1999. As head of the Federal Committee for the International 
Year for Older Persons, AoA convened the first ever federal 
symposium ``Coming of Age: Federal Agencies and the Longevity 
Revolution.'' As part of the IYOP activities, the Assistant 
Secretary for Aging addressed the 54th Session of the United 
Nations General Assembly on the aging challenges of a longer 
living U.S. society.
    Joined as a partner with Sister Cities International, Inc. 
which joins aging professionals and volunteers in the US with 
their counterparts in other countries to provide technical 
assistance in meeting the needs of any population.
    The Administration on Aging is a principal partner in the 
US-Mexico Bilateral Commission Health Working Group convened as 
part of the 1996 Annual Meeting of the US-Mexico Bilateral 
Commission. AoA assists in the identification of public health 
issues that effect both countries including aging, migrant 
health, prevention of tobacco abuse, women's health, 
immunization, and substance abuse.
    AoA was a member of the 1999 World Health Day Advisory 
Committee. ``Healthy Aging'' was designated by the World Health 
Organization as the topic of World Health Day 1999. In the US, 
the theme ``Healthy Aging, Healthy Living - Start NOW! was 
selected by the American Association for World Health and the 
advisory committee as fitting since 1999 was IYOP.

                          Network Security/Y2K

    AoA was the first in the Department of Health and Human 
Services to achieve Y2K compliancy, and worked for two years 
with its national aging network of state and area agencies on 
aging to ensure they were ready for the year 2000.
    Security of AoA's computer network has been improved in 
response to the President's Decision Directive 63 concerning 
anticipated cyberterrorism.


    The Office of the Assistant Secretary for Planning and 
Evaluation (ASPE) serves as the principal advisor to the 
Secretary on policy and management decisions for all groups 
served by the Department, including the elderly. ASPE oversees 
the Department's legislative development, planning, policy 
analysis, and research and evaluation activities and provides 
information used by senior staff to develop new policies and 
modify existing programs.
    ASPE is involved in a broad range of activities related to 
aging policies and programs. It manages grants and contracts 
which focus on the elderly and coordinates other activities 
which integrate aging concerns with those of other population 
groups. For example, the elderly are included in studies of 
health care delivery, poverty, State-Federal relations and 
public and private social service programs.
    ASPE also maintains a national clearinghouse which includes 
aging research and evaluation materials. The ASPE Policy 
Information Center (PIC) provides a centralized source of 
information about evaluative research on the Department's 
programs and policies by tracking , compiling, and retrieving 
data about ongoing and completed HHS evaluations. In addition, 
the PIC data base includes reports on ASPE policy research 
studies, the Inspector General's program inspections and 
investigations done by the General Accounting Office and the 
Congressional Budget Office. Copies of final reports of the 
studies described in this report are available from PIC.
    During 2000, ASPE undertook or participated in the 
following analytic and research activities which had a major 
focus on the elderly.

                      1. Policy Development--Aging

Federal Interagency Forum on Aging-Related Statistics

    ASPE is a member of the Federal Interagency Forum on Aging-
Related Statistics. The Forum was established to encourage the 
development, collection, analysis, and dissemination of data on 
the older population. The Forum seeks to extend the use of 
limited resources among the agencies through joint problem-
solving, identification of data gaps, and improvement of the 
statistical information bases on the older population. The 
primary goals of the Federal Forum were to provide federal 
agencies a venue for discussing aging-related data issues and 
concerns that cut across agency boundaries, facilitate the 
improvement of existing aging data bases and the development of 
new sources of information, improve the dissemination of 
information on aging-related research and data, and encourage 
cross-national research and data collection on population 
aging. The Federal Forum was instrumental in gathering support 
for several important surveys of the aging U.S. population 
(e.g., the Health and Retirement Survey, the survey of Assets 
and Health Dynamics Among the Oldest-Old, and the Second 
Longitudinal Study of Aging) and produced several stand-alone 
reports including Trends in the Health of Older Americans and 
65+ in the United States.

                 2. Research and Demonstration Projects

Panel Study of Income Dynamics

    University of Michigan, Institute for Social Research
    Principal Investigators: James N. Morgan, Greg J. Duncan, 
Martha S. Hill
    Through an interagency consortium coordinated by the 
National Science Foundation, ASPE assists in the funding of the 
Panel Study of Income Dynamics (PSID). This is an ongoing 
nationally representative longitudinal survey that began in 
1968 under the auspices of the Office of Economic Opportunity 
(OEO). The PSID has gathered information on family composition, 
employment, sources of income, housing, mobility, health and 
functioning, and other subjects. The current sample size is 
over 7,000 persons, and an increasing number of them are 
elderly. The data files have been disseminated widely and are 
used by hundreds of researchers in this and other countries to 
get an accurate picture of changes in the well-being of 
different demographic groups, including the elderly.
    Funding: ASPE and HHS precursors: FY67 through FY79--
$10,559,498; FY80--$698,952; FY81--$600,000; FY82--$200,00; 
FY83--$251,000; FY84--$550,000; FY85--$300,000; FY86--$225,000; 
FY87--$250,000; FY88--$250,000; FY89--$250,000; FY90--$300,000; 
FY93--$300,000; FY94--$800,000; FY95--150,000; FY96--205,000; 
FY97--100,000; FY98: $200,000
    End Date: Ongoing

1999 NLTCS/ICS: File Preparation and Preliminary Data Analysis

    MEDSTAT Group
    The purpose of this project is to prepare the 1999 NLTCS/
ICS data file for analysis and to perform some preliminary 
descriptive analyses. This is a necessary prerequisite for more 
detailed analyses, which will be used to update the ASPE 
booklet ``Informal Caregiving: Compassion in Action'' 
(published in 1998, based on 1995 NLTCS data).
    Funding: $49,452 (FY00)
    End Date: September 30, 2001

A Comparative Study of the Outcomes and Costs Associated with Medicare 
        Post-Acute Services in Skilled Nursing Facilities, 
        Rehabilitation Hospitals/Units, and Home Health Settings

    University of Colorado
    Using the outcome measurement instrument developed for 
patients suffering from a stroke (i.e., developed under the 
project Medicare Post-Acute Care: Quality Measurement), two 
projects have been combined to study the outcome and costs of 
Medicare post acute care services for Medicare beneficiaries 
who have suffered a stroke and are discharged from acute care 
hospitals to skilled nursing facilities (SNFs), rehabilitation 
hospitals/units (RFs), home health agencies (HHAs), or use 
multiple post-acute care settings. These studies will examine 
in a post-prospective payment system environment the: (1) 
demographic and health related characteristics of and assess 
the extent of overlap in stroke patients treated in each of the 
post-acute care settings; (2) patterns of service use and costs 
associated with the treatment of similar patients in each 
setting and across episodes of care; (3) outcomes across an 
episode of care for similar Medicare beneficiaries treated by 
each post acute provider type and those treated by multiple 
providers; (4) the relationship between outcomes for similar 
patients and differences in the mix and intensity of services 
provided, and level of reimbursement across post acute care 
providers and episodes of care; and (5) core measures that are 
most useful to incorporate into on-going reporting requirements 
to monitor outcomes in each post-acute care setting and across 
episodes of care.
    Funding: Total Award $1,593,536 (FY99 $898,956; FY00 
    End Date: August 28, 2003

Analyses of Changes in Elderly Disability Rates: Implications for 
        Health Care Utilization and Costs

    The Urban Institute
    The purpose of this project is to conduct analyses using 
the 1984 to 1999 National Long-Term Care Survey (NLTCS) and the 
Medicare Current Beneficiary Survey (MCBS) to understand the 
nature of recent declines in elderly disability rates and their 
implications for health care utilization and costs. 
Specifically, researchers at The Urban Institute are (1) 
decomposing changes in elderly disability rates using the 1984 
to 1999 NLTCS and exploring possible reasons for the decline, 
and (2) linking changes in elderly disability rates to the use 
of specific medical procedures (e.g., cataract surgery, 
coronary and joint replacement surgeries) and/or assistive 
technology. The MCBS is the primary data set for the latter 
    Understanding the structure of the decline will give us our 
first clues as to the reasons for the overall decline, the 
likelihood that disability rates will continue to fall in the 
future, and its potential impact on health care spending. 
Current hypotheses for the decline include improvements in 
nutrition (including advances in food preparation and storage 
over the century), healthier life-styles (higher levels of 
physical activity, lower levels of drinking and smoking), 
better treatment of chronic diseases through medical procedures 
and pharmaceuticals, and use of assistive devices and 
technology. It is likely that future improvements in disability 
and changes in health care utilization and spending will be 
heavily dependent on which of these hypotheses is correct. For 
example, if declines in disability rates are due primarily to 
improvements in IADLs or equipment use and reflect 
environmental changes rather than improvements in the intrinsic 
health of the elderly population, then the declines observed 
over the last decade may not continue into the next century and 
may have limited impact on acute health care spending. This 
project is a first step in understanding the policy 
implications of the changes that we are observing in elderly 
disability rates.
    Funding: $254,409 (FY99 $179,409; FY00 $75,000)
    End Date: December 31, 2001

Analyses of Residential Transition of Older Americans.

    Urban Institute
    There are four main questions to be addressed in this 
project: (1) How do characteristics (both individual and 
environmental) of elderly persons residing in institutional 
settings differ from those residing in community-based 
settings? (2) How do these characteristics vary over time? (3) 
Are there differences in these characteristics between 
subgroups of institutionalized and non-institutionalized 
elderly? (4) What is the relationship between selected 
individual and environmental factors and the transition of the 
elderly between community and institutional residential 
settings? Data from six years of the Medicare Current 
Beneficiary Survey will be used to answer these questions. 
Understanding residential transitions will help staff in the 
Department improve surveys that monitor acute health and long-
term care use in different settings (e.g., the Medical 
Expenditure Panel Survey) and address outstanding long-term 
care policy issues (e.g., allocation of resources between 
community and institutional settings).
    Funding: Total Award $153,494 (FY00 $153,494)
    End Date: March 31, 2002

Assessment of Home Care Benefits Used by Holders of Private Long-Term 
        Care Insurance

    Life Plans, Inc.
    Most experts agree that long-term care insurance products 
must include both nursing home and home care benefits if they 
are to be commercially acceptable. Yet private insurers as well 
as public payers are concerned about their ability to control 
home care claims, particularly given the potential substitution 
of formal home care services for care provided by families. The 
purpose of this study was to collect detailed information on 
the experience of long-term care policy holders who have filed 
insurance claims to receive home care benefits and how their 
formal and informal service use compares to a comparable 
population of elderly persons without private insurance. 
Primary data collection involved face-to-face interviews with 
approximately 1,000 persons (500 disabled insurance claimants 
and 500 next-of-kin of those claimants) to collect information 
on functional and medical characteristics of claimants as well 
as formal and informal services use. The sample of claimants 
was drawn from the files of insurance companies that account 
for the majority of private long-term care policies now in 
    Funding: $50,000
    End Date: March 1, 2000

Case Studies of Nursing Home Transition Programs

    Medstat Group
    The purpose of this project is to conduct case studies of 
Nursing Home Transition Programs in up to eight states (with 
possible additions depending on future grant awards). The 
programs being evaluated were developed and implemented with 
funding from an ongoing grant initiative sponsored by the 
Health Care Financing Administration (HCFA) and the Office of 
the Assistant Secretary for Planning and Evaluation (ASPE). A 
case study approach is proposed for two reasons: (1) the vast 
differences in state Medicaid programs, state long-term care 
infrastructures, and proposed nursing home transition programs; 
and, (2) the small number of nursing home residents expected to 
participate in the transition programs.
    Each case study will attempt to determine the most 
significant barriers faced by nursing home residents in 
returning to the community, and, to glean the relative success 
or failure of the strategies used by grantees to overcome these 
barriers. As HCFA and ASPE intend to continue making additional 
grants in this area, an evaluation of grantee activity will 
assist federal policy makers in further grant making, and state 
policy makers in developing transition programs.
    Funding: Total Award $300,006 (FY00 $300,006)
    End Date: February 1, 2002

Characteristics of Nursing Home Residents

    Hebrew Rehabilitation Center for Aging
    Caring for persons with disabilities in the least 
restrictive setting is a major long-term care policy objective. 
It is important to identify nursing home residents who could be 
discharged to the community if appropriate home and community-
based services were available. This project will analyze data 
from a new source--the Minimum Data Set (MDS)--in nine states. 
The MDS consists of assessments which have been conducted on 
all nursing home residents in selected States as part of a HCFA 
demonstration (and starting in the summer of 1998, the data 
will be collected in electronic form in all 50 States). We will 
learn much more about the medical conditions, functional needs, 
and specific services used by nursing home residents than was 
possible with previous data sets. We will also be able to study 
important subpopulations, especially the nonelderly. The policy 
implications of the findings will be assessed.
    Funding: Total Award $150,000 (FY98 $150,000)
    End Date: September 30, 2001

Evaluation of Practice in Care (EPIC)

    University of Colorado
    From 1989 to 1992, there was a 210 percent increase in 
Medicare expenditures for home health services. This increase 
in utilization has generated widespread policy interest in 
appropriate measures to control expenditures without 
compromising quality. Medicare home health has been the subject 
of considerable research, but the actual practice of home 
health care has not been extensively examined. This study will 
analyze ``episodes'' of care under the Medicare home health 
benefit, assess the actual practice of care, the extent to 
which there is variation in practice between acute and long-
term patients, and the factors that account for that variation. 
This study will also examine decision-making processes between 
patients, providers and physicians. What takes place during a 
visit and between visits as ``actual practice'' has never been 
measured. Furthermore, the function of decision-making by 
various parties has not been observed in ``actual practice.'' 
This effort to understand issues surrounding regional and 
practice variations of home health care delivery will aid the 
Department and the industry in combating fraud and abuse, as 
well as contribute valuable data to a future prospective 
payment system.
    Funding: Total Award $1,400,000 (FY97 $200,000)
    End Date: March 1, 2001

Informal Caregivers Supplement to the 1999 National Long-Term Care 

    Duke University
    The Office of the Assistant Secretary for Planning and 
Evaluation (ASPE) has been involved in the past in designing a 
modest respite benefit for Medicare beneficiaries with 
Alzheimer's disease for inclusion in the President's budget. In 
1998, there is renewed interest in having proposals for respite 
services and other caregiver supports, on a broader scale, 
incorporated into the President's long-term care budget 
initiative. We are currently working with White House, OMB, and 
Treasury staff to explore the use of tax incentives to help 
informal caregivers be able to afford paid home care services 
as a supplement to their own informal efforts. In order to 
respond to these kinds of policy analysis requests, it is 
important for ASPE to look ahead and anticipate future data 
needs. In this case, the need is to have data collection 
mechanisms in place to track, over time, changes in the 
characteristics of informal caregivers of the disabled elderly, 
as we have to follow changes in the population of disabled 
elders themselves. ASPE supported the first and second Informal 
Caregiver's Supplement to the National Long-Term Care Survey in 
1982 and 1989 respectively. A third round of data collection on 
informal caregivers is now needed in order to remain up-to-
    Family members typically initiate the process of nursing 
home placement for disabled elders when they feel that the 
disabled elder needs more help than can be provided in a home 
setting. Often families come to such a decision when one or 
more family caregivers have been providing upwards of 60 hours 
per week of unpaid assistance. This project will enable in-
depth analysis of the conflicts informal caregivers experience 
between employment and eldercare as well as provide information 
about the health status of caregivers and measures of caregiver 
stress and burden. These data can then be used in crafting 
policy initiatives to support caregivers and prevent 
``caregiver burnout'' which could result in premature 
institutionalization. It will help determine whether and to 
what extent caregivers' age, marital status, relationship to 
the care recipient, household income, employment, health 
status, and various measures of caregiver stress and burden are 
associated with greater or lesser use of supplemental formal 
care. We will also be able to measure the extent to which 
caregivers as well as the disabled elders themselves experience 
out-of-pocket spending for supplemental home care.
    Funding: Total Award $300,000 (FY98 $300,000)
    End Date: March 1, 2000

Long-Term Care Microsimulation Model

    Lewin Group
    This project will update and expand the capability of the 
Brookings/ICF Long-Term Care Financing Model, which currently 
takes a national sample of persons, ages them over time, and 
estimates their long-term care use and financing when they 
become elderly. It will incorporate results from recent surveys 
of nursing homes and home care utilization; e.g., the 1989 and 
1994 National Long-Term Care Surveys. The model will also be 
expanded to include acute care use and expenditures, and the 
period of simulation will be extended to 2030. The economic 
assumptions will be updated.
    The model will continue to be used to project future trends 
and to perform policy simulations, including expanded coverage 
for nursing home and home care, changes in Medicaid eligibility 
and services, and expanded enrollment in private long-term care 
insurance plans. It will also be used to estimate the impact of 
changing trends in disability and the combined burden of acute 
and long term care services on the elderly.
    Funding: $1,304,820 (FY97 $232,266; FY98 $211,709)
    End Date: December 31, 2000

Managed Delivery Systems for Medicare Beneficiaries with Disabilities 
        and Chronic Illnesses

    Mathematica Policy Research
    The last decade has brought tremendous changes in the 
health care system as payers and providers struggle to bring 
health care expenditures under control. The momentum to achieve 
a reformed, more managed U.S. health care system, one which 
seeks to bring costs under control while improving access to, 
continuity and coordination of care, appears unstoppable. 
However, it remains unknown how this transforming health care 
system will affect the health and well-being of people with 
significant disabilities and chronic illnesses. The Medicare 
program has lagged behind the private insurance market and even 
the Medicaid program in the proportion of its beneficiaries 
participating in managed care plans. In 1995, about 2.3 million 
older persons out of a total Medicare beneficiary population of 
25 million were enrolled in the Medicare Risk Program 
implemented under TEFRA. There is little information on the 
experience of older persons with disabilities in these and 
other managed care plans.
    The purpose of this study is to: (1) address the 
characteristics of elderly persons with chronic illnesses and 
disabilities that need to be accommodated in designing and 
operating managed delivery systems (MDS); (2) examine the 
issues that health care policy makers, plan administrators and 
providers need to consider in designing, operating, and 
monitoring MDS for the elderly with disabilities and chronic 
illness; (3) examine how MDS actually perform in meeting the 
needs of the elderly disabled; and (4) identify the factors 
that influence the success of MDS in meeting the needs of this 
    Funding: Total Award $349,450 (FY97 $244,450; FY00 
    End Date: May 31, 2001

Medical Expenditure Panel Survey (MEPS) Nursing Home Component

    Medstat Group
    The Office of the Assistant Secretary for Planning and 
Evaluation (ASPE) and the Agency for Health Care Policy and 
Research (AHCPR) entered into this Interagency Agreement for 
the purpose of allowing ASPE and an ASPE contractor (The 
MEDSTAT Group) access to the Nursing Home Component of the 1996 
Medical Expenditure Panel Survey (MEPS) including the Community 
Caregiver Supplement. Through its contractor, ASPE will edit 
and prepare data files and analyze data from the MEPS Nursing 
Home Component and the Community Caregiver Supplement. The 
purpose of the ASPE-supported analyses is to better understand 
how to promote and improve home and community-based services as 
opposed to institutional services for persons with significant 
functional disabilities.
    End Date: July 1, 2000

Medicare Post-Acute Care: Quality Measurement

    Urban Institute
    This project developed four outcome measurement instruments 
and methods of data collection that could be used in future 
research to examine outcomes and costs associated with Medicare 
post-acute care (PAC) services for patients who have suffered a 
stroke, congestive heart failure(CHF), pneumonia, and back and 
neck conditions. These conditions were selected because of 
their prevalence within and across PAC settings. The 
instruments and the data collection methodology will be revised 
based on two field tests and technical expert input. The 
outcome measurement instrument developed for stroke patients 
will be used in other ASPE funded studies (i.e., A Comparative 
Study of the Outcomes and Costs Associated with Medicare Post-
Acute Services).
    Funding: Total Award $482,943 (FY97 $321,035; FY99 
    End Date: December 31, 2000

Monitoring the Health Outcomes for Disabled Medicare Beneficiaries

    Laguna Research Associates
    The Balanced Budget Act (BBA) of 1997 mandated major 
changes in home health payment requiring the implementation of 
a Prospective Payment System (PPS) by October 1999 (later 
delayed until October 2000) and an Interim Payment System (IPS) 
prior to the implementation of PPS. It also contained changes 
in eligibility and coverage for home health services. These 
changes, while intended to reduce Medicare home health costs, 
run the risk of reducing beneficiaries' access to appropriate 
care and adversely affecting health outcomes, especially for 
beneficiaries needing the most care (Komisar and Feder 1998, 
Smith and Rosenbaum 1998, MedPAC 1999, GAO 1998, Gage, 1998). 
Disabled Medicare beneficiaries are especially vulnerable.
    The purpose of this project is to study the impact of 
recent payment policy changes on disabled Medicare 
beneficiaries' satisfaction and quality of life with a view 
toward formulating inferences that will inform national home 
health care policy for the disabled. The study will build on a 
research project recently funded by the Home Care Research 
Initiative of The Robert Wood Johnson Foundation that examines 
the direct and indirect effects of the BBA changes. The 
project's main focus is to examine BBA impacts on Medicare 
beneficiaries' access to care, costs, satisfaction, and quality 
of care. Also examined will be the effects on agencies and on 
the overall health system.
    Funding: Total Award $150,000 (FY99 $150,000)
    End Date: September 30, 2001

National Study of Assisted Living for the Frail Elderly

    ``Assisted living'' refers to residential settings for 
people with disabilities which combine both housing and 
personal assistance services within a homelike or 
noninstitutional environment. The number of assisted facilities 
nationally is not known; estimates range from 8,000 to 30,000. 
Similarly, estimates for the number of frail elderly and other 
persons residing in such facilities range from 350,000 to 
1,000,000. This study will, among other things, generate a more 
reliable estimate of the number of these facilities and their 
residents. As assisted living options multiply, a challenge 
facing the Federal and State governments is how to regulate 
such arrangements, balancing consumer protection concerns 
(especially if public funds reimburse costs) with resident 
rights for self-direction, taking risks and maintaining 
accustomed lifestyles.
    The major purpose of this project is to analyze the role of 
assisted living within the current long-term care system from 
the perspective of consumers, owners/operators, workers, 
regulators, investors and other stakeholders, and to issue a 
report on its current status and future directions. The study 
will address several broad policy-relevant issues, including 
supply and demand trends; barriers; how closely practice 
parallels philosophy; the impact of key features on outcomes; 
and quality and accountability. The contractor will assist HHS 
and other Federal agencies in the formulation of regulatory and 
financing policy options for assisted living. A Technical 
Advisory Group has been established to provide guidance to the 
    Funding: Total Award $2,025,000 (FY98 $350,000; FY99 
    End Date: June 30, 2000

``Cash and Counseling'' Demonstration/Evaluation.

    University of Maryland, Center on Aging
    This project, which is being done in collaboration with the 
Robert Wood Johnson Foundation, will employ a classical 
experimental research design (i.e., random assignment of 
participants to treatment and control groups) to test the 
effects of ``cashing out'' Medicaid-funded personal assistance 
services for the disabled. The demonstration will include 
elderly as well as younger disabled consumers. Two States are 
expected to participate in the demonstration. In these States, 
control group members will receive ``traditional'' benefits--
i.e., case managed home and community-based services, where 
payments for services are made to vendors--while treatment 
group members receive a monthly cash payment in an amount 
roughly equal to the cash value of the services they would have 
received under the traditional program.
    It is hypothesized that cash payments will foster greater 
client autonomy and that, as a result, consumer satisfaction 
will be greater. Consumers are expected to purchase a somewhat 
different mix of disability-related services and/or assistive 
technologies when they make the decisions and payments 
themselves than when case managers contract with vendors on 
their behalf. It is also hypothesized that States will save 
Medicaid monies (mostly in administrative expenses) from 
cashing out benefits. The analysis will consider the effects of 
the demonstration according to the varying characteristics of 
the consumers including age, disability, gender, family 
support, and other factors.
    Funding: Total Award $1,902,794 (FY97 $350,000; FY98 
$111,389; FY99 $250,000; FY00 $191,405)
    End Date: September 30, 2004

Synthesis and Analysis of Medicare Hospice Benefits

    Urban Institute
    The rapid rise in Medicare hospice expenditures, 
particularly on behalf of nursing home residents, has drawn the 
attention of a wide variety of health policy makers and the 
Office of the Inspector General (OIG). In a recent study, the 
OIG recommended ways to modify how Medicare and Medicaid pays 
for hospice services. Most experts agree that, however, that a 
larger study is needed to examine key hospice trends nationally 
and in selected States. This current study will collect 
additional information on the Medicare hospice benefit, 
including trends in utilization and expenditures, who is 
covered, and in which care settings. This information will help 
inform health policy makers as they consider alternative 
hospice benefit and payment designs.
    End Date: April 1, 2000
    Funding: Total Award $234,970.04 (FY97 $174,980.60; FY98 

Synthesis and Analysis of Medicare Post-Acute Care Benefits and 

    Urban Institute
    This two-part project synthesized what was known about: (a) 
coverage and payment policies for post-acute care (PAC); (b) 
predictors of PAC use and nonuse and of the type, amount, and 
duration of PAC use; (c) PAC utilization including 
characteristics of PAC patients, patterns of PAC utilization, 
and geographic distribution of providers; (d) Medicare 
expenditures during the course of PAC episodes; (e) outcomes of 
patients in and across PAC settings; and (f) State policies 
designed to maximize Medicare PAC coverage.
    The first report, ``Medicare's Post-Acute Care Benefits: 
Background, Trends, and Issues to be Faced'', provides 
background on post-acute care expenditures and utilization, and 
Medicare policy changes that have contributed to these trends; 
the supply and changes in distribution of post-acute care 
providers; beneficiary, provider, and market characteristics 
associated with differential post-acute care provider use; and 
issues that need to be addressed regarding Medicare post-acute 
care services.
    The second report, ``Interviews with Provider and Consumer 
Groups, and Researchers and Policy Analysts'', summarizes 
discussions with key stakeholders regarding issues with 
Medicare's skilled nursing facility, home health, 
rehabilitation and long-term care hospital benefits. Many 
comments were raised regarding the impact of the changes 
enacted in the Balanced Budget Act on these benefits.
    Funding: Total Award $227,675.88 (FY97 $162,731; FY99 
    End Date: May 2000

The Contribution of Changes in Medication Use to Improvements in 
        Functioning among Older Adults

    Philadelphia Geriatric Center
    A possible explanation for the recently observed decline in 
the prevalence of disability in the U.S. elderly population is 
that better treatment of chronic diseases through medical 
procedures and pharmaceuticals has led to an improvement in 
functioning in the elderly population. Lending some credence to 
this hypothesis is research by Freedman and Martin (forthcoming 
in the American Journal of Public Health) that documents an 
increase in the prevalence of chronic health conditions such as 
arthritis, diabetes, stroke and heart disease during the same 
period that disability has fallen. They hypothesize that 
changes in the management of chronic disease--and changes in 
medication use in particular--have caused chronic health 
conditions to become less debilitating as their prevalence has 
    This project supplements an existing National Institute on 
Aging. Under that grant, the role of changes in the use of 
medications in explaining aggregate changes in functioning in 
the U.S. population aged 51-61 will be examined. The data sets 
for the analyses are the first (1992) and fourth (1998) waves 
of the Health and Retirement Survey (HRS), which provide 
nationally representative cross-sections of the 
noninstitutionalized population in this age range.
    Funding: Total Award $125,000 (FY00 $125,000)
    End Date: September 30, 2001


  National Center for Chronic Disease Prevention and Health Promotion

    CDC's National Center for Chronic Disease Prevention and 
Health Promotion (NCCDPHP) is involved in a wide array of 
chronic disease prevention and control activities on behalf of 
older Americans. NCCDPHP programs include musculoskeletal 
diseases (osteoarthritis, osteoporosis), cardiovascular health, 
Alzheimer's disease, urinary incontinence, the health care and 
long-term care needs of women and minorities, health status 
surveillance, physical activity promotion, disability 
prevention, diabetes management, cancer prevention and control, 
oral health, and the elimination of health disparities. Each is 
reviewed briefly below.


    Arthritis and other musculoskeletal diseases are prevalent 
and disabling chronic diseases, affecting approximately 38 
million persons in the United States. Data indicate that 49.4 
percent of persons 65 years and older have symptomatic 
musculoskeletal diseases and 11.6 percent of persons in this 
age group have arthritis as a major or contributing cause of 
activity limitation. Data are needed to describe the natural 
history of disease as well as to direct development of 
effective intervention efforts. To address the burden of 
arthritis, NCCDPHP:
           widely disseminated the National Arthritis 
        Action Plan--A Public Health Strategy. This plan was 
        released in November of 1998 and was developed under 
        the leadership of CDC, the Arthritis Foundation, and 
        the Association of State and Territorial Health 
        Officials. The plan proposes action in three major 
        areas: surveillance, epidemiology, and prevention 
        research; communication and education; and programs, 
        policies, and systems. It is designed to encourage 
        public health organizations, arthritis organizations, 
        and other interested organizations to work together at 
        the national, state, and local levels.
           analyzed the Arthritis Self-Help Course. 
        This analysis showed the course to be a cost-saving 
        intervention from both the societal and health care 
        system perspectives.
           determined the prevalence of hip and knee 
        osteoarthritis among whites and blacks in Johnston 
        County, NC, a rural, southern county. The Johnston 
        County Osteoarthritis Project is beginning follow-up of 
        3200 Caucasian and African-American residents of a 
        rural North Carolina county to determine factors 
        associated with the development and progression of hip 
        and knee osteoarthritis--the leading causes of 
        arthritis disability.

                          Alzheimer's Disease

    Chronic neurological diseases, conditions common among 
elderly, causes high levels of morbidity, disability, family 
stress, and economic burden. For example, the costs due to 
dementias were estimated at $24-$48 billion in 1985, and will 
increase as the population ages. However, the epidemiology of 
these conditions is poorly understood. NCCDPHP is studying the 
epidemiology of Alzheimer's Disease to determine disease rates, 
risk factors, and prevention factors.

                  Health Care and Long-term Care Needs

    The WISEWOMAN (Well-Integrated Screening and Evaluation for 
Women in Massachusetts, Arizona, and North Carolina) program is 
funded by NCCDPHP to determine whether adding other preventive 
services such as cardiovascular disease risk factor screening 
and intervention to the National Breast and Cervical Cancer 
Early Detection Program is effective in improving the health 
status of uninsured women age 50 and older.
    NCCDPHP conducted an assessment of long-term care needs 
among older adults in the Indian Health Service Santa Fe 
Service Unit, New Mexico. The objectives of the project were 
(1) to provide estimates of the population of functionally 
dependent adults age 55 and over within the Santa Fe Service 
Unit (SFSU) and distinguish clinically relevant subgroups; (2) 
to document the extent of informal care provided by family 
members to elders with chronic care needs; (3) to analyze the 
strengths and weaknesses of the current formal long-term care 
service system within the SFSU to accommodate the needs of the 
target population.
    NCCDPHP has initiated the EnPOWER project to improve 
prevention services in older women in HMO's. The project aims 
to enhance and promote preventive health services for older 
women in a managed care setting.

                       Health Status Surveillance

    NCCDPHP conducts surveillance of the health status of the 
elderly. Projects include:
           the publication of ``Surveillance for 
        Selected Public Health Indicators Affecting Older 
        Adults United States,'' Morbidity and Mortality Weekly 
        Report, December 17, 1999;
           the assessment of the prevalence of 
        electroconvulsive therapy on older adults by age, 
        gender, and ethnicity;
           the assurance of complete, timely, and 
        accurate cancer surveillance data at the state, 
        regional, and national levels;
           the generation of national and state 
        estimates of the prevalence and incidence of diabetes, 
        the processes and outcomes of care, and the costs of 
        care in the Medicare population;
           the use of several health-related quality-
        of-life measures in the state-based Behavioral Risk 
        Factor Surveillance System (BRFSS) to track quality of 
        life in the States; and
           determination of the feasibility of a 
        Medicare claims-based surveillance system for possible 
        adverse effects of folic acid food fortification among 
        persons with vitamin B12 deficiency.


    More than 30 percent of deaths from breast cancer in women 
over age 50 are preventable through widespread use of 
mammography screening for early detection. The National Breast 
and Cervical Cancer Early Detection Program targets underserved 
women, including older women with low income, and women of 
racial and ethnic minority groups. NCCDPHP currently funds the 
50 states, 4 U.S. territories, the District of Columbia, and 15 
American Indian/Alaska Native organizations through this 
    NCCDPHP supports a project to generate information about 
attitudes towards prostate cancer screening and treatment. The 
project investigates (1) how quality of life is related to 
early detection and treatment; (2) whether screening for 
prostate cancer actually reduces mortality; and (3) the 
development of appropriate health messages for men and their 
families about prostate cancer screening and early detection.
    NCCDPHP sponsors a program promoting the early detection of 
colorectal cancer. The objectives of the project are (1) to 
promote awareness and use of colorectal cancer screening among 
health care providers and the public, especially the older 
population; (2) to support research that promotes the inclusion 
of colorectal cancer screening in quality measures applied to 
managed care organizations; and (3) to support the development 
of standards for screening sigmoidoscopy.

                         Cardiovascular Health

    Recognizing the immense burden of CVD, in FY1998, Congress 
made available funding to initiate a national, state-based CVD 
prevention program, starting with eight states, and in FY1999 
to expanded to eleven states. In FY2000, CDC will spend more 
than $25 million for the prevention and control of CVD and its 
disabling conditions. These activities include:
           Funding 5-6 additional states to implement 
        CVD prevention and control programs with environmental 
        interventions and policy strategies.
           Assisting states to better measure the 
        burden of CVD, monitor progress in reducing risk 
        behaviors, and determine the economic cost of the 
           Funding state programs and research that 
        address racial and ethnic disparities in CVD.
           Enhancing CDC's National Standards 
        Laboratory to improve state laboratory capacity and 
        tailor screening procedures for youth, elderly and 
        minority populations.
    While strategies for preventing CVD (lipid management, 
hypertension control, diabetes awareness, smoking cessation, 
dietary modification, and physical activity behavior) exist, 
more efficient and practical methods for reaching low-income 
women and making prevention services available to them are 
needed. The NCCDPHP is collaborating with the University of 
North Carolina Prevention Center to produce a monograph that 
describes appropriate research and programmatic methods and 
protocols for integrating cardiovascular disease screening, 
intervention, and evaluation programs aimed at financially 
disadvantaged women. This monograph will include 
recommendations for laboratory tests, clinical measurements, 
interviews and surveys, field procedures, program tracking 
systems, and analytic plans. It will include practical examples 
of how to integrate CVD screening and intervention into 
existing health service programs that come from the experience 
of the WISEWOMAN (Well Integrated Screening and Evaluation for 
Women) projects in North Carolina, Massachusetts, and Arizona. 
This monograph will be written as a practical guide for state 
and local health departments for use in designing and adapting 
their own integrated prevention programs.


    The burden of diabetes is heavier among elderly Americans. 
More than 18 percent of adults over age 65 have diabetes. 
NCCDPHP funds diabetes control programs (DCP) in all 50 states, 
the District of Columbia, and eight U.S. affiliated island 
jurisdictions to effect changes and improvements in systems 
that care for and support people with diabetes. The primary 
goal of the DCPs is to improve access to affordable, high-
quality diabetes care and services. Priority is on reaching 
high-risk and disproportionately burdened populations which 
include the aged. NCCDPHP provides resources and technical 
assistance to state-based diabetes control programs to:
           determine the size and nature of diabetes-
        related problems and why they exist,
           develop and evaluate new strategies for 
        diabetes prevention,
           establish partnerships to prevent diabetes 
           increase awareness of diabetes prevention 
        and control opportunities among the public, the health 
        care and business communities, and people with 
        diabetes, and
           improve access to quality diabetes care to 
        prevent, detect, and treat diabetes complications.

                              Oral Health

    In the United States, 30,000 new cases of oral and 
pharyngeal cancer will be diagnosed this year, and more than 
8,000 people will die of these largely preventable cancers. 
About 1 in 3 adults has untreated tooth decay and 25 percent of 
adults older than 65 years have lost all of their teeth. Only 
about half of people with diagnosed oral or pharyngeal cancer 
survive more than 5 years; among African American men, only 
about a third survive. People who do survive are at increased 
risk of developing additional cancers and frequently have the 
physical and psychological scars of what is one of the most 
disfiguring of all cancers.
    CDC is working with a consortium of public- and private-
sector organizations to develop a national program to prevent 
oral and pharyngeal cancers and to promote early detection and 
treatment, which can improve long-term survival. With its 
partners, CDC is also working to promote cessation of tobacco 
use, which especially when combined with heavy alcohol use is 
the major risk factor for more than 75 percent of oral and 
pharyngeal cancers in the United States.
    CDC is also working to
           Enhance surveillance of oral diseases using 
        state- and community-based data
           Support water fluoridation through 
        surveillance, training, and quality assurance
           Influence oral health policy and practice by 
        developing and distributing guidelines based on sound 
        science, e.g., infection control, fluoride use
           Develop a national alliance of partners to 
        prevent and control oral cancer
           Train dental and public health professionals 
        through residency and fellowship programs

                   Elimination of Health Disparities

    Chronic diseases disproportionately affect racial and 
ethnic minority populations in the U.S. The leading causes of 
death and disability (such as cardiovascular disease) are 
dramatically higher among these populations. Rates of death 
from stroke are 60 percent higher among African Americans than 
among whites. The prevalence in diabetes is higher among every 
racial and ethnic minority compared to whites of similar age. 
Among persons 65 years of age or older with one or more 
physician visits in the past year, influenza and pneumococcal 
vaccination levels among African Americans and Hispanics are 
substantially lower than those of whites. Death rates due to 
cancers, such as prostate and breast, are often higher among 
minorities as well.
    NCCDPHP administers the Racial and Ethnic Approaches to 
Community Health Program (REACH 2010), a major part of the 
President's Initiative on Race. The goal of this program is to 
eliminate disparities in health status experienced by racial 
minority and ethnic populations in key health areas (including 
cardiovascular disease, diabetes, and immunizations) by the 
year 2010. REACH demonstration projects are two-phase projects 
through which communities mobilize and organize their resources 
in support of effective and sustainable programs that will 
eliminate the health disparities of racial and ethnic 
minorities. These demonstrations require collaboration of both 
program and research experts for the purpose of identifying 
and/or developing successful community-based disease prevention 
and health promotion models that can be replicated for the 
ultimate goal of eliminating health disparities among racial 
and ethnic minorities. In Phase I, REACH communities are 
granted 12 months to develop a Community Action Plan (CAP). 
Phase II communities are granted four additional years of 
funding to implement and evaluate the CAP. Thirty-two community 
coalitions were funded in FY1999. The California Endowment 
contributed funding to support three additional organizations 
in the state of California identified through CDC's competitive 
process. In FY2000, 24 Phase II and 14 new Phase I communities 
were funded.
    Through an inter-agency agreement, NCCDPHP provided $1 
million to the Administration on Aging (AoA) to fund four 
demonstration projects focusing on health disparities among 
older racial and ethnic minority populations. In addition to 
the four projects funded directly by the AoA, other REACH 2010 
communities include activities that impact aging populations as 
well. Elderly-specific projects were:
           Boston Public Health Commission was funded 
        to address cardiovascular disease (CVD), diabetes, and 
        immunization in elderly African American communities.
           The Latino Education Project, Inc. was 
        funded to address CVD and late-stage diabetes among 
        rural and urban elders of Hispanic decent.
           Special Services for Groups, Inc. was funded 
        to lead six community coalitions to address CVH, 
        diabetes, and immunization disparities among 
        individuals of Southeast Asian decent.
           National Indian Council on Aging, Inc. was 
        funded to lead a community coalition focused on Indian 
        and Alaska native elders in nine states.
    NCCDPHP funding will support Phase I of demonstration 
projects. These projects serve as the foundation for Phase II 
projects. The AoA is responsible for funding Phase II of REACH 
2010 contingent upon availability of funds.
    Cardiovascular disease (CVD) continues to be the leading 
cause of death in the United States for women. African-American 
women are at particular risk, with coronary heat disease (CHD) 
and mortality rates 35.3 percent higher and stroke rates 71.4 
percent higher than for white women. Low socioeconomic status 
(SES) is also associated with higher CVD incidence and 
mortality. NCCDPHP is collaborating with the University of 
Alabama at Birmingham Prevention Research Center to produce the 
``Women's Wellness Sourcebook Module III Heart Disease and 
Stroke''. The Sourcebook is a culturally-appropriate training 
curriculum designed to promote CVD prevention among low SES 
minority women by teaching Community Health Advisors (CHAs) to 
conduct risk-reduction counseling.
    The Johns Hopkins University Prevention Research Center, in 
partnership with the NCCDPHP, is exploring how church-based 
programs in Baltimore can help prevent or control chronic 
diseases. Program components include weight control and 
nutrition, exercise and fitness, and smoking cessation, offered 
in the church by trained lay leaders; interwoven with the 
spiritual life and activities of the church, such as prayer 
groups, sermons, testimony, choir practice, and meals.
    The St. Louis University Prevention Research Center, 
another NCCDPHP-supported center, has collected and analyzed 
determinants of physical activity among 3,000 US women aged 40 
to 75 years, including 600 each from the following subgroups: 
African-American, Asian/Pacific Islander, American Indian/
Alaska Native, Hispanic,White, and low education (high school 
or less).

               Disability Prevention and Health Promotion

    NCCDPHP is collaborating with the AARP, the American 
College of Sports Medicine, the American Geriatrics Society, 
the National Institute on Aging, and The Robert Wood Johnson 
Foundation to create a ``National Plan to Increase Physical 
Activity Among Adults Aged 50 and Older.'' These partners 
hosted the ``Blueprint Conference'' on physical activity 
promotion in Washington, DC on October 30-31, 2000.
    NCCDPHP funds the Center for Health Promotion in Older 
Adults at the University of Washington at Seattle, School of 
Public Health to promote health among men and women aged 65 
years or older. The Center evaluates the presence of social 
networks and the influence of healthy eating and physical 
activity on elderly residents of public housing units. The 
Center also focuses on reducing disability and falls in older 
adults through interventions to improve physical activity, 
nutrition, and home safety.
    NCCDPHP is collaborating with the Administration on Aging 
(AOA) on a review of AOA's state and territorial aging agency 
health promotion programs.
    NCCDPHP is collaborating with the Association of State and 
Territorial Chronic Disease Program Directors to document 
chronic disease prevention and control program activities 
within state and territorial health departments.
    NCCDPHP released a monograph on quality of life and 
indicators of healthy days at the 15th National Conference on 
Chronic Disease Prevention and Control, November 29, 2000, in 
Washington, DC.
    NCCDPHP's Office on Smoking and Health provides web-based 
educational materials for people who want to quit smoking and 
for clinicians who want to help them. For older adults, 
quitting smoking is one of the most important health actions 
they can take. Materials include:
           You Can Quit Smoking
           Don't Let Another Year Go Up In Smoke: Quit 
           Treating Tobacco Use and Dependence: A 
        Clinical Practice Guideline, Public Health Service
    NCCDPHP is studying the cost-effectiveness of different 
interventions designed to prevent osteoporosis in women who are 
perimenopausal or postmenopausal.
    The Health Promotion and Education Database and Cancer 
Prevention and Control Database contain aging-related health 
information useful for health care providers and program 
planners in state health and aging agencies. The databases 
include literature and programmatic information about disease 
prevention, health promotion, and health education information 
on nutrition, smoking cessation, cholesterol, high blood 
pressure, injury prevention, exercise, weight management, 
stress management, diabetes mellitus, and breast and cervical 
cancer screening. They are available through CDC's CDP (Chronic 
Disease Prevention) File CD-ROM, the Public Health Service's 
Combined Health Information Database (CHID) and CDC's WONDER 
system. CDP File is available from the Superintendent of 
Documents, Government Printing Office, Washington, DC 20402, 
202-512-1800 (Stock No. 717-145-00000-3). CHID can be accessed 
through most library and information services. CHID may be 
accessed via the Internet at For more 
information about WONDER, contact CDC WONDER Customer Support 
at 404-332-4569.

                National Center for Environmental Health

    CDC's National Center for Environmental Health (NCEH) 
addresses the prevention of secondary conditions and promotion 
of health among the 54 million Americans with disabilities. The 
Center is analyzing NHIS and NHIS-Supplement on Aging data to 
identify the correlates of aging related to sensory impairments 
and to characterize disability in the above 55 age groups by 
race/ethnicity, gender, region, and activity limitation. These 
analyses will be included in the disability chapter of the 
upcoming MMWR Supplement on Aging.
    The NCEH environmental health laboratory is working to 
improve measurement of biochemical markers of bone loss to help 
physicians threat people with osteoporosis. The currently 
accepted gold standard for measuring bone status is a bone 
density test. However, such tests can only be repeated every 1-
2 years. The biochemical marker tests for bone loss can be 
performed more frequently to assess the success of treatments 
for osteoporosis.
    The NCEH environmental health laboratory also is 
collaborating on the Age-Related Eye Disease Study conducted by 
the National Eye Institute. The laboratory is testing patients 
participating in the study for levels of vitamins A, C, and E, 
carotenoids, retinyl esters, lipids, zinc, and copper. The 
laboratory is also assisting with genetic testings as part of 
this study.

                 National Center for Health Statistics

    CDC's National Center for Health Statistics (NCHS) is the 
Federal Government's principal health statistics agency. The 
NCHS data systems address the full spectrum of concerns in the 
health field from birth to death, including overall health 
status, morbidity and disability, risk factors, and health care 
    The Center maintains over a dozen surveys and vital 
statistics data files that collect health information through 
personal interviews, physical examination and laboratory 
testing, administrative records, and other means. These data 
systems, and the analyses that result are designed to provide 
information useful to a variety of policy makers and 
researchers. NCHS frequently responds to requests for special 
analyses of data that have already been collected and solicits 
broad input from the health community in the design and 
development of its surveys.
    A broad range of data on the aging of the population and 
the resulting impact on health status and the use of health 
care are produced from these systems. For example, NCHS data 
have documented the continuing rise in life expectancy and 
trends in mortality that are essential to making population 
projections. Data are collected on the extent and nature of 
disability and impairment, limitations on functional ability, 
and the use of special aids. Surveys currently examine the use 
of hospitals, nursing homes, physicians' offices, home health 
care and hospice, and are being expanded to cover hospital 
emergency rooms and surgi-centers.
    In addition to NCHS surveys of the overall population that 
produce information about the health of older Americans, a 
number of activities provide special emphasis on the aging. 
They are described below.

                 The Second Longitudinal Study of Aging

    The Second Longitudinal Study of Aging (LSOA II) is a 
collaborative project of the National Center for Health 
Statistics and the National Institute on Aging. This 
prospective survey consists of a baseline interview, called the 
Second Supplement on Aging (SOA II), and two followup 
interviews fielded at two-year intervals. The SOA II interviews 
were conducted with a nationally representative sample of 9,447 
civilian noninstitutionalized Americans 70 years of age and 
over. It was fielded as part of the 1994 National Health 
Interview Survey and interviews were collected in-person 
between 1994 and 1996. The two reinterviews were administered 
by phone with these sample persons and have now been completed, 
one in 1997-1998 and one in 1999-2000.
    The LSOA II is designed primarily to measure changes in the 
health, functional status, living arrangements, and health 
services utilization of older Americans as they move into and 
through the oldest ages. Secondarily, the objective of the 
study is to provide a mechanism for monitoring the impact of 
proposed changes in Medicare and Medicaid and the accelerating 
shift towards managed care on the health status of the elderly 
and their patterns of health care consumption. Finally, the 
LSOA II replicates the first Longitudinal Study of Aging which 
was conducted ten years earlier between 1984 and 1990. To this 
end, questions concerning physical functioning and health 
status and their correlates which were part of the first LSOA 
are repeated in the LSOA II. These include questions on 
activities of daily living, instrumental activities of daily 
living, and work-related activities, as well as medical 
conditions and impairments, family structure and relationships, 
and social and community support. In addition to these repeated 
items, the LSOA II questionnaire was been expanded to include 
information on risk factors (including tobacco and alcohol 
use), additional detail on both informal and formal support 
services, and questions concerning the use of prescription 
    The SOA II microdata were released to the public in 1998. 
The first followup is expected to be released in 2001 and the 
second follow up in 2003. These data, when used in conjunction 
with data from the LSOA, enable researchers to identify changes 
in functional status, health care needs, living arrangements, 
social support, and other important aspects of life across two 
cohorts with different life course perspectives. This will 
provide those who use the data with an opportunity to examine 
trends and determinants of ``healthy aging.'' Users of the LSOA 
and LSOA II data have typically consisted of researchers, both 
those in the Federal government and in university settings, 
policy planners, and agencies and organizations serving older 

         Health, United States, 1999 Health and Aging Chartbook

    In October 1999, the Health, United States, 1999 Health and 
Aging Chartbook was published. This special study on health and 
aging was part of the annual report on the nation's health 
submitted by the Secretary of the U.S. Department of Health and 
Human Services to the President and Congress. In 34 figures and 
accompanying text, it summarizes the health of older people in 
the United States at the end of the twentieth century, using 
nationally representative health surveys and vital statistics. 
Measures of health status, including mortality, the prevalence 
of chronic conditions, disability, oral health, hearing and 
visual impairments are presented in the volume. In addition, 
health care access and utilization measures such as hospital 
discharge rates, use of home health care services, and health 
insurance coverage are included. Special attention is paid to 
differences in health by age, sex, and race and ethnicity. The 
chartbook was distributed to all members of Congress and 
highlighted in a Congressional briefing sponsored by Senator 
Mikulski and Representative Hoyer.

                       Trends in Health and Aging

    Trends in Health and Aging is a major data dissemination 
project funded in part by the National Institute on Aging and 
located within NCHS's Office of Analysis, Epidemiology, and 
Health Promotion (OAEHP). Trends in Health and Aging draws upon 
the statistical resources of NCHS and other Federal statistical 
agencies to provide up-to-date information on health behaviors, 
health status, utilization and cost of care for the older 
population in the United States.

               Trends in Health and Aging Data Warehouse

    The core of the project is the Trends in Health and Aging 
Data Warehouse (DWHA). DWHA is intended for use by policy and 
program analysts, researchers and the general public. DWHA 
contains information from NCHS surveys and other data systems 
in a format easily accessible to users. The list of topics and 
measures grows based on users' suggestions and the data are 
updated as soon as new figures become available. The data 
warehouse became available to the public on the Internet in 
November 1999. It can be accessed at the following address: It serves as an important 
electronic resource for those seeking relevant national data on 
a host of issues related to future access to affordable health 
care and the enhancement of quality of life.
    In the DWHA trend data on the elderly population in the 
United States is organized under six general topic areas: 
demography (or population composition), vital statistics, 
health status and well-being, risk factors and health behavior, 
health care utilization, and health care expenditure.
    The target population is persons of 65 years of age and 
older, but the majority of the tables also contain data on 45-
64 year olds for comparison purposes and for representation of 
the baby boom generation. The indicators are presented by 5- or 
10- year age groups. Open-age intervals (for example, 65 and 
over) can be seen in a crude and age-adjusted form. Usually, 
for age adjustment the year 2000 standard residential 
population of the United States was used.
    The data are aggregated in interactive tables developed 
using a user-friendly dissemination tool, Beyond20/20. Tables 
prepared in Beyond20/20 are capable of presenting the data in 
the form of charts and maps by the exact variables needed by 
the user, and the data from the table can be extracted in 
formats acceptable by most software packages.
    Each table displays the selected measure(s) by sex, age 
interval, race or Hispanic origin for as many years as the data 
from the particular data system are available. Where possible, 
the tables present the information by States. Metadata 
accompanying each table provide important information on data 
sources, statistical methods used to get the information, and 
references to corresponding publications and supporting 
Internet sites.
    Examples of selected tables are as follows:

Demography (population composition)

    Population (number and percent of people, national and 
state estimates)

Vital Statistics

    Life Expectancy
    Mortality (national and state estimates)
    Living Arrangements

Health Status and Well-Being

    Self-assessed health
    Functional status of older adults
    Functional limitation
    Total tooth loss
    Mental health status of nursing home residents
    Selected chronic conditions

Risk Factors

    Current cigarette smoking

Health Care Utilization

    Nursing home use
    Hospital discharges
    All-listed procedures for hospital inpatients
    Several special web-based reports based on data from DWHA 
have been written and will be posted to the web site and 
available in hard-copy formats. The topics include trends in 
elderly mortality, oral health of older Americans, trends in 
vision and hearing, and trends in nursing home use.

               Federal Forum on Aging-Related Statistics

    The Forum was initially established in 1986, with the goal 
of bringing together Federal agencies with a common interest in 
database development and statistical compilation on issues in 
aging. The Forum has played a key role in improving aging-
related data by critically evaluating existing data resources 
and limitations, stimulating new database development, 
encouraging cooperation and data sharing among Federal 
agencies, and preparing collaborative statistical reports.
    During 1998, an organizing committee was established to 
coordinate the activities and goals of the Forum for 1999 and 
beyond. In addition to the Bureau of the Census, the National 
Center for Health Statistics, and the National Institute on 
Aging--the original core agencies--the members now include 
representatives from the Administration on Aging, the Bureau of 
Labor Statistics, the Health Care Financing Administration, the 
Office of Management and Budget, the Office of the Assistant 
Secretary for Planning and Evaluation, and the Social Security 
    On August 10, 2000, the Federal Interagency Forum on Aging-
Related Statistics (Forum) released ``Older Americans 2000: Key 
Indicators of Well-Being.'' As one of the core members of the 
Forum, NCHS took the lead in producing, promoting, and 
disseminating this well received report. The report included 31 
key indicators carefully selected by the Forum to portray 
aspects of the lives of older Americans and their families. The 
report is divided into five subject areas: population, 
economics, health status, health risks and behaviors, and 
health care. The report can be accessed via the Forum's Web 

                 NHANES I Epidemiologic Follow-Up Study

    The first National Health and Nutrition Examination Survey 
(NHANES I) was conducted during the period 1971-75. The NHANES 
I Epidemiologic Follow-up Study (NHEFS) tracks and re-
interviews the 14,407 participants who were 25-74 years of age 
when first examined in NHANES I. NHEFS was designed to 
investigate the relationships between clinical, nutritional, 
and behavioral factors assessed at baseline (NHANES I) and 
subsequent morbidity, mortality, and hospital utilization, as 
well as changes in risk factors, functional limitation, and 
    The NHEFS cohort includes the 14,407 persons 25 74 years of 
age who completed a medical examination at NHANES I. A series 
of four follow-up studies have been conducted to date. The 
first wave of data collection was conducted from 1982 through 
1984 for all members of the NHEFS cohort. Interviews were 
conducted in person and included blood pressure and weight 
measurements. Continued follow-ups of the NHEFS population were 
conducted by telephone in 1986 (limited to persons age 55 and 
over at baseline), 1987, and 1992.
    Participant tracing and data collection rates in the NHEFS 
have been very high. Ninety-six percent of the study population 
has been successfully traced at some point through the 1992 
follow-up. While persons examined in NHANES I were all under 
age 75 at baseline, by 1992 more than 4,000 of the NHEFS 
subjects had reached age 75, providing a valuable group for 
examining the aging process. Public use data tapes are 
available from the National Technical Information Service for 
all four waves of follow-up. The 1992 NHEFS public use data is 
also available via the Internet. NHEFS data tapes contain 
information on vital and tracing status, subject and proxy 
interviews, health care facility stays in hospitals and nursing 
homes, and mortality data from death certificates. All NHEFS 
Public Use Data can be linked to the NHANES I Public Use Data.

                           NHANES IV Planning

    The Fourth National Health and Nutrition Examination Survey 
began field operations in April of 1999. Although a wide range 
of the conditions assessed in NHANES IV are most common among 
the elderly, several components are particularly relevant to 
aging research:
           Muscle Strength, Impairment, and Disability: 
        All persons age 50+ will have measurement of isokinetic 
        muscle strength of knee extensors and flexors and all 
        persons age 60+ will have an assessment of ability and 
        time to get up from an armless chair five times and 
        time to perform a twenty foot walk at the usual speed. 
        Both sets of measures will provide important data on 
        physical impairment and function in the elderly and 
        will be correlated to other disability related self 
        reported items and other objective measurements 
        obtained in the survey.
           Lower Extremity Disease: For the first time, 
        the survey includes an evaluation of lower extremity 
        disease in persons age 40+, including Ankle-Brachial 
        Pressure Index measurement and assessment of peripheral 
        neuropathy. These data are especially important for 
        assessing the complications of diabetes and the 
        prevalence of peripheral vascular disease.
           Visual and Hearing Impairment: Vision (age 
        12+) and hearing (age 20+) are being assessed including 
        assessment of visual acuity, near vision (age 50+), 
        pure tone audiometry thresholds, and typanometry. 
        Sensory impairment is an important component of 
        functional impairment in the elderly.
           Bone Mineral Status: Bone mineral status is 
        being assessed including total bone mineral content and 
        bone mineral density by dual X-ray absorptiometry. 
        Osteoporosis is an important risk factor for hip 
        fractures in the elderly.
           Cognitive Function: Cognitive function is 
        being assessed in persons age 60+ with the Digit Symbol 
        Substitution Test.
           Balance and Vestibular Function: The 
        standard Romberg test of postural sway is being 
        assessed in all persons age 20+. Balance impairment is 
        related to the incidence of many fractures caused by 
        falling, especially hip fractures in the elderly.

                      Analysis of NHANES III Data

    NCHS is engaged in a range of projects analyzing data from 
NHANES III related to aging. These projects include:
           Prevalence of Disability and Risk Factors 
        Associated with Disability. NHANES III data will be 
        analyzed to assess the prevalence of physical and 
        functional limitation. It includes self reported data 
        obtained in the household interview and performance-
        based data obtained in the mobile examination center. 
        The risk factors associated with disability will be 
        assessed to provide a better understanding of the 
        etiology and treatment of disability in the elderly.
           Region of Birth and Cardiovascular Risk 
        Factors. NHANES III data will be used to assess early-
        life influences such as region of birth on the pattern 
        of risk factors for cardiovascular disease in later 
           Nutritional Intake among the Elderly. The 
        patterns of nutrient intake among adults age 60+ in 
        NHANES III will be analyzed.

                       Vital Statistics on Aging

    Information on mortality from the national vital statistics 
system plays an important role in describing and monitoring the 
health of both the institutionalized and non-institutionalized 
elderly population. The data include measures of life 
expectancy, causes of death, and age-specific death rate 
trends. The basis of the data is information from death 
certificates, completed by physicians, medical examiners, 
coroners, and funeral directors, used in combination with 
population information from the U.S. Bureau of the Census.
    Effective with mortality data for 1997, additional detail 
on the aging population was included in the official national 
life tables. For the first time life expectancy and other life 
table values for the population aged 85 to 100 years were shown 
in the annual life tables by incorporating information from the 
Medicare program on the mortality experience of the aged 
population with standard information from the vital statistics 
    NCHS is expanding outreach to certifying physicians on 
proper completion of the cause-of-death section of the death 
certificate by designing material appropriate for diverse 
settings including professional meetings and electronic death 
    Effective with mortality data for 1999, two important 
changes are being implemented for state and national mortality 
statistics: (1) causes of death are coded and classified by the 
Tenth Revision of the International Classification of Diseases 
(ICD-10), replacing ICD-9, which was used by the U.S. during 
1979-1998; and (2) the standard population used for age-
adjusting death rates is changed from 1940 to the year 2000 
population. The 1940 standard has been used for about 50 years. 
Use of ICD-10 affects the comparability of cause-of-death 
trends over time; the extent of the discontinuities is measured 
using a Comparability Study, results of which will be available 
at the time the 1999 mortality data are published in early 
2001. The new population standard for age-adjusting death rates 
affects the absolute level of death rates for many causes of 
death, in particular, deaths from chronic diseases; it also 
affects the relationship of mortality among the race groups. 
NCHS publications describe the extent and implications of these 

                    The National Health Care Survey

    The National Health Care Survey (NHCS) is an integrated 
family of surveys conducted by the NCHS to provide annual 
national data describing the Nation's use of health care 
services in ambulatory, hospital and long-term care settings. 
Currently, the NHCS includes six national probability sample 
surveys and one inventory. These seven data collection 
activities include:
           the National Hospital Discharge Survey which 
        examines discharges from non-Federal, short-stay and 
        general hospitals;
           the National Survey of Ambulatory Surgery 
        which examines visits to hospital-based and 
        freestanding ambulatory surgery centers;
           the National Ambulatory Medical Care Survey 
        which examines office visits to non-Federal, office-
        based physicians;
           the National Hospital Ambulatory Medical 
        Care Survey which examines visits to emergency and 
        outpatient departments of non-Federal, short-stay and 
        general hospitals;
           the National Health Provider Inventory which 
        is a national listing of nursing homes, hospices, home 
        health agencies and licensed residential care 
           the National Home and Hospice Care Survey; 
           the National Nursing Home Survey.

         Improving Self-Reports of Health Status by the Elderly

    The National Laboratory for Collaborative Research in 
Cognition and Survey Measurement of NCHS has conducted several 
cognitive research projects with elderly respondents. In 1998, 
Lab staff continued their investigation of recall and judgment 
issues that elderly respondents may have when answering 
questions regarding health status and quality of life. This 
project involved both in-house and extramural research. In-
house research is conducted by recruiting subjects to the NCHS 
Questionnaire Design Research Laboratory. Extramural research 
is conducted by the University of Maryland's Survey Research 
Center using split-ballot field experiments.

                     National Immunization Program

    CDC's National Immunization Program provides medical and 
epidemiologic expertise and collaborates with other CDC 
organizations and HHS agencies in developing strategies to 
enhance immunization coverage of adults, including influenza, 
pneumococcal, hepatitis B, measles, mumps, rubella, and 
varicella vaccines and combined tetanus and diphtheria toxoids. 
One of the greatest challenges we face is extending the success 
in immunization with children to the adult population.
    Immunization rates for influenza and pneumococcal disease 
are at record highs in persons 65 years of age or older. The 
Healthy People 2000 Objective for influenza vaccination in this 
age group has been achieved. It is estimated that in 1996-1997, 
about 19,500 deaths were prevented by influenza vaccination in 
persons in persons 65 years or older. In addition, increased 
use of pneumococcal vaccine between 1993 and 1997 saved almost 
$27 million in hospital costs alone.
    In spite of the progress that has been made, adult vaccines 
continue to be underutilized. Reasons for this include: 1) 
limited appreciation of the impact of adult vaccine-preventable 
diseases and missed opportunities to vaccinate during contacts 
with health-care providers; 2) failure to organize programs in 
medical settings that ensure adults are offered the vaccines 
they need; 3) doubts about the safety and efficacy of adult 
vaccines; 4) selective rather than universal approaches to 
vaccination; and 5) inadequate reimbursement for adult 
vaccination services.
    To overcome these challenges, CDC has taken a number of 
steps including:

                Testing Vaccine Safety and Effectiveness

    CDC is actively engaged in determining vaccine 
effectiveness. CDC and three health plans assessed the 
effectiveness of influenza vaccine in patients age 65 or older 
in preventing hospitalizations and deaths. Results showed that 
vaccination prevented 18-24 percent of the hospitalizations for 
pneumonia and 35-61 percent of all deaths. These findings 
support the concept that health plans should cover influenza 
vaccination, as well as actively promote the vaccine each fall.
    In January of 1999, CDC and others published a study on the 
safety of pneumococcal vaccination in the Journal of the 
American Medical Association, ``The Safety of Revaccination 
with Pneumococcal Polysaccharide Vaccine.''

                         Education and Training

    Enhancing education and training is a priority in adult 
vaccination efforts. CDC aired the first national video-
conference on adult immunization technical issues in June 1998 
and rebroadcast the presentation in June 1999. It was also 
broadcast in Spanish, with special efforts to promote it in all 
of the boarder states, Mexico, and the Caribbean.
    CDC and the Association of Teachers of Preventive Medicine 
developed and tested the ``What Works'' interactive software 
(CD ROM) program targeted at private primary care providers who 
provide health care services primarily for adults. This program 
focuses on strategies to increase immunization coverage levels 
among adults and technical issues relating to adult 
    Immunization teaching materials for physicians were 
developed through a collaboration with CDC, Association of 
Teachers of Preventive Medicine, and the Department of Family 
Medicine at the University of Pittsburgh. The training 
materials are designed to be used by medical schools for 
students and residents. These products were published between 
April 1998 and April 1999 and include a Facilitators Guide, a 
Small Group Booklet, and a Reference Booklet.
    Two large print booklets were designed in 1999 to be 
distributed by health care providers to adult and senior 
patients. The focus of the booklets is to empower adults and 
seniors to take action for their own health. The vaccines 
presented include all immunizations important for adults of all 
ages. With the senior book emphasizing the vaccines for those 
diseases that can cause the most serious problems, i.e., 
influenza, pneumococcal disease, and adult tetanus and 
diphtheria among the elderly.


    CDC worked with the National Medical Association to develop 
a consensus document ``Adult Immunizations: Increasing 
Immunization Rates among African-American Adults'' published in 
1999. The document clearly demonstrates the need for improving 
vaccination in African-American adults and offers 
recommendations on how to do so.
    Task Force for Community Preventive Services included 
recommendations about successful interventions to increase 
coverage among adults in the published Guide to Community 
Preventive Services.
    The National Vaccine Advisory Committee and CDC published 
recommendations for vaccination of adults in non-traditional 
sites in the March 24, 2000 MMWR.
    Revision of Standards for Adult Immunization Practices, 
which were first developed in 1990, are under way. Revision 
began in 2000 and will be completed by December of 2001.
    The guide, ``Prevention and Control of Vaccine-Preventable 
Disease in Long-Term Care Facilities,'' was published in the 
September/October 2000 issue of the Journal of the American 
Medical Directors Association, and widely disseminated by CDC 
and HCFA to state health departments and nursing home 
    Authors from CDC published an article, ``Vaccine 
recommendations for Patients on Chronic Dialysis,'' in the 
March/ April 2000 issue of Seminars on Dialysis.

                            Standing Orders

    Dissemination of guidelines for health care providers is 
another important activity. CDC, in collaboration with the 
Advisory Committee on Immunization Practices and the Health 
Care Financing Administration, has recommended a key strategy 
called ``standing orders'' to improve influenza and 
pneumococcal vaccination levels in nursing homes throughout the 
country. A standing order enables nursing homes to provides 
these vaccinations to nursing home residents without an 
individual prescription.
    A project started in July of 1999 to evaluate the 
effectiveness of standing order programs to improve 
pneumococcal and influenza vaccination rates in nursing homes. 
It is a multi-state project (9 intervention, 5 control) to 
develop, implement and evaluate standing order programs and 
other immunization programs for influenza and pneumococcal 
vaccination among seniors in nursing homes funded by CDC 1 
percent Evaluation funds and the National Vaccine Program 
Office. It is run in collaboration with HCFA and Peer Review 
Organization (PRO).

                     Delivering Vaccines to Adults

    Since 1997, CDC immunization grant guidance has instructed 
grantees to assign at least 0.5 FTE to coordinate adult 
immunization activities; in CY 2000, 35 states reported having 
at least 0.5 FTE designated for this purpose. CDC has an annual 
influenza vaccine contract which many states use to purchase 
influenza vaccine for use by the state or local health 
departments. In 2000, CDC negotiated contracts for 2 million 
doses of influenza vaccine. Over 90 percent of local health 
departments deliver influenza vaccine, 85 percent deliver 
tetanus toxoid, 77 percent deliver hepatitis B vaccine, and 48 
percent deliver pneumococcal vaccine. Since 1997, CDC has 
conducted the Life Preserver campaign in collaboration with 
state health departments, to promote influenza and pneumococcal 
vaccination among persons with diabetes.

                           Understanding Gaps

    CDC commissioned an Institutes of Medicine (IOM) Report on 
the financing of vaccines. Calling the Shots: Immunization 
Policies and Practices found that ``additional funds are needed 
to purchase vaccines for uninsured and undersinsured adult 
populations within the states.'' Work is now being done to 
implement and respond to the recommendations.
    CDC also conducts research to better understand and improve 
adult vaccine delivery, including:
           Reviewing adult immunization activities in 
        the state immunization programs, 1997-99, to determine 
        best practices.
           Tested AFIX (Assessment, Feedback, 
        Incentive, and eXchange) methods, very successful for 
        childhood immunization, for physicians of Medicare 
        beneficiaries in New Jersey.
           Surveying African American physicians to 
        identify barriers to delivery of adult immunization, 
        and will use the results to design and evaluate a 
        provider-based intervention to improve vaccination 
           Designing and evaluating a multi-component 
        intervention in New Jersey to improve the use of 
        influenza and pneumococcal vaccination and cancer 
        screening (mammography and Pap testing) among African 
        American women enrolled in Medicare.

                    Improved Monitoring of Coverage

    Influenza and pneumococcal vaccination status is asked 
annually on the NHIS. In 1999, the BRFSS added a question on 
the type of place where influenza vaccination was received. 
Additionally, CDC has recommended standardization of 
pneumococcal vaccination questions in all relevant surveys 
(NHIS, BRFSS, HCFA's Medicare Current Beneficiary Survey). 
Hepatitis B vaccination status will be included on the 2000 
NHIS. CDC also worked with three HMO's to evaluate the 
feasibility of including a measure of pneumococcal vaccination 
among persons 65 years of age and older on HEDIS. Based on the 
results of this work, the measure has been approved for 
addition to HEDIS. CDC is also developing software suitable for 
assessing vaccination levels in adult patient practice 

                       2000-2001 Influenza Season

    The influenza season of 2000-2001 has posed new challenges 
to immunization efforts. In June, influenza vaccine 
manufacturers told federal public health officials to expect 
delays in flu vaccine shipments this flu season and possible 
shortages. This delay was due to a combination of factors 
including problems growing one of the virus strains used in 
vaccine and problems in the manufacturing process. Although all 
influenza vaccine is produced in the private-sector, and more 
than 90 percent distributed through the private-sector, CDC 
undertook a number of actions to minimize the adverse impact of 
delays. First, CDC contracted for up to 9 million doses of 
vaccine to be produced. This added production of additional 
influenza vaccine was done to make up for possible shortfalls 
experienced by some of the vaccine manufacturer and to help 
fill some gaps to vaccinate people at highest risk of 
complications of influenza. As a result, flu vaccine supplies 
were approximately what was distributed last year; however, a 
substantial amount of vaccine reached providers later than 
usual. Other actions taken to alleviate problems related to the 
delay in influenza vaccine availability included CDC's 
initiation of a media campaign to educate providers and the 
public regarding the recommendations for this year's influenza 
season, development of a web-based system to facilitate the 
exchange and redistribution of vaccine and ongoing 
communications with health care providers and partners to keep 
them informed of influenza vaccine availability.

                National Center for Infectious Diseases

    Infectious diseases remain a serious problem in the U.S. 
Pneumonia and influenza remain the sixth leading cause of death 
in the United States and septicemia has risen dramatically 
during the past three decades to become the 11th leading cause 
of death. Chronic liver disease, a substantial proportion of 
which is due to hepatitis C virus, is the 10th leading cause of 
death in the U.S. Pneumonia and septicemia are also 
contributing and precipitating factors in the deaths of many 
Americans with other illnesses, especially cardiovascular 
diseases, cancer, and diabetes. Infectious diseases have a 
disproportionate impact on older Americans, 65 years old and 
older. Quality of life also declines for millions of older 
Americans as a result of infectious illnesses. Prevention and 
control of infectious diseases will enhance and lengthen the 
lives of older Americans, make them more productive, and reduce 
associated medical costs.
    CDC emphasizes surveillance and training to prevent and 
control hospital-acquired and other institutionally acquired 
infections in elderly patients. Additionally, CDC staff 
provides education regarding infection control to care 
providers at nursing home and patient care conferences. This 
education focuses on patient care treatment and procedures 
associated with the highest risk of infection. Through the 
National Nosocomial Infections Surveillance (NNIS) system, 
special infection risks of elderly patients have been 
identified. According to NNIS, over half of the hospital-
acquired infections occur in elderly patients, although these 
patients represent about one-third of all discharges from 
hospitals. The use of certain devices, such as urinary 
catheters, central lines, and ventilators, are associated with 
high risk of infection in all types of patients. In elderly 
patients, the risk of infection is high even when a device is 
not used, suggesting that infection control must address other 
risk factors such as lack of mobility and poor nutrition, in 
addition to device use.

                          Monitoring Influenza

    Although delivering the influenza vaccine to persons at 
risk is a critical step in preventing illness and death from 
influenza, immunization is only part of the prevention 
equation. Other CDC efforts to combat influenza in the elderly 
include: (1) improving domestic surveillance through the 
sentinel and state health department laboratory surveillance 
networks; (2) conducting studies to better define the 
immunological response of the elderly to influenza vaccines and 
to natural infection; (3) conducting immunological studies 
involving laboratory and clinical evaluation of inactivated and 
live attenuated influenza vaccines in an effort to identify 
improved vaccine candidates; (4) increasing surveillance of 
influenza in the People's Republic of China and other countries 
in the Pacific Basin to better monitor antigenic changes in the 
virus; (5) improving methodologies for rapid viral diagnosis; 
(6) using recombinant DNA techniques to develop influenza 
vaccines that may protect against a wider spectrum of antigenic 
variants; and (7) providing laboratory training in the People's 
Republic of China, other Pacific Basin countries, and Latin 
America to develop and expand capacity for the diagnosis and 
detection of antigenic changes in the virus.

                    Preventing Pneumococcal Disease

    Pneumococcal pneumonia causes an estimated 7,500-12,500 
deaths each year; about 60 percent of these are in persons 65 
years old and older. Prevention of pneumococcal disease in the 
elderly requires widespread application of effective 
immunization. CDC is currently evaluating the emergence of 
drug-resistant pneumococcal strains through laboratory-based 
surveillance and is actively promoting increased vaccine use in 
the elderly and other groups at risk. New vaccines under 
development , including conjugate and common protein antigen 
approaches, offer the potential for improved prevention of 
pneumococcal disease in the elderly. Improved use of current 
vaccine, as well as evaluation of new tools, are critical to 
decrease illness and death from pneumococcal infections in the 

                      Other Respiratory Infections

    Recent studies have suggested that noninfluenza viruses 
such as respiratory syncytial virus and the parainfluenza 
viruses may be responsible for as much as 15 percent of serious 
lower respiratory tract infections in the elderly. These 
infections can cause outbreaks that may be controlled by 
infection control measures and treated with antiviral drugs. It 
is important to define the role of these viruses and risk 
factors for these infections among the elderly. CDC is working 
to define the disease burden associated with respiratory 
syncytial virus and parainfluenza virus infections in the 
elderly and helping to develop vaccination strategies for 
respiratory syncytial virus.

        Healthcare-acquired Infections and Adverse Health Events

    The Institute of Medicine (IOM) has reported that 
preventable adverse events associated with healthcare result in 
98,000 deaths and $29 billion in additional healthcare costs 
annually. Overall, 3-4 percent of all patients suffered a 
healthcare related adverse event. The elderly are 
disproportionately affected by such adverse events.
    Existing technology and knowledge can prevent many adverse 
events but prevention strategies have not been widely and 
successfully implemented. However, some successes have 
occurred. For example in 2000, CDC reported that bloodstream 
infections among patients in U.S. intensive care units, most of 
whom are elderly, declined by 32 percent to 43 percent during 
the 1990's (MMWR 2000:49;149-153). This success is due to 
improved efforts in infection control in U.S. hospitals, to 
technological advances, and to improved patient care. CDC is 
embarking on a 5 year plan to substantially reduce bloodstream 
infections in other healthcare settings such as cancer and 
dialysis centers, respiratory infections in long term care 
patients, infections following surgery, and infections due to 
antimicrobial resistant organisms. CDC has increased its focus 
on the use of new information technologies to improve 
efficiency, developed new collaborations with both private 
sector partners and public sector partners, and expanded its 
work in non-hospital settings (long-term care, home health 
care, cancer centers, dialysis centers) where a substantial 
portion of healthcare for the elderly is provided. Regarding 
antimicrobial resistance, CDC, through the Chicago 
Antimicrobial Resistance Project (CARP) is currently evaluating 
the impact of infection control strategies on the prevention of 
antimicrobial resistance in hospitals and long-term care 

                     Group B Streptococcus Disease

    Group B streptococcus (GBS) is a major cause of invasive 
bacterial disease in elderly persons in the U.S. To document 
the magnitude of GBS disease in the elderly and develop 
preventive measures, CDC established population-based 
surveillance for GBS disease and case control studies to 
identify risk factors. An analysis of active surveillance data 
from 1993-1998 that was published in the New England Journal of 
Medicine in 2000 showed that the incidence of disease in adults 
 65 years old in 1998 was 20.1/100,000 population 
and the case fatality ratio was 15 percent compared to 8 
percent in adults 15-64 years old. Consistent with findings 
from earlier surveillance, the incidence of disease in black 
adults was approximately twice that in non-black adults. These 
data, along with serotype data on adult invasive GBS isolates, 
will be utilized to develop and evaluate vaccines and to 
promote the prevention and treatment of GBS disease in the 
elderly population.

                           Foodborne disease

    Foodborne disease is of particular concern in the elderly, 
who typically can have higher illness and death rates from 
foodborne pathogens than younger persons. Of particular concern 
are Salmonella enteritidis infections, often caused by 
undercooked eggs, and Escherichia coli O157:H7 infections, 
often caused by undercooked hamburger. CDC is working with USDA 
and FDA to encourage use of pasteurized eggs in nursing homes 
and thorough cooking of hamburger meat.
    Listeriosis is a severe bacterial foodborne infection that 
particularly affects the elderly, as well as pregnant women and 
immunocompromised person. CDC is participating in the 
interagency federal control plan for listeriosis, that includes 
enhanced surveillance, investigation of sporadic cases and of 
outbreaks to determine the sources, so that control measures 
can be targeted, and increased efforts to educate persons at 
higher risk in prevention measures.

                    Preventing Legionnaires' Disease

    An estimated 8,000-18,000 cases of Legionnaires' disease 
occur each year in the United States. Legionnaires' disease is 
a severe form of pneumonia caused by the bacterium, Legionella 
spp. Between 5-30 percent of persons contracting Legionnaires' 
disease die depending on underlying risk factors. The elderly, 
particularly those with underlying chronic diseases, are at 
greatest risk. Although attack rates are low, legionnaires' 
disease can be transmitted when susceptible persons are exposed 
to mists that come from a water source (e.g., air conditioning 
cooling towers, whirlpool spas, showers) contaminated with 
Legionella bacteria. Novel prevention strategies are focusing 
on the use of new disinfectants in water systems that may have 
the potential for greatly reducing the occurrence of 
legionnaires' disease. In addition, CDC is developing improved 
surveillance systems to better.

                        Gastrointestinal Disease

    Studies using information from national data bases show 
that of all age groups, the elderly (70 years old) 
have the highest rates of hospitalizations and deaths 
associated with diarrhea in the United States. In the elderly, 
caliciviruses (also called Norwalk-like viruses or Small Round 
Structured Viruses) are likely to be the most common cause of 
both epidemics and sporadic hospitalizations for acute 
gastroenteritis and studies needed to confirm this hypothesis 
are now underway. These studies should lead to a better 
understanding of ways to prevent gastrointestinal disease in 
the elderly. The recent identification of rotavirus as a cause 
of epidemic diarrhea in the elderly suggests that one approach 
to control may involve use of vaccines currently used for young 
children. Further study is now needed to determine the 
importance of rotavirus to gastrointestinal disease in the 

                       Other Infectious Diseases

    It is becoming increasingly evident that infections play a 
major role in causing or contributing to some chronic diseases. 
Some of these conditions result from infection acquired at a 
younger age (including liver cancer and cirrhosis related to 
chronic hepatitis B or hepatitis C, stomach and duodenal ulcers 
or gastric cancer from Helicobacter pylori), while others 
develop from exposures later in life. CDC is actively promoting 
and pursuing ways to prevent initial infection and the chronic 
consequences of such infections. Microbes are also suspected 
but not yet proven as triggers of still other chronic 
conditions. CDC is developing research activities that identify 
and define these relationships. The potential to use infection 
control in the prevention or treatment of infections that 
produce chronic disease can improve the quality and length of 
life for many elderly persons.

           National Center for Injury Prevention and Control

    CDC's National Center for Injury Prevention (NCIPC) is 
involved in a wide array of activities to promote enhanced 
mobility and independent living among older Americans by 
preventing injuries and injury-related disabilities. Our 
research and programmatic efforts that target older Americans 
focus on falls prevention, understanding issues affecting older 
drivers, and preventing elder abuse. We also support two 
organizations focusing broadly on unintentional injury 
prevention among older Americans:
           The National Resource Center on Aging and 
        Injury was established at the end of FY1999 with the 
        San Diego State University. The Resource Center applies 
        cutting edge technology to collecting, organizing, 
        evaluating, and disseminating information about 
        preventing unintentional injuries among older adults. 
        In FY2000 the Resource Center established a repository 
        of over 1,000 resource items; developed an interactive 
        web site ( with a searchable 
        data base; and provided information to over 636,000 
        people, including health care professionals, care 
        givers, and other individuals concerned about reducing 
        injuries among older adults.
           The Edward R. Roybal Institute for Applied 
        Gerontology in Los Angeles, CA is funded to develop 
        training materials for community organizations and 
        agencies that serve Hispanic and other minority older 
        adults in East Los Angeles. These materials enable 
        organizations to conduct outreach and educational 
        programs, and to integrate unintentional injury 
        prevention activities into their existing service 
        delivery programs.

                            Falls Prevention

    National studies show that one-third of the people over 65 
living at home will fall each year, and for people over 80, 
this rate increases to 40 percent. Falls are the second leading 
cause of injury deaths among persons aged 65 84 years and the 
leading cause among persons aged 85 years and older. Of all 
fall injuries, hip fractures produce the greatest morbidity and 
mortality. Approximately 250,000 hip fractures occur each year 
and half of those who sustain hip fractures never regain their 
former level of functioning.
    Falls are the leading cause of traumatic brain injury (TBI) 
among older people, accounting for more than half of TBIs among 
older men and more than three-fourths among older women. TBI is 
an important and under-recognized public health problem among 
older people. NCIPC analyzed population-based data for 1997 
from Arkansas, Colorado, and South Carolina (NCIPC-funded 
states conducting TBI surveillance), and found that among 
people 65 years of age or older who experience TBI, an 
estimated 1 in 3 men and 1 in 10 women have a fatal outcome.

Disseminating What Works

    A Tool Kit to Prevent Senior Falls, developed in 1999 by 
NCIPC, is a comprehensive collection of health education 
materials and assessment tools designed to reduce falls and 
related injuries among older adults. In FY2000 the Tool Kit was 
distributed to over 14,500 organizations and agencies concerned 
with preventing injuries among older adults. Pfizer 
Pharmaceuticals is mass producing these materials for 
distribution to their customers.
    NCIPC developed U.S. Fall Prevention Programs for Seniors: 
Selected Programs Using Home Assessment and Modification in 
November 2000. This document fully describes 18 comprehensive 
fall prevention programs as well as contact information for 21 
additional programs. These programs are intended to be used as 
models by agencies or organizations that want to develop fall 
prevention programs for older adults.

Fall Prevention Programs

    In September 2000, NCIPC funded the State of California to 
conduct a fall prevention demonstration program for community-
dwelling older adults that includes three strategies: increased 
physical activity, medication review, and home assessment and 
safety modifications. This is the first demonstration of a 
combined program of several proven prevention strategies.
    NCIPC funded fire/fall prevention programs in September 
2000 that target older adults in North Carolina, Minnesota, 
Maryland, Virginia and Arizona. These programs implement a pre-
developed program curricula for preventing fire and fall-
related injuries among older adults utilizing home visits, 
group presentations, and other innovative outreach strategies.

Gathering Better Data on Falls

    In order to understand more about fall risk factors and how 
falls occur locations, circumstances, predisposing and enabling 
factors, especially for sub-population groups (such as the 
oldest old, minorities), NCIPC is supporting the expansion of 
the National Electronic Injury Surveillance System of the 
Consumer Product Safety Commission to collect information about 
fall injuries from hospital emergency departments. We are also 
funding the 2nd Injury Control And Risk Survey, a national 
injury survey that will include information related to fall 
risk factor prevalence and fall prevention behaviors among 

Research on Falls Prevention

    NCIPC conducts research by NCIPC scientists, and through a 
peer-reviewed, investigator-initiated grants program in 
universities and other research institutions across the 
    In an NCIPC study using National Hospital Discharge Survey 
data, we analyzed hip fracture hospitalization rates occurring 
between 1988 and 1996, and found that hip fracture 
hospitalization rates for older women increased 40 percent 
while the rates for men remained stable. Over 95 percent of hip 
fractures were caused by falls.
    Previous extramural research on reduction of falls in 
nursing homes has shown promising results in reducing falls by 
as much as 19 percent. Research has also identified the 
following modifiable risk factors: inactivity and muscle 
weakness, over medication, and environmental hazards. Less well 
understood are other risks, e.g., impaired vision and types of 
footwear. To improve our knowledge in one of these areas, NCIPC 
is consulting with the Atlanta, GA Veteran's Administration 
hospital to study footwear and falls. Current extramural 
research grants relating to falls prevention include:
    Project Title: ``Hip Fracture Prevention from Falls in the 
    Project Director: Wilson Hayes, Ph.D.
    Institution: Beth Israel Hospital; Orthopedic Biomechanics 
Laboratory; Boston, MA
    The goals of this project are to understand the 
biomechanics of hip fractures among the elderly, to resolve 
uncertainties regarding the relative importance of trauma 
severity and age-related bone loss, and to design a protective 
pad to be worn over the hips and test its acceptability to 
potential users.
    Project Title: ``An Assessment of Fall Prevention/Safety 
Practices in Tennessee Nursing Homes''
    Project Director: Wayne Ray, Ph.D.
    Institution: Vanderbilt University School of Medicine; 
Nashville, Tennessee
    This study tests the hypothesis that the Tennessee Fall 
Prevention Program (TFPP), a reduces falls that result in 
serious injuries. TFPP is a statewide, safety practices 
training program for nursing home staff. Investigators are 
conducting a randomized controlled trial of an estimated 112 
nursing homes with a combined population of approximately 9,000 
residents. The primary analysis is assessing program 
effectiveness by comparing rates of falls resulting in serious 
injuries in intervention and control facilities. If effective, 
the TFPP could provide a model for feasible, cost-effective 
injury prevention programs in long-term care settings.
    Project Title: ``Antidepressants and the Risk of Falls''
    Project Director: Wayne Ray, Ph.D.
    Institution: Vanderbilt University School of Medicine; 
Department of Preventive Medicine; Nashville, Tennessee
    The investigator is conducting a retrospective, inception 
cohort study of an estimated 2,500 new antidepressant users and 
2,500 nonusers for the period of 7/1/93 through 6/30/95. The 
study is being conducted in nursing homes because residents 
have the highest prevalence of depression and antidepressant 
use, are particularly vulnerable to tricyclic antidepressants 
adverse effects, and have the highest rates of falls and 
related injuries. Study findings are expected to further injury 
control by providing information clinicians need to choose 
pharmacotherapy that minimizes risk of falls.
    Project Title: ``Biomechanics of Injury Prevention During 
    Project Director: Stephen Robinovitch, Ph.D.
    Institution: Simon Fraser University; Office of Research 
Services; Burnaby, Brit. Col. Canada
    Considerable evidence now exists that fall severity, as 
defined by the configuration and velocity of the body at 
impact, is a stronger predictor than bone density of hip 
fracture risk. Data also suggest that specific protective 
responses exist for reducing fall severity and fracture risk, 
including braking the fall with the outstretched hands, and 
absorbing energy in the lower extremity muscles during descent. 
This study is designed to better define the biomechanical and 
neuromuscular variables that govern safe landing during a fall, 
and to identify the neuromuscular variables governing the 
efficacy of the protective responses as the basis exists for 
designing exercise-based interventions for reducing hip 
fractures in the elderly and other fall-related injuries.
    Project Title: ``Hip Fracture Reduction with the Penn State 
Safety Floor''
    Project Director: Donald Streit, Ph.D.
    Institution: Pennsylvania State University; Center for 
Locomotion Studies; Pennsylvania
    This proposal builds upon previous work in which a dually 
stiff floor intended to reduce the incidence of hip fractures 
in the elderly was successfully designed and developed. The 
Penn State Safety Floor (PSUSF) is stiff to loads typical of 
everyday activities but yields when forces such as those 
encountered during falls occur. Laboratory testing and finite 
element modeling have shown the floor to be capable of reducing 
the impact force of a fall by 28 percent investigators are now 
validating these promising initial results by conducting a 
carefully controlled study designed to directly demonstrate 
that hip fractures can be reduced by the use of the floor. In 
addition, investigators are monitoring a double occupancy room 
in a local nursing home where the floor is installed to 
demonstrate the livability of the floor.

                             Older Drivers

    In 1999, 7,088 people 65 years and older died in motor 
vehicle crashes. People 65 years and older represented 13 
percent of the population in 1999 and 17 percent of motor 
vehicle deaths. By 2030, elderly people are expected to 
represent 20 percent of the population. Once they're in 
crashes, elderly people are more susceptible than younger 
people to medical complications following motor vehicle 
injuries. Little is known about how the physical changes that 
accompany the aging process and diagnosed medical conditions 
effect driving performance. For example, there is some evidence 
to suggest that Parkinson's disease may impair driving, 
although the evidence is weak. More needs to be known about the 
connection between specific medical conditions and adverse 
driving outcomes.
    NCIPC has analyzed fatal and nonfatal injury data to assess 
trends over time in motor vehicle-related deaths to older 
persons. The rate of both fatal and nonfatal motor vehicle-
related injury increased during the study period. Rates 
increased as age increased, and men had rates twice as high as 
women. NCIPC collaborated with the University of California, 
San Diego to explore why older drivers stop driving. This study 
found that medical conditions were the most commonly given 
reason for stopping, and vision loss was the most common 
    NCIPC is also conducting research through peer-reviewed, 
investigator-initiated grants program in universities and 
research institutions across the country. Research grants 
relating to older drivers include:
    Project Title: ``Time Since License Renewal and Motor 
Vehicle Crash Risk Among Older Drivers''
    Project Director: Thomas D. Koepsell, M.D, M.P.H.
    Institution: University of Washington, Department of 
    States vary considerably with regard to how long a driver's 
license remains valid before it must be renewed. Although some 
states shorten the time between renewals for older drivers, 
most do not. The time between license renewal for older drivers 
is a public policy choice, balancing the risk of crashes due to 
drivers who have become impaired against the cost and 
inconvenience of more frequent renewal checks. The aim of this 
project is to determine the relationship between crash risk and 
time since last license renewal for drivers 65 years and older. 
Investigators hypothesize that longer time periods since last 
renewal will be significantly associated with a higher crash 
risk, compared to drivers with more recent renewals. The long 
term objective is to guide public policy related to license 
renewal for older drivers in the United States, by determining 
the degree to which decreasing the interval between renewals 
for older drivers may lessen the risk of crash.
    Project Title: ``Elderly Driver Referral Project''
    Project Director: James McKnight, Ph.D.
    Institition: National Public Services Research Institute; 
Landover, MD
    The proposed study attempts to ascertain relationships 
between the capabilities of drivers and their safety of 
operation in order to enable license administrators to initiate 
licensing actions that minimize the threat from those who 
cannot operate safely while preserving the mobility of those 
who can. The psychophysical capabilities of the entire sample 
are being assessed through a battery of test measures designed 
specifically to tap capabilities shown to relate separately to 
age and highway accidents. The relationships obtained in this 
manner are applied to (1) improve the methods of detecting 
drivers whose abilities may be diminished by age, (2) develop 
tests to validly assess drivers' ability to drive safely, and 
(3) formulate licensing actions capable of achieving an optimum 
balance between safety and mobility.
    Project Title: ``Longitudinal Study of Elderly Drivers''
    Project Director/Lead Investigator: Jane Stutts, PhD;
    Other Investigators: Richard Stewart, PhD; Carol Hogue, 
    Institution: University of North Carolina at Chapel Hill, 
Highway Safety Research Center
    A prospective cohort study is underway to assess the impact 
of selected functional impairments and medical conditions on 
the safety of older drivers. Drivers ages 65 and above coming 
in to renew their licenses were asked to participate in the 
study which involved a series of visual and cognitive 
functional assessments, along with a survey to gather 
information on self-reported medical conditions, use of 
medications, and driving habits. During the 1\1/2\ year data 
collection period, a total of 5,438 license renewal applicants 
were identified by the license examiners as potential study 
participants. Of these, 3,238, or 60 percent, elected to 
participate in the study. Participant and non-participant cases 
were linked with the North Carolina driver history files, and 
initial data analyses were carried out examining the role of 
various cognitive and visual functional impairments in recent 
prior crash involvement and in current driving exposure. Follow 
up analyses are planned in the project's final year to examine 
the usefulness of the driver functional assessments in 
predicting future crash involvement.
    In addition to these efforts, supplemental funding was made 
available by NCIPC to link North Carolina driver history data 
to data collected by UNC's Sheps Center for Health Services 
Research as part of an earlier study examining changes in 
health status and costs associated with Medicare-reimbursed 
screening and health promotion services. This ``add-on'' effort 
permitted further analyses of associations between motor 
vehicle crashes and injuries and a broad range of health 
measures in a separate population of elderly NC residents.

                              Elder Abuse

    Abuse of elderly persons is on the rise in the U.S. In 
1996, the National Elder Abuse Incidence Study reported 550,000 
incidents of abuse among elderly persons. There are no federal 
requirements for elderly protective services, nor are there 
regulations on training staff who provide protective services 
or for those investigating alleged cases of elder abuse. State 
protective services for the elderly vary widely; some are 
merged with children's services while others are separate.
    CDC's NCIPC and Public Health Practice Program Office have 
awarded a grant to the University of Iowa to evaluate the 
implementation and impact of state adult protective service 
statutes and regulations on the conduct of elder abuse 
investigations and outcomes. This study is expected to increase 
CDC's knowledge and understanding of state regulations related 
to elder abuse. Research findings from this study also will aid 
in the standardization of definitions in legislation and 
healthcare, and inform public health law practitioners about 
elder abuse reporting at the state level.



    According to the U.S. Census Bureau, America's population 
aged 65 or older grew by 74 percent between 1970 and 1999, from 
20 million to almost 35 million people. As the percentage of 
older Americans in the Nation's population continues to 
increase the Food and Drug Administration (FDA) has been giving 
increasing attention to the elderly in the programs developed 
and implemented by the Agency.
    Some of the challenges associated with older Americans, 
such as multiple drug interactions, food safety, different 
physiological characterizations and reactions to drug regimens, 
and the need for better medical device design for home self-
diagnostics and therapies, will become more acute. These 
challenges will require greater inclusion of the elderly in 
clinical testing for drugs, medical devices, and other FDA-
regulated products. Further, the increasing educational needs 
of the elderly will require more focused educational programs, 
including specific dietary information and foods targeted to 
their nutritional requirements. The elderly population and food 
service workers who prepare food for the elderly also will 
require special education initiatives concerning proper food 
handling because as the population ages it becomes more 
susceptible to foodborne diseases. Some of the major 
initiatives that are underway are described below.


    The FDA is a regulatory consumer protection Agency. FDA's 
mission is to promote and protect the public health by 
providing timely clearance of safe and effective products and 
monitoring products for continued safety after they are in use. 
The Agency's primary responsibilities are to ensure that: (1) 
foods are safe, nutritious, wholesome, and honestly labeled; 
(2) cosmetics are safe and properly labeled; (3) all drug 
products used for preventing, diagnosing, and treating disease 
are safe and effective, and information on their proper use is 
available; (4) biological products (blood and blood products, 
test kits, vaccines and antigens, therapeutic agents, and other 
biologicals) are safe, potent, and effective for the 
prevention, diagnosis, and treatment of disease; (5) medical 
devices are safe, effective, and properly labeled, and the 
public is not exposed to excessive radiation from medical, 
industrial, and consumer products; (6) animal drugs, devices, 
and feeds are safe and effective; and (7) food from animals 
that are administered drugs are safe for human consumption.
    FDA accomplishes its mission through enforcement of the 
Federal Food, Drug, and Cosmetic Act and subsequent 
regulations. FDA's current areas of emphasis are to implement 
the Food and Drug Administration Modernization Act of 1997, to 
strengthen the Agency's science-base, and to implement the 
Administration's initiatives on food safety and blood safety.

                        Leveraging Partnerships

    Leveraging is the creation of relationships and/or formal 
agreements with others outside the FDA that will ultimately 
enhance FDA's ability to meet its public health mission. By 
choosing to work with other organizations that share our public 
health and safety goals, FDA can significantly amplify its 
public health impact, leverage the intellectual capital of 
others, and make wise use of its resources. FDA has formed many 
leveraging partnerships with other government agencies, 
regulated industry, academia, health providers, consumers, and 
national and community based organizations to help the Agency 
meet its public health responsibilities. As part of the 
Agency's long-standing tradition of involving the public in its 
activities, FDA is forging new relationships with organizations 
in the aging network on national and grassroots levels. The 
Agency has been quite successful with its collaborations, and 
FDA intends to expand and build upon this foundation in 
developing new partnerships. During 1999 and 2000, the Agency 
conducted a variety of activities intended to establish and 
strengthen two-way communication between FDA and its 
constituencies. These activities included national and local 
consumer roundtables, meetings with organizations, stakeholder 
meetings, and public meetings.

                          Public Participation

    FDA has processes that provide access to decision-making 
and information programs by its stakeholders. FDA's 
stakeholders include industry, small business, consumers, and 
health professionals. Stakeholders may interact with FDA policy 
makers, express opinions, or ask for information to address 
specific concerns. FDA provides balanced opportunities for 
public access to the pre- and post-market regulatory processes 
in addition to timely education and information.
    FDA convened a series of national and local roundtables and 
stakeholder meetings with consumers, health professional 
associations, and community-based organizations. These forums 
provide opportunities for the Agency to dialogue with diverse 
groups on the FDA Modernization Act and an array of regulatory 
and health policy issues. One of the issues addressed was risk 
management associated with the use of medical products, a 
significant matter of interest for the older American 

                           Advisory Committee

    The Agency continues its efforts to involve older Americans 
to serve on its advisory committees by working with aging 
organizations to help identify potential candidates. Advisory 
committees have served an important role at FDA for many 
decades. FDA's advisory committees help the Agency make sound 
decisions based on good science in its review of regulated 
products. Advisory committees consist of individuals who are 
recognized as experts in their field from many different 
sectors including medical professionals, scientists and 
researchers, industry leaders, consumer representatives, and 
patient representatives. While advisory committee 
recommendations are valuable, all final decisions related to a 
regulated product are made by FDA. Currently there are 32 
advisory committees serving the Agency.

                              Health Fraud

    Health fraud is the deceptive promotion and distribution of 
false and unproven products and therapies to diagnose, cure, 
mitigate, prevent, or treat disease. These fraudulent practices 
can be serious and often expensive problems for the elderly. In 
addition to economic loss, health fraud can also pose direct 
and indirect health hazards to those who are misled by the 
promise of quick and easy cures and unrealistic physical 
    The elderly are often the victims of fraudulent schemes. 
Almost half of the people over 65 years of age have at least 
one chronic condition such as arthritis, hypertension, or a 
heart condition. Because of these chronic health problems, 
senior citizens provide promoters with a large, vulnerable 
market. To combat health fraud, FDA uses a combination of 
enforcement and education. In each case, the Agency's decision 
on appropriate enforcement action is based on considerations 
such as the health hazard potential of the violative product, 
the extent of the product's distribution, the nature of any 
mislabeling that has occurred, and the jurisdiction of other 
    The FDA has developed a priority system of regulatory 
action based on two general categories of health fraud: direct 
health hazards and indirect hazards. The Agency regards a 
direct health hazard to be extremely serious, and it receives 
the Agency's highest priority. FDA takes immediate action to 
remove such a product from the market. When the fraud does not 
pose a direct health hazard, the FDA may choose from a number 
of regulatory options to correct the violation, such as a 
warning letter, a seizure, or an injunction.
    The Agency also uses education and information to alert the 
public to health fraud practices. Both education and 
enforcement are enhanced by coalition-building and cooperative 
efforts between government and private agencies at the 
national, State, and local levels. The Agency also evaluates 
its efforts to help ensure that our enforcement and education 
initiatives are correctly focused.
    The health fraud problem is too big and complex for any one 
organization to effectively combat by itself. Therefore, FDA is 
working closely with many other groups to build national and 
local coalitions against health fraud. By sharing and 
coordinating resources, the overall impact of our efforts to 
minimize health fraud will be significantly greater. Currently, 
FDA is leveraging resources with the Federal Trade Commission 
(FTC) in an effort to target Internet health fraud. This 
initiative, ``Operation Cure-All,'' is aimed at false and 
misleading claims, fraudulent and unproven ``miracle'' cures.
    FDA has worked with the National Association of Attorneys 
General and other organizations to provide consumers with 
information to help avoid health fraud. Since 1986, FDA has 
worked with the National Association of Consumer Agency 
Administrators (NCAA) to establish the ongoing project called 
the NCAA Health Products and Promotions Information Exchange 
Network. Information from FDA, the Federal Trade Commission, 
the U.S. Postal Service, and State and local offices is 
provided to NCAA periodically for inclusion in the Information 
Exchange Network. This system provides information on health 
products and promotions, consumer education materials for use 
in print and broadcast programs, and the names of individuals 
in each contributing agency to contact for additional 
    The Internet poses new and challenging problems to Agency 
efforts to prevent health fraud. Snake oil salesmen of the past 
have abandoned their wagons to hop on the Internet with offers 
of eternal youth and potions for the prevention, treatment and 
cure of many diseases. FDA recently seized and destroyed 
Chuifong Black Pills, offered as an Asian herbal treatment for 
the cure of arthritis. Analysis of the pills showed they 
contained several prescription drugs that may pose a serious 
health hazard, especially to consumers who were combining 
Chuifong with their own prescribed medications.
    FDA recently worked with State of California officials to 
stop the distribution of an unapproved diabetic drug imported 
from China. This herbal product, marketed under several names, 
contained the prescription diabetic drug, glyburide. There was 
at least one report of an adverse reaction that required 
medical treatment. FDA published a brochure in cooperation with 
many health care organizations, designed to warn consumers 
about buying medical products online. FDA continues to work 
with the U.S. Customs Service and state law enforcement 
agencies to prevent the Russian product Corvalolum from 
entering the United States. Corvalolum contains dangerous 
levels of Phenobarbital.
    Unapproved new drugs offered as treatments for cancer 
continues to be marketed illegally. FDA took action against 
Laetrile, a fraudulent cancer cure marketed by two firms. The 
Agency obtained a consent decree of permanent injunction 
against one firm and the second firm is under a preliminary 
injunction as of September 2000.
    Another unapproved new drug, hydrazine sulfate, also 
marketed illegally as a treatment for cancer, may cause serious 
adverse effects. Studies have shown that hydrazine sulfate is 
not effective and that it may actually decrease survival time. 
The Agency is taking steps to stop the distribution of this 

                       Office of Consumer Affairs

    The FDA's Office of Consumer Affairs (OCA) seeks consumer 
participation in Agency policy-making and ensures that FDA 
decision-makers hear consumer concerns before completing policy 
decisions. OCA's primary functions include encouraging public 
participation and consumer education and outreach. OCA 
routinely includes older Americans in their public 
participation, education, and outreach initiatives, as well as 
the recruitment process for consumer representatives. OCA 
continues to work with its Agency counterparts, as well as its 
constituents, to ensure consumer involvement in Agency 
    One method the Agency uses to ensure that FDA gets 
consumers' points of view is by including consumer 
representatives on Agency advisory committees. The role of the 
consumer representative is to (1) represent the consumer 
perspective on issues and actions before the advisory 
committee; (2) serve as a liaison between the committee and 
interested consumers, associations, coalitions, and consumer 
organizations; and (3) facilitate dialogue with the advisory 
committees on scientific issues that affect consumers.
    OCA co-sponsored a variety of consumer roundtables and 
consumer education programs that highlighted issues of 
importance to older Americans. For example:
           OCA in conjunction with FDA's Office of 
        Regulatory Affairs, Pacific Region, convened three 
        public forums. These forums entitled, ``Public Input on 
        Public Health, FDA Listens to You, A Town Hall 
        Meeting'' were held in May 1999 in Oakland, California; 
        Los Angeles, California; and Portland, Oregon. The 
        purpose of the forums was to provide an opportunity for 
        FDA's primary stakeholders, U.S. consumers, to have an 
        open dialogue with FDA's senior policy makers about 
        their consumer protection concerns. Some of the topics 
        addressed were safety and labeling of dietary 
        supplements, access to clinical trials, health fraud, 
        and food safety.
           On October 26, 1999, ``FDA's Consumer 
        Roundtable'' was held in Houston, Texas. This meeting 
        provided an opportunity for consumer to engage in an 
        open dialogue with senior Agency officials on how FDA 
        can work with consumers and community organizations to 
        manage and communicate the risk and benefits of drug 
           On April 27, 2000, a consumer roundtable 
        ``FDA Celebrates Alliances with Hispanic Communities: 
        Moving Forward'' was held in San Diego, California. 
        This roundtable established interaction between the 
        public and Agency officials on how the Agency can work 
        with the community to manage and communicate the risks 
        and benefits associated with drug products.
           On December 13, 2000, a discussion was held 
        in Washington, D.C. between senior FDA officials, 
        consumer leaders, and consumers to discuss key public 
        health and consumer protection priorities for the 
        Agency. The purpose of this roundtable was to 
        strengthen consumer involvement in the Agency's process 
        for assessing how it is currently directing its 
        consumer protection responsibilities and determining 
        whether there is a need to redirect or shift priorities 
        to better meet those responsibilities.

                        Office of Public Affairs

    The FDA's Office of Public Affairs (OPA) is the agency's 
primary point of contact for the news media. It also manages 
the agency's website at and develops information 
materials on FDA-related public health and consumer protection 
activities. While working very closely with the different 
centers within the agency, OPA has published a number of FDA 
Consumer magazines, articles, press releases, and talk papers 
that focus on topics of interest and concern to older 
    The agency website has a page dedicated to older Americans 
entitled ``FDA Information for Older People.'' This site gives 
information regarding buying medicines online, seniors and food 
safety, and linkages to other organizations outside of FDA with 
information of interest to older Americans. This webpage also 
has numerous articles and other publications with information 
for older Americans on a wide range of health issues such as:
           Arthritis: Timely Treatments for an Ageless 
           Help Your Arthritis Treatment Work (Spanish 
           Preventing Colon Cancer
           FDA Sets Higher Standards for Mammography
           Lung Cancer
           Prostate Cancer: No One Answer for Testing 
        or Treatment
           Health Claim for Foods That Could Lower 
        Heart Disease Risk
           Keeping Cholesterol Under Control
           Taking Charge of Menopause
           Taking Time to Use Medicines Wisely
           How to Spot Health Fraud

                    Office of Special Health Issues

    The FDA's Office of Special Health Issues (OSHI) serves the 
public by answering their questions about the Agency's 
activities related to HIV/AIDS, cancer, and other diseases. 
OSHI works with patients and their advocates to encourage and 
support their active participation in the formulation of FDA 
regulatory policy. Additionally, OSHI (1) serves as a channel 
through which patient issues and viewpoints can be brought to 
the attention of FDA medical and regulatory staff; (2) ensures 
a comprehensive and timely response to individuals with 
questions and concerns related to life-threatening diseases and 
other special health issues; (3) participates in the 
development of national policies and practices concerning HIV/
AIDS, cancer, and issues related to special populations; and 
(4) provides FDA representation to scientific and policy 
meetings related to life-threatening diseases and other special 
health concerns.

                        Office of Women's Health

    The FDA's Office of Women's Health (OWH) serves as a 
champion for women's health both within and outside the Agency. 
To meet its goals OWH (1) ensures that FDA's regulatory and 
oversight functions remain gender sensitive and responsive; (2) 
works to correct any identified gender disparities in drug, 
device, and biologics testing and regulation policy; (3) 
monitors the progress of priority women's health initiatives 
within FDA; (4) promotes an integrative and interactive 
approach regarding women's health issues across all the 
organizational components of the FDA; and (5) forms 
partnerships with government and non-government entities, 
including consumer groups, health advocates, professional 
organizations, and industry, to promote FDA's women's health 
    OWH has developed a number of initiatives to further its 
inclusion of older Americans in their programs such as:
           Take Time To Care (TTTC) encouraged women 
        nationwide to educate themselves and their families 
        about using medicines wisely. Educational grassroots 
        programs were developed with 80 national organizations 
        and cosponsored by the National Association of Chain 
        Drugstores (20,000 community pharmacies). Their efforts 
        coupled with nearly 100 media outlets brought the FDA 
        message to 26 million readers and viewers. For these 
        efforts, the Health Care Quality Alliance (97 health 
        care associations) selected TTTC as a recipient of the 
        prestigious Pinnacle Award, which annually ``recognizes 
        pioneering contributions and exemplary leadership in 
        medication use quality improvement.''
           Breast Cancer Awareness Month--In 
        collaboration with the Center for Devices and 
        Radiological Health the FDA/OWH sent a letter to all 
        10,000 certified mammography facilities inviting them 
        to showcase the availability of our Mammography Today 
        brochure and distribute a one-page abbreviated version 
        of the brochure to inform patients about their new 
           Pink Ribbon Sunday--OWH sponsored activities 
        of the FDA Public Affairs Specialists in Houston, 
        Dallas, and Atlanta to conduct ``Pink Ribbon Sunday'' 
        activities that encourage ``women of color'' to get 
        screened. In the city of Houston alone, 153 churches 
        participated and reached about 110,000 people with FDA 
        materials. The Public Affairs Specialists received the 
        American Cancer Society's ``Partner of Courage Award.''
           Breast Cancer Videotape--OWH developed a 
        Breast Cancer ``Early Detection Saves Lives'' videotape 
        to encourage churches to sponsor screening and 
        educational activities. The videotape will be given to 
        the Public Affairs Specialists, and the National Cancer 
        Institute for distribution through their clearinghouse.
           New Publications--(1) Created a quarterly 
        newsletter for our stakeholders focusing on FDA 
        actions, meetings and activities of interest to women. 
        (2) Published the first FDA history document describing 
        the agency's role in protecting women's and the 
        public's health over the last 100 years. The milestones 
        presented highlight specific actions taken by the 
        agency so that all Americans can enjoy safer, healthier 
           OWH Website--Redesigned the OWH website that 
        became a recipient of the ``Hot Site Award.''

            Other Outreach Projects (for delivery in FY2001)

           OWH will work in partnership with the 
        American Pharmaceutical Association Foundation and the 
        National Wholesale Druggists' Association Healthcare 
        Foundation to promote distribution of TTTC medicine 
        tips in hospitals. Hospital-based pharmacies will 
        encourage consumers to play a role in managing risks 
        associated with medication use as in-patients and out-
           In December 2000, the Emergency Nurses 
        Association (ENA) announced to its 25,000 members its 
        decision to adopt TTTC as a national campaign. ENA will 
        distribute ``My Medicines'' brochures in emergency 
        settings, hospital auxiliaries, civic meetings, and 
        retirement homes.
           OWH funded a grant for the translation of 
        materials about cervical and breast cancer screening 
        for Asian-American Pacific-Islander communities through 
        a website coordinated by APANet.
           OWH funded a bi-regional women's health 
        conference in DHHS Regions II and III for health 
        professionals and consumers to raise awareness about 
        health disparities found in minority communities.
           OWH funded the development of a multi-media 
        Women's Health Care Trainer's Kit and Consumer Guide to 
        assist women in planning for screenings and preventing 
           OWH funded a ``Read the Label'' project that 
        will use graphics to provide instructions for non-
        English readers in a variety of Asian languages. This 
        model may then be applied to other language groups.

                 Office of Orphan Products Development

    It is the intent of the Orphan Drug Act, and the Office of 
Orphan Products Development (OPD), to stimulate the development 
and approval of products to treat rare diseases. The OPD plays 
an active role in helping sponsors meet Agency requirements for 
product approval. From 1983--when the Orphan Drug Act was 
passed--through the end of 2000, 216 products to treat small 
populations of patients were approved by FDA.
    By the end of 2000 there were 856 designated orphan 
products. One hundred thirty-two of these designated orphan 
products (15 percent) represent therapies for diseases 
predominately affecting older Americans. Seventy-five are for 
treating rare cancers in the elderly, such as ovarian cancer, 
pancreatic cancer, and metastatic melanoma. Twenty-two  of the  
orphan  products  designated  for treating elderly populations 
are for rare neurological diseases, such as amyotrophic  
lateral sclerosis  (ALS), and advanced  Parkinson's disease. 
Twenty-nine orphan-designated therapies for elderly populations 
have received FDA market approval. Most noteworthy among these 
is Eldepryl for treatment of idiopathic Parkinson's disease, 
postencephalitic Parkinsonism, and symptomatic Parkinsonism; 
riluzole for treatment of ALS; and Novantrone for treatment of 
refractory prostate cancer.
    FDA's orphan product grants had their beginning in 1983 as 
one of the incentives provided by the Orphan Drug Act. This 
program provides financial support for clinical studies 
(clinical trials) to determine the safety and efficacy of 
products to treat rare disorders, and to achieve marketing 
approval from the FDA under the Federal Food, Drug, and 
Cosmetic Act. Studies funded by the orphan products grant 
program have contributed to the marketing approval of twenty-
eight products.
    Because the orphan products program is issue-specific/
indication-specific, it is typical for an approved product to 
be funded under the orphan products grant program for study in 
an indication unique to a distinct group of people, such as 
women, children, or the elderly. Under the orphan drug program, 
disease populations are small and in many instances the firms 
themselves are very small. The goal of the Orphan Drug Act is 
to bring to market products for rare diseases or conditions. In 
so doing, orphan product development promotes research and 
labeling of drugs for use by and for special populations. The 
orphan products grant program has funded more than 42 studies 
aimed at treatment of diseases affecting adults and older 

             The National Center for Toxicological Research

    The National Center for Toxicological Research's (NCTR) 
mission is to conduct peer-reviewed scientific research that 
supports and anticipates the FDA's current and future 
regulatory needs. This involves fundamental and applied 
research specifically designed to define biological mechanisms 
of action underlying the toxicity of products regulated by the 
FDA. This research is aimed at understanding critical 
biological events in the expression of toxicity and at 
developing methods to improve assessment of human exposure, 
susceptibility, and risk.
    NCTR has worked with the National Institute on Aging (NIA) 
in the past to study the role caloric restriction plays in the 
aging process and what affect a reduced caloric diet has on 
disease etiology. The Interagency Agreement with the NIA 
terminated in 1999 with the animals that were raised in support 
of this work being transferred to Harlan Sprague Dawley, a 
commercial laboratory animal breeder. Scientists working on the 
Project on Caloric Restriction have concentrated on determining 
the mechanisms by which caloric restriction inhibits 
spontaneous disease, modulates agent toxicity and affects the 
normal aging process. Since 1999 the only studies that have 
been continuing are a collaborative study with the University 
of Tennessee at Memphis designed to determine if the 
physiological, metabolic, and molecular changes that occur with 
caloric restriction in rodents are similar in humans, and 
additional rodent studies to measure how different levels of 
caloric restriction might influence body changes.
    Although the work over the last several years has 
concentrated on the mechanisms of toxic interaction in the body 
and the role caloric restriction has on this process, studies 
with calorically restricted animals have repeatedly shown that 
caloric restriction extends the life span of animals. How this 
affects aging is still in question; however, the research being 
conducted in this area is continuing to chip away at the 
problem of how diet affects the aging process, and what 
elements or lack thereof in the human diet may help to extend 
human life.


    MedWatch, the FDA's voluntary Medical Products Reporting 
and Safety Information Program, serves both healthcare 
professionals and the medical product-using public. MedWatch 
strives to educate health professionals about the critical 
importance of being aware of, monitoring for, and reporting 
adverse events and product problems to FDA and/or the 
manufacturer, as well as to ensure that new safety information 
is rapidly communicated to the medical community, thereby 
improving patient care. The purpose of the MedWatch program is 
to enhance the effectiveness of postmarketing surveillance of 
medical products as they are used in clinical practice and to 
assist in rapidly disseminating information about significant 
health hazards associated with these products. Health 
professionals, as well as consumers, are encouraged to report 
serious adverse reactions and product problems associated with 
FDA-regulated products to the Agency.
    Older Americans are generally more susceptible to adverse 
events because of the probability they will use more 
medications and medical device products.

               Center for Devices and Radiological Health

    The FDA's Center for Devices and Radiological Health (CDRH) 
promotes and protects the health of the public by ensuring the 
safety and effectiveness of medical devices and the safety of 
radiological products. Medical devices include products ranging 
from mechanical heart valves to ophthalmic lasers to pregnancy 
test kits products that are intended for use in the diagnosis 
of disease or other conditions, or in the cure, mitigation, 
treatment or prevention of disease. Radiation-emitting 
electronic products include such things as microwave ovens, 
televisions, sunlamps, medical and baggage inspection x-ray 
machines, and laser products such CD and DVD players, light 
shows and bar code scanners. CDRH provides information to 
consumers, including older Americans, regarding medical devices 
and radiation-emitting products to enhance their ability to 
avoid risk, achieve maximum benefit, and make informed 
decisions about the use of such products.


    Because a woman's risk for breast cancer increases as she 
gets older, the need to have a regularly scheduled mammogram is 
critical to ensure early detection. Congress enacted the 
Mammography Quality Standards Act of 1992 (MQSA) to ensure that 
all women have access to quality mammography for the detection 
of breast cancer in its earliest, most treatable stages.
    As of April 28, 2000, there were 9,994 MQSA-certified 
mammography facilities in the United States and its 
territories. All of these facilities are subject to clinical 
accreditation by outside expert bodies, and certification and 
inspection by FDA to ensure compliance with quality standards.
    Older women are the focus of this effort:
           CDRH targets older Americans for particular 
        outreach efforts. Groups such as AARP have been on our 
        mailing list to receive mammography information and 
        Mammography Matters (our newsletter) since the 
        inception of our program.
           CDRH has collaborated extensively with FDA's 
        Offices for Women's Health, Consumer Affairs, Public 
        Affairs, and Special Health Issues, and they have 
        distributed educational materials about mammography to 
        their constituents, including newsletter editors.
           Older Americans were included in the 
        outreach about the availability of the 1-800-4-Cancer 
        hotline. Callers to this number can locate FDA-
        certified mammography facilities in their areas, get 
        answers to questions about breast cancer, and request 
           Consumer representatives with ties to senior 
        advocacy groups are members of our National Mammography 
        Quality Assurance Advisory Committee.

                          Hospital Bed Safety

    FDA continues its work to reduce the hazards associated 
with patient entrapment in hospital beds. Patient entrapment 
with hospital bedside rails can occur in hospitals, nursing 
homes and at home. The FDA continues to receive reports of 
death and injury when patients become entangled or trapped 
between the mattress and bed rail or in the bed rail openings. 
The patients most at risk for entrapment are frail, elderly or 
    FDA initiated and is an active member of The Hospital Bed 
Safety Work Group, which most recently met in Chicago on 
October 24-25, 2000. The Hospital Bed Safety Work Group is made 
up of representatives of the federal government, national 
health care organizations, manufacturers of hospital beds and 
medical researchers. To date, the work group has primarily 
focused on raising awareness of the entrapment hazard and 
educating caregivers and family members on the problems 
associated with bed rail use. The work group recently issued an 
educational brochure, ``A Guide to Bed Safety,'' that 
highlights the benefits and risks of bed rails, ways to meet a 
patient's need for safety, and patient or family concerns about 
bed rail use. This brochure and the work of The Hospital Bed 
Safety Work Group are available on the FDA web site for bed 
safety at: Planned work includes 
developing clinical guidance for caregivers on appropriate bed 
rail use and developing a measurement tool for clinical 
facilities to determine if an entrapment hazard exists with 
their beds.

               Treatment for Benign Prostatic Hyperplasia

    On October 11, 2000, FDA sent a Public Health Notification 
to alert the medical community of the potential for serious 
injuries from microwave thermotherapy for benign prostatic 
hyperplasia (BPH). Although the use of microwave thermotherapy 
for the treatment of BPH has been demonstrated to be safe and 
effective, FDA is concerned about reports of unexpected 
procedure-related complications that have occurred since the 
marketing of these devices. The letter identified several 
factors that may have contributed to the injuries and made 
recommendations to avoid injury.

                        Medical Device Approvals

Heart and Cardiovascular System

           The AngioJet System, approved on March 15, 
        1999, removes blood clots from blocked heart arteries 
        or bypass grafts prior to angioplasty. The device will 
        provide an alternative treatment to so-called clot-
        busting drugs, and will be particularly useful for 
        patients in whom these drugs cannot be used.
           On November 6, 2000, FDA approved the Cordis 
        CheckmateTM System and the Novoste Beta-
        CathTM System, both of which use catheters 
        to deliver radiation inside a coronary stent, following 
        the opening of a blocked artery. The radiation helps 
        reduce the risk of new tissue growth inside the 
        coronary stent and the resulting narrowing of the 
           FDA continues to review and approve for 
        marketing improved versions of heart valves, 
        pacemakers, implanted cardioverter defibrillators and 
        other cardiac devices that will help many older 
        Americans live longer, more comfortable lives.


           Verteporfin for injection (Visudyne), the 
        first therapy to slow vision loss in people with 
        classic ``Wet Age-Related Macular Degeneration (AMD)'' 
        was approved on April 13, 2000. AMD, a retinal disease 
        causing severe and irreversible vision loss, is a major 
        cause of blindness in individuals older than 60 years 
        in the Western World.


           Approved on April 19, 1999, the T-SCAN 2000 
        is intended for use as a follow-up step to mammography 
        for patients whose mammograms are ambiguous. The device 
        has the potential to reduce the number of negative 
        biopsies, thus saving women worry about breast lesions 
        that turn out to be non-cancerous.
           Approved January 31, 2000, the Senographe 
        2000D is the first mammography system that produces 
        digital images on a solid state receptor instead of 
        analog images on a radiographic film. Unlike 
        radiographic film, digital images can be electronically 
        stored and transferred, so that a specialist at a 
        remote location can evaluate them. The images also can 
        be manipulated to correct for under- or over-exposure. 
        Early diagnosis remains the best weapon against breast 
        cancer, which annually affects 185,000 women, 46,0000 
        of whom die of the disease. Most women who get breast 
        cancer are over 50 years of age. The approval of 
        digital mammography benefits older Americans because 
        the ability to manipulate computer images means fewer 
        call-backs for additional imaging, which can be 
        difficult for older Americans who often depend on 
        others for their transportation.
           FDA allowed continued marketing of two types 
        of saline-filled breast implants that had been approved 
        for breast reconstruction and for breast augmentation 
        in women 18 years or older. This decision was made 
        following the conclusion of clinical studies involving 
        9,000 women and the recommendations of our expert 
        advisory committee. Many women feel that breast 
        reconstruction is an essential part of their recovery 
        after mastectomy because of breast cancer.
           The Optical Biopsy System is a laser system 
        that improves a physician's ability to identify 
        suspicious growths in the colon. It is operated through 
        an endoscope and can be used to evaluate polyps less 
        than 1 cm in diameter. This device was approved on 
        November 15, 2000.
           Another device, FocalSeal-L Surgical 
        Sealant, was approved on May 30, 2000, for sealing air 
        leaks in lungs following the removal of cancerous 
        tumors. FDA reviewed the sealant, which is ``painted'' 
        on the lung and activated by light, on an expedited 
        basis because of its potential importance for patients 
        with lung cancer.
           Levulan Kerastick (aminolevulinic acid HCI) 
        for Topical Solution, 20 percent is to be used in 
        conjunction with photodynamic therapy for treatment of 
        actinic keratoses (AKs) (pre-cancerous skin lesions) of 
        the face or scalp. AKs are rough, scaly, red or brown 
        patches that begin on the surface of the skin. They are 
        mostly found among individuals with light complexions 
        affecting more than 50 percent of elderly fair-skinned 
        persons in hot, sunny climates. This product was 
        approved on December 6, 1999.


           The Continuous Glucose Monitoring System, 
        approved on June 16, 1999, provides physicians with 
        continuous measures of tissue glucose levels in adults 
        with diabetes.
           Apligraf is intended to be used on patients 
        who have not responded well to standard methods of 
        treating foot ulcers. Approved on June 20, 2000, 
        Apligraf is a cellular, bi-layered skin substitute 
        produced from bovine collagen and cells derived from 
        human infant foreskins. Many diabetics have difficulty 
        healing and might benefit from this product.


           A laboratory test for detecting 
        Streptococcus pneumoniae, one of the bacteria that is a 
        leading cause of pneumonia was approved on August 30, 
        1999. Pneumonia can be a life-threatening disease for 
        the elderly.

Hearing Loss

           Vibrant Soundbridge is a surgically 
        implanted hearing device intended to help adults with 
        moderate to severe nerve hearing loss. Approved on 
        August 31, 2000, this device is an alternative for 
        people who have not been helped by hearing aids. About 
        20 percent of Americans--more than 56 million--
        experience some nerve deafness by the age of 55.


    Gender effects on coronary arteries and balloon 
angioplasty.--FDA scientists have established a large animal 
cardiovascular research program to develop and study models of 
cardiovascular disease, vascular injury, and long-term vascular 
implant performance. FDA scientists are using the laboratory to 
study effects of gender and hormonal state on the function and 
mechanical properties of coronary arteries and on the response 
of arteries to balloon injury. More than 75 subjects have been 
studied and the results thus far will be announced at the FDA 
Science Forum in February 2001. The motivation for the study is 
the observed greater incidence of cardiovascular death in 
postmenopausal women and men of all ages compared to 
premenopausal women.
    Early detection of diabetes-related eye diseases.--One of 
the most threatening aspects of diabetes is the development of 
visual impairment due to cataract formation, diabetic 
retinopathy, and glaucoma. In many cases, diabetes-related 
ocular pathologies go undiagnosed until visual function is 
compromised. In order to develop techniques for early cataract 
detection, FDA scientists are studying the progression of 
diabetes in a unique animal model and monitoring the changes in 
the lens using a safe, nondestructive dynamic light scattering 
    Ultrasonic measurement of bone density.--FDA has approved 
several ultrasound bone densitometers, which are used in the 
assessment of osteoporosis, and more applications for these 
devices are in progress. Because this is a new technology, 
there is little standardization between devices, and the 
technology is likely to continue evolving. FDA scientists are 
investigating the ultrasonic measurements (backscatter, 
attenuation, and sound speed) on 50 women ranging in age from 
50-90. The objective is to investigate the diagnostic utility 
of the backscatter measurement for diagnosis of osteoporosis. 
Preliminary experiments conducted on bone samples in vitro 
increased understanding of how and why ultrasound bone 
sonometry is effective and should, therefore, lead to better 
review of these devices.
    Acoustic detection of cavitation near heart valves.--
Transient cavitation--the formation and collapse of tiny 
bubbles in the blood--has been observed near operating 
mechanical heart valves. Cavitation can damage the valve and 
break down the blood cells. FDA is conducting studies to 
determine if the broad-spectrum acoustic energy that occurs 
when the bubbles collapse might be used to detect cavitation by 
``listening'' with a hydrophone to the noise produced by valve 
closing when cavitation is present.
    Electromagnetic interference with electronic implants.--
CDRH scientists have conducted studies to help determine the 
risk of various magnetic fields to electronic implanted medical 
devices. Magnetic fields from various types of electrical 
equipment can interfere with the proper operation of implanted 
medical devices, such as cardiac pacemakers and defibrillators, 
and spinal cord stimulators. CDRH engineers have completed 
magnetic and electric field mapping of eight electronic article 
surveillance systems. A special laboratory environment was 
required to conduct this study. CDRH's three-dimensional 
electromagnetic field-strength mapping apparatus was relocated 
to a new laboratory and the required support structure was 
designed and constructed using non-magnetic components; a walk-
through metal detector was obtained from the Federal Aviation 
Administration. The results of these tests were published in 
the September-October 1999 issue of Compliance Engineering.
    Standards Development.--CDRH scientists have participated 
heavily in the development of performance standards for many 
types of devices of interest to older Americans. These include 
standards for devices to relieve the consequences of arthritis 
such as total orthopedic joints and mobility aids such as 
wheelchairs, as well as devices to assist the cardiovascular 
system such as pacemakers, heart valves, and cardiovascular 
stents. CDRH currently supports more than 500 domestic and 
international standards development efforts.


    CDRH's website provides consumer information on many topics 
of interest to older Americans such as mammography, newly 
approved medical devices, and reducing user error. There are 
also webpages devoted to LASIK, the popular laser surgery for 
improving vision, and the safety of hospital beds. CDRH's 
website can be found at


           ``Mammography Today: Questions and Answers 
        for Patients on Being Informed Consumers--Better 
        Treatments Save More Lives''
           ``FDA Sets Higher Standards for 
           Mammography Matters newsletter
           ``A Guide to Bed Safety; Bed Rails in 
        Hospitals, Nursing Homes and Home Health Care: The 
           ``Breast Implant Risks''
           ``Breast Implants An Information Update--

CDRH FDA & HHS Press Releases, Fact Sheets, Public Health Notifications 
               and Statements Related to Older Americans

           FDA Approves New Device To Remove Blood 
        Clots From Coronary Arteries (Angio-jet)--March 15, 
           FDA Approves New Breast Imaging Device (T-
        Scan)--April 19. 1999
           Potential Cross-Contamination Linked to Hem 
        odialysis Treatment--May 1999
           Laser Facts--June 1999
           FDA Clears Quick New Lab Test for Pneumonia 
        Antigen--August 30, 1999
           Consumer Update on Mobile Phones--October 
        20, 1999
           Temporomandibular Joint Implants: A Consumer 
        Information Update--November 1999
           First Drug Device Combined Treatment for 
        Certain Pre-Cancerous Skin Lesions Approved--December 
        6, 1999
           FDA Statement about ColorMax Eyeglass 
        Lenses--December 21, 1999
           FDA Approves First Digital Mammography 
        System--January 31, 2000
           Risks of Burns from Eruption of Hot Water 
        Overheated in Microwave Ovens--March 8, 2000
           Microwave Oven Radiation--March 8, 2000
           FDA Alerts Health Professionals and 
        Consumers to a Nationwide Recall of Clinipad Antiseptic 
        Sterile Products--March 10, 2000
           FDA Approves Treatment for Wet Macular 
        Degeneration--April 13, 2000
           Two Firms Get FDA Approval To Continue 
        Marketing Saline-Filled Breast Implants--May 10, 2000
           FDA Approves New Surgical Sealant For Lung 
        Cancer--May 30, 2000
           FDA Approves New Product For Diabetic Foot 
        Ulcers--June 20, 2000
           Risk of Electromagnetic Interference with 
        Medical Telemetry Systems--July 10, 2000
           Serious Injuries from Microwave 
        Thermotherapy for Benign Prostatic Hyperplasia--October 
        11, 2000
           FDA Approves New Implanted Hearing Device--
        October 23, 2000
           FDA Approves Two New Devices To Help Reduce 
        the Risk of Repeat Coronary Stent Re--Narrowing (In-
        Stent Restenosis)--November 6, 2000
           FDA Approves New Device To Help Distinguish 
        Harmless from Pre-Cancerous Growths in Colon--November 
        15, 2000
           Court Orders Refund to Purchasers of Gas 
        Grill Igniters Marketed for Pain Relief--November 30, 

                Center for Drug Evaluation and Research

    The mission of FDA's Center for Drug Evaluation and 
Research (CDER) is to promote and protect the public health by 
helping to ensure that safe and effective drugs are available 
to the American public including older Americans. FDA is 
continuing to make drugs safer for older Americans, who consume 
a large share of the nation's medications. Adults over age 65 
buy 30 percent of all prescription drugs and 40 percent of all 
over-the-counter (OTC) drugs.

                          Public Participation

    CDER continues to maintain its long-standing tradition of 
involving the public in its activities. On June 28 and 29, 
2000, FDA held a public meeting to get input and opinions on 
the type of drugs for which it would be appropriate to switch 
from prescription status to OTC status. Many of the drugs 
discussed were drugs commonly used by the aging population in 
America. For example, one part of the meeting focused on 
cholesterol-lowering drugs and whether they should be 
considered as candidates for OTC drug status. The meeting 
attracted considerable attention from consumer and patient 
groups, as well as industry, and was covered by C-Span.

                     OTC Labeling Changes Campaign

    Many older Americans find the print on OTC labels too small 
to be legible. In 1997, FDA issued a proposal to establish a 
standardized format for the labeling of OTC drug products and 
provided over 7 months for interested persons to comment on the 
OTC labeling proposal. The Agency received more than 1,800 
comments from health professionals, students, professional 
organizations, trade associations, manufacturers, consumers, 
and consumer organizations. An overwhelming majority of the 
comments supported the Agency's initiative to standardize the 
format of OTC drug product labeling and to make the labeling 
easier to read and understand by requiring a minimum type size, 
user-friendly headings, and other well-accepted visual cues. 
The regulations became effective on April 16, 1999. In many 
cases, OTC drugs with the new labeling will begin appearing on 
the shelves by 2002. The remainder of more than 100,000 OTC 
drugs will be required to adopt the new labeling within the 
next six years. CDER reached more than 17 million people with a 
print campaign and 137 million listeners with radio Public 
Service Announcements notifying them of the OTC labeling 

                   Materials, Outreach, and Exhibits

    The FDA continually strives to establish an ongoing 
dialogue between the Agency and its constituents on important 
public health problems and issues. Of recent interest is the 
use of the Internet by the public to buy medical products. Many 
consumers, including older Americans or those who cannot leave 
their homes, benefit from the convenience and privacy of this 
new option. The safe use of the Internet by consumers is 
threatened, however, by fraudulent or disreputable Internet 
pharmacies that sell products illegally. CDER prepared a 
brochure, a newspaper article, and a print Public Service 
Announcement designed to inform the public about the potential 
dangers of buying medical products on the Internet, and to 
increase consumer awareness about the problems related to 
online drug purchases. This information is available on FDA's 
website on
    In addition, the Agency actively participated in outreach 
activities including a two-day national workshop with the 
National Patient Safety Foundation to address the safe use of 
medical products from the consumer and patient perspectives. 
Held in March 2000, one of the goals of the meeting was to 
stimulate a national dialogue about safe medical treatment 
among consumer groups and health professional organizations. 
Following the meeting, CDER produced four videotaped 
presentations to be used during future public meetings about 
safe medical treatments. In May 2000, CDER provided an exhibit 
at the First National Conference of the American Society of 
Aging and the National Council of the American Association of 
Retired Persons in Orlando, Florida.
    Finally, CDER has prepared several brochures specifically 
for older Americans. Titles include: ``AgePage, Medicines: Use 
Them Safely,'' ``Reducing Your Risk of Heart Attack or Stroke 
with Aspirin Therapy: Know the Facts,'' and ``Be an Active 
Member of Your Health Care Team.''

             Postmarket Drug Surveillance and Epidemiology

    CDER's Office of Postmarketing Drug Risk Assessment is 
responsible for receiving, entering into a database, and 
analyzing reports sent to the Agency on adverse reactions to 
drugs. In 1999, there were approximately 261,000 reports 
entered into CDER's Adverse Event Reporting System. For 2000, 
the approximate number increased to 300,000. Reports 
representing patients aged 65 years or older numbered 54,000 
(21 percent of total for 1999) and 52,000 (17 percent of total 
for 2000). These percentages are similar to those reported in 
the past.

                           Geriatric Labeling

    On December 11, 1998, the Agency made public a draft 
publication entitled: ``Guidance for Industry on the Content 
and Format for Geriatric Labeling.'' This guidance discusses 
the following issues related to the submission of geriatric 
labeling: 1) who should submit revised labeling; 2) 
implementation dates; 3) description of the regulation and 
optional standard language in proposed labeling; 4) content and 
format for geriatric labeling; and 5) applicability of user 
fees to geriatric labeling supplements. Comments submitted to 
the proposed rule currently are being addressed by the Agency.

                             Generic Drugs

    During 1999-2000, FDA's Office of Generic Drugs approved 
699 abbreviated new drug applications. These drug products are 
often substantially less expensive and provide a safe and 
effective alternative to brand-name products. Many of these 
approvals represent the first time a generic drug was made 
available for products of special interest to older Americans 
such as doxazosin mesylate capsules used in the treatment of 
enlarged prostate and hypertension, paclitaxel injection used 
in the treatment of various ovarian and breast cancers, and 
digoxin tablets used in the treatment of heart failure. These 
and other recently approved generic drug products could save 
the American public and federal government millions of dollars. 
In July 1998 the Congressional Budget Office (CBO) published a 
report: How Increased Competition from Generic Drugs Has 
Affected Prices and Returns in the Pharmaceutical Industry. The 
CBO estimated that in 1994, purchasers saved between $8 billion 
to $10 billion on prescriptions at retail pharmacies by 
substituting generic drugs for their brand-name counterparts.

              Center for Food Safety and Applied Nutrition

    While the American food supply is among the safest in the 
world, there are still too many Americans stricken by illness 
every year caused by the food they consume, and some mostly the 
very young, elderly, and the immune compromised die every year 
as a result. The FDA's Center for Food Safety and Applied 
Nutrition (CFSAN) promotes and protects the public health and 
economic interest by striving to be a leader in food safety, 
protecting consumers from economic fraud, promoting sound 
nutrition, and encouraging innovation. The following programs 
and activities demonstrate the center's commitment to provide 
benefits for older Americans.

                CFSAN's Outreach and Information Center

    CFSAN's new Outreach and Information Center (O⁣) 
considerably expanded access and assistance to all consumers 
throughout the country, especially older consumers. Expanding 
coverage of the live toll-free Information Line, 1-888-SAFEFOOD 
(10:00-4:00) was particularly beneficial since a large 
proportion must rely on the telephone for information. Of the 
55,000 calls received, a majority were from older persons 
seeking information on a variety of food and cosmetic-related 
issues. With more now having access to computers, we have seen 
a steady increase in the number of older consumers requesting 
food safety information through CFSAN's electronic-mail system. 
However, we also responded to more that 2500 written letters, 
again a majority from older persons. Most notably, older 
consumers are the single largest group requesting FDA/CFSAN 
publications and other materials. The O⁣ and the Consumer 
Education Staff have developed workshops, served as presenters, 
provided materials and staffed exhibits at conferences 
throughout the country, with a particular focus on providing 
information to older consumers.

           Food Safety Campaign Aimed at Seniors is Launched

    ``To Your Health! Food Safety for Seniors'' is a new 
educational program developed by CFSAN's Food Safety Initiative 
staff and the U.S. Department of Agriculture's Food Safety and 
Inspection Service. The materials focus on seniors because they 
are one of the more susceptible populations for developing 
foodborne illness. And once they become sick, they face the 
risk of more serious health problems, even death.
    The 14-minute video and companion publication were designed 
in cooperation with a variety of senior advisors including 
representatives from the Administration on Aging, the State 
Units on Aging, and the National Institutes of Health. In 
format and design, the materials are tailored to seniors. The 
publication features large type to make easy reading for older 
eyes. The graphics are colorful and bold. The video contains 
portraits of other seniors. Through them, we learn about safe 
food handling at home and food safety when eating out. This 
program is not targeted to seniors who are living in nursing 
homes or assisted-living facilities where all meals are 
    A comprehensive, nationwide distribution plan is underway 
for the 550,000 publications and 47,000 videos produced. Health 
educators and program leaders at more than 10,000 senior 
centers; 5,000 county extension offices; 5,000 county health 
departments 1,000 area offices of aging; 50 state extension and 
health departments; as well as 50 national organizations 
representing seniors will be receiving the materials. FDA's 
Public Affairs Specialists will be complementing this 
distribution with their own outreach activities. Individual 
consumers can receive a free copy of the publication by 
contacting the Consumer Information Center in Pueblo, Colorado. 
A small supply of publications and videos are in stock. If you 
would  like a  copy of  the publication,  please  contact  
Laura Fox, FSI Education Team, at 202-260-0574; or by e-mail to 
[email protected] The video will shortly be on the CFSAN 

                    Program Priority Accomplishments

    The following is a listing of program priority 
accomplishments for CFSAN. Each of these accomplishments 
addresses an action taken by the Agency to enhance the lives of 
consumers while protecting the U.S. food supply and promoting 
public health. With an increase in the variety of foods and the 
number of convenience items that are currently available to 
consumers in the market place a number of public health 
concerns have evolved, especially for older Americans because 
of their greater susceptibility to illnesses. The 
accomplishments listed below will address some of those 
           Nutrition, Health Claims, and Labeling--
        CFSAN published a final rule authorizing a health claim 
        for soy protein and heart disease (21 CFR 101.82) on 
        October 26, 1999. CFSAN completed the evaluation of two 
        additional health claim petitions within statutory 
        timeframes. One petition was for sterol esters and 
        heart disease. The other was for stanol esters and 
        heart disease. The agency issued an interim final rule 
        authorizing these health claims on September 8, 2000 
        (65 FR 54686)(21 CFR 1010.83).
           Food Safety Report--In accordance with 
        Senate Report 106-80, in consultation with the U.S. 
        Department of Agriculture, prepared a report to 
        Congress on how to educate the public about the safety 
        of our food supply.
           Public Meeting--Held a public meeting in 
        Chicago, Illinois on July 21, 2000 to discuss the use 
        of term ``fresh'' in the labeling of foods processed 
        with alternative non-thermal technologies. The purpose 
        of this meeting was to solicit views on whether the use 
        of the term ``fresh'' is truthful and non-misleading on 
        foods processed with these alternative technologies and 
        on what type of criteria FDA should use when 
        considering the use of the term with future 
           Enforcement Procedures--CFSAN established 
        procedures to evaluate food label complaints and 
        respond to significant or precedent setting 
        discrepancies in food labeling.
           Safety Issues--Contracts were arranged with 
        the National Academy of Science's Institute of Medicine 
        to establish a scientific framework for assessing the 
        safety of dietary supplements, and to apply that 
        framework to several specific dietary supplement 
           Ephedra--Published three Federal Register 
        notices announcing the availability of new adverse 
        event reports and related information on dietary 
        supplements containing ephedrine alkaloids, and 
        announcing withdrawal of the provisions of the 
        ephedrine alkaloids proposed rule relating to the 
        dietary ingredient level and duration of use limit for 
        these products (65 FR 17474-17510; April 3, 2000). 
        Participated in a public meeting on August 8-9, 2000 
        sponsored by the Public Health Service, to discuss the 
        available information about the safety of dietary 
        supplements containing ephedrine alkaloids.
           Health Claim Regarding Fiber and Colorectal 
        Cancer--On October 10, 2000 issued a final 
        determination on a second of the four Pearson claims. 
        FDA determined that the proposed health claim about 
        dietary fiber and reduced risk of colorectal cancer 
        could not be authorized because the results of studies 
        about dietary fiber consistently showed a lack of 
        relationship between dietary fiber supplements and the 
        risk of colorectal cancer. Neither could the claim be 
        qualified because the suitable evidence against the 
        claim outweighed the evidence for it.
           Health Claim Regarding Omega-3 Fatty Acids 
        and Coronary Heart Disease--On October 31, 2000 issued 
        a final determination on the third of four Pearson 
        claims. FDA is using its enforcement discretion to 
        allow a qualified claim about the use of omega-3 fatty 
        acids in dietary supplements and the reduced risk of 
        coronary heart disease. The qualified claim applies to 
        daily intakes that do not exceed three grams per person 
        per day from conventional food and dietary supplement 
           Claims for Mitigation of Disease--Following 
        a public meeting on May 26, 2000 denied a petition 
        requesting authorization of a health claim concerning 
        the relationship between dietary supplements containing 
        saw palmetto and benign prostatic hyperplasia (BPH). 
        FDA's response noted that claims about effects on 
        existing diseases do not fall within the scope of the 
        health claim provisions of the Act and therefore may 
        not be the subject of an authorized health claim.
           Health Claim Petitions--CFSAN continues to 
        meet its statutory obligations for health claims for 
        dietary supplements. CFSAN denied, by operation of the 
        statue (on December 1, 1999) and formally on May 26, 
        2000 a health claim for saw palmetto extracts and 
        symptoms of BPH. CFSAN also denied on January 11, 2000 
        a petition for vitamin E and heart disease due to lack 
        of significant scientific agreement to support the 
           Dietary Supplement Strategic Plan--On 
        January 3, 2000 the Dietary Supplement Strategic Plan 
        was distributed to stakeholders and posted on the web 
        page. The plan establishes a clear program goal to 
        have, by the year 2010, a science-based regulatory 
        program that fully implements the Dietary Supplement 
        Health and Education Act of 1994, and that provides 
        consumers with a high level of confidence in the 
        safety, composition, and labeling of dietary 
        supplements products.
           Bottled Water Feasibility Study--Solicited 
        comments on the draft feasibility study in the Federal 
        register of February 22, 2000 (65 FR 8718) and 
        published in the Federal register of August 25, 2000 
        (65 FR 51833), a final report on the feasibility of 
        appropriate methods of informing customers of the 
        contents of bottled water, as required by the Safe 
        Drinking Water Act Amendments.
           Advisory Committee--A standing Dietary 
        Supplement Subcommittee was officially added to the 
        restructured Food Advisory Committee on June 26, 2000. 
        A request for membership nominees having the requisite 
        scientific expertise to serve on the new subcommittee 
        appeared in the Federal Register on July 28, 2000 (65 
        FR 46463).
           Biotechnology--On May 3, 2000 made a public 
        announcement on plans to strengthen the regulatory 
        approach for bioengineered foods. Three initiatives 
        were announced: (1) Development of a proposed rule 
        requiring that developers of bioengineered foods notify 
        the agency before they market such products; (2) the 
        addition of scientists to the Food Advisory Committee 
        that have expertise in biotechnology; and (3) the 
        development of labeling guidance to assist 
        manufacturers who wish to voluntarily label their foods 
        being made with or without the use of bioengineered 
           Food Allergens--Held meetings at 14 
        locations to raise consumer and industry awareness to 
        the presence of allergens in foods and on labeling 
        approaches to identify the presence of allergens.
           Food Safety Initiative--Completed 
        development of the survey instrument for the Food 
        Safety Consumer Survey Cycle IV. The survey is used to 
        monitor the impact of food safety initiatives and to 
        identify consumer education needs.
           Dietary Supplements--Communicated dietary 
        supplement enforcement policies and procedures to the 
        general public, FDA field offices, health care 
        professionals, and industry. The Agency met with 
        several organizations to share information concerning 
        dietary supplement enforcement policies and procedures.
           CFSAN--FDA & HHS Press Releases, Talk 
        Papers, Fact Sheets and Statements
                    7/1/99--New Egg Safety Steps Announced, 
                Safe Handling Labels and Refrigeration will be 
                    7/9/99--Consumers Advised of Risks 
                Associated with Raw Sprouts
                    7/10/99--FDA Issues Nationwide Health 
                Warning about Sun Orchard Unpasteurized Orange 
                Juice Brand products
                    10/1/99--FDA Issues Nationwide Public 
                Health Advisory about Contaminated Pet Chews
                    10/20/99--FDA Approves New Health Claim for 
                Soy Protein and Coronary Heart Disease
                    10/25/99--FDA Issues Guidance to Enhance 
                Safety of Sprouts
                    11/16/99--FDA Issues Warning About Sun 
                Orchard Fresh Squeezed Unpasteurized Orange 
                    11/19/99--Sun Orchard Adds an Additional 
                Production Code to its unpasteurized Orange 
                Juice Recalled Because of Possible Health Risk
                    12/23/99--Nationwide Recall of Certain 
                Royal Baltic Brand Smoked Fish Products Due to 
                Potential Health Risk
                    1/5/00--FDA Finalizes Rules for Claims on 
                Dietary Supplements
                    1/10/00--Royal Baltic expands Nationwide 
                Recall of Smoked Fish Products Due to Potential 
                Health Risk
                    1/27/00--FDA Issues Nationwide Warning on 
                Felix's, Trader Joe's, Delicioso, and the 
                Carryout Cafe Brands of 5 Layer Dip because of 
                Possible Health Risk
                    2/10/00--FDA Public Health Advisory: Risk 
                of Drug Interactions with St. John's Wort and 
                Indinavir and Other Drugs
                    5/26/00--FDA Advises Consumers About Fresh 
                Produce Safety
                    9/5/00--FDA Authorizes New Coronary Heart 
                Disease Health Claim for Plant Sterol and Plant 
                Stanol Esters
                    9/8/00--FDA Database of Foodborne Illness 
                Risk Factors Released
                    11/21/00--FDA Warns Against Consuming 
                Dietary Supplements Containing Tiratricol
                    11/24/00--FDA Announces Nationwide Recall 
                of Certain Soups Due to Potential Health Risk 
                From Botulism
                    11/30/00--FDA Finalizes Safe Handling 
                Labels and Refrigeration Requirements for 
                Marketing Shell Eggs


    CFSAN's website has an informational page entitled, 
``Seniors and Food Safety.'' This page gives a broad spectrum 
of information about foodborne illness, food preparation and 
storage and additional links for seniors. Also on CFSAN's 
website is another informational page entitled, ``Information 
for Women Over 65 Years Old.'' This site has links to 
information on food, nutrition, cosmetics, publications for 
older consumers, mammography and medications from the agency as 
well as links to other federal government agencies.

                     Center for Veterinary Medicine

    The FDA's Center for Veterinary Medicine (CVM) regulates 
the manufacture and distribution of food additives and drugs 
that will be given to animals. These include animals from which 
human foods are derived, as well as food additives and drugs 
for pet (or companion) animals. CVM is responsible for 
regulating drugs, devices, and food additives given to, or used 
on, over one hundred million companion animals, plus millions 
of poultry, cattle, swine, sheep, and minor animal species. 
(Minor animal species include animals other than cattle, swine, 
chickens, turkeys, horses, dogs, and cats.)
    Pets are very important to all people including the 
elderly. CVM has approved drugs that may make it easier for 
elderly to keep their pets. CVM approved two drugs to treat two 
different behavioral problems affecting some dogs--Clomicalm 
Tablets (clomipramine hydrochloride) to be used as part of a 
comprehensive behavioral management program for separation 
anxiety in dogs greater than six months of age, and Anipryl 
Tablets to control the clinical signs associated with canine 
Cognitive Dysfunction Syndrome (CDS).
    Separation anxiety is a complex behavior disorder displayed 
when the owner or someone the dog is attached to leaves the 
dog. Dogs with separation anxiety may exhibit one or more of 
the following symptoms: barking, destructive behavior, 
excessive salivation, and inappropriate elimination.
    Anipryl Tablets can control the clinical signs associated 
with CDS, an age-related deterioration typified by multiple 
cognitive impairments that affect the dog's ability to function 
normally. Behavioral changes associated with CDS include 
disorientation, decreased activity level, abnormal sleep wake 
cycles, loss of house training, decreased or altered 
responsiveness to family members, and decreased or altered 
greeting behavior.

                       Public Affairs Specialists

    Public Affairs Specialists (PASs) are located throughout 
the country in FDA field offices. PASs participate in diverse 
outreach activities to update and educate the Agency's 
stakeholders on a multitude of important public health issues. 
PASs also respond to consumer questions about the Agency, its 
authorities, activities, and the products it regulates.The 
Agency has established networks and communication channels to 
reach the national and local aging network with consumer-
oriented information. By working with a variety of external 
constituencies--consumers, patients, health professionals, 
academia and scientific organizations, industry, women's 
organizations, minority groups, and the international 
community--FDA is able to form the collaborations and 
cooperative arrangements to significantly extend its outreach 
to older consumers.
    PASs have conducted a variety of community-based programs 
in 1999-2000 to address the health concerns and information 
needs of older Americans. The Agency also exhibits at major 
annual meetings of national organizations, as well as at 
community events and local health fairs sponsored by grassroots 
organizations. The topics that were addressed by field 
programs, exhibits, training activities, and speeches were food 
labeling, food safety, safe use of medications, health fraud, 
clinical trials, dietary supplements, drug approval, food and 
drug interactions, and buying prescription drugs on the 
           PAS (San Juan, Puerto Rico) participated in 
        a day long health fair targeting older persons and 
        members of the AARP.
           PAS (Houston, Texas) participated in an 
        exhibit at the American Health Association ``Living 
        Longer-Living Well'' seminar. The event was designed to 
        guide women in taking wellness to heart by providing 
        health information on diet, stress reduction, 
        nutrition, and how disease affects the heart.
           PAS (San Francisco, California) worked with 
        the local hospitals to provide workshop materials for 
        its ``Senior Medication Awareness Training Program.''
           PAS (New Orleans, Louisiana) staffed an 
        exhibit at the ``4th Annual Mayor's Senior Summit.''
           PAS (New Orleans, Louisiana) participated in 
        a ``Community Resources Sharing Forum'' sponsored by 
        the New Orleans Elder Action Coalition. The purpose of 
        the forum was to bring together key community leaders 
        to share information, ongoing programs, concerns, and 
        ideas. The PAS prepared FDA information packages.
           PAS (Philadelphia, Pennsylvania) gave a 
        health fraud presentation to older Americans, older 
        American organizations, industry, and other federal 
           PAS (Denver, Colorado) gave a presentation 
        on FDA's role and responsibilities in drug approval to 
        older Americans at the ``Prescription for Your Future'' 
           PAS (Indianapolis, Indiana) gave a 
        presentation to a group of older Americans on FDA and 
        good nutrition for the elderly.
           PAS (New Orleans, Louisiana) gave a 
        presentation on prevention and treatments for 
        osteoporosis and arthritis.
           PAS (San Juan, Puerto Rico) gave a 
        presentation about the safe use of medications to a 
        group of retired consumers.
           PAS (Parisippany, New Jersey) participated 
        in the 7th and 8th Annual Congressional Senior Expo. 
        Congressman Bob Franks sponsored this event in the hope 
        of connecting senior citizens of Central New Jersey 
        with the organizations and programs designed to serve 
        them.PASs regularly speak with media representatives, 
        give interviews and provide background information for 
        newspaper, magazine, newsletters, and television and 
        radio reporters.
           PAS (Parisippany, New Jersey) worked with 
        the Glaucoma Foundation in developing an article on how 
        FDA reviews drugs and medical devices.
           PAS (San Francisco, California) conducted an 
        on-camera interview with a local NBC station on how to 
        spot health fraud, a part of a series covering 
        fraudulent products and the elderly.
           PAS (San Francisco, California) delivered a 
        food safety speech on the local Cable Network that 
        included information on microbiology, with a focus on 
        the four messages of the ``Fight BAC'' program.
           PAS (New Orleans, Louisiana) taped a 30-
        minute interview with the WSM Radio News Director on 
        the topics food safety for the holidays, drug 
        approvals, and stockpiling drugs.
    For the last three years, CFSAN in cooperation with FDA's 
Office of Regulatory Affairs has funded grassroots food safety 
education projects proposed by FDA PASs emphasizing:
           The Fight BAC! Campaign materials developed 
        by the Partnership for Food Safety Education;
           National Food Safety Education Month;
           Populations at severe risk from foodborne 
        illness (young children, older Americans, immuno-
        compromised individuals);
           People of low literacy or who primarily 
        speak languages other than English; and
           Safe handling and preparation of raw shell 
        eggs and egg dishes.
    The following projects geared toward older Americans were 
funded by CFSAN in cooperation with FDA's Office of Regulatory 
           Development of education packets on Listeria 
        monocytogenes for use in training health professionals 
        working with at-risk populations in New York;
           An island-wide campaign stressing egg safety 
        targeting at-risk populations, food service and retail 
        workers, and health professional in Puerto Rico;
           Food safety and food allergy workshops in 
        Pennsylvania and Delaware for hospital, nursing home, 
        day care centers, and church food prepares;
           Development and testing of methods for 
        improved communication of food recall and food safety 
        messages for at-risk populations;
           Expansion of the train-the-trainer volunteer 
        program for senior food safety education to cover the 
        entire state of Florida; and
           Food safety workshops for food preparers in 
        nursing homes, meals-on-wheels programs, and other 
        elderly nutrition sites in Douglas County, Wisconsin.


                             HCFA Projects

    Evaluation System for Medicare+Choice
    Prj #: 500-95-0047/06
    Start Date: 09/16/1998
    End Date: 09/15/2001
    Funding: $746,887
    Vehicle: Task Order
    PI: Lyle Nelson, Ph.D.
    Awardee: Mathematica Policy Research, Inc.
    PO: Brigid Goody, Sc.D
    Description: The Balanced Budget Act of 1997 (P.L. 105-33) 
makes several changes that affect the eligibility criteria for 
and payment to health plans contracting with HCFA to provide 
services to Medicare beneficiaries. The concurrent 
implementation of several initiatives could have unintended 
effects on the managed care choices available to Medicare 
beneficiaries, as well as on the additional benefits provided 
to beneficiaries and on the quality of care delivered to 
beneficiaries enrolled in health plans. The purpose of this 
task order is to design and implement a strategy for tracking 
and evaluating managed care performance both nationwide and 
within specific markets across the country during the 
implementation of the Medicare+Choice provisions. Dimensions of 
performance to be tracked include beneficiary access to managed 
care options, as well as the cost and quality of services 
delivered to beneficiaries by managed care organizations.
    Status: Data preparation and analyses are ongoing. The 
contractor has prepared exploratory case studies of 12 markets 
and an interim report containing information on 69 markets 
representing 74 percent of Medicare managed care enrollees. 
Dimensions of performance included in these reports are the 
availability of Medicare managed care organizations, enrollment 
and disenrollment, and the variation and generosity of benefit 
offerings. The principal findings of these preliminary analyses 
indicate that early experience under varies substantially 
across markets, especially with respect to contract nonrenewals 
and the availability and generosity of prescription drug 
benefits. Future analyses will include additional years' data 
and expand the dimensions of performance to include access and 
quality, provider behavior, and financial viability.
    Next Generation Medicare Managed Care Payment System
    Prj #: 500-00-0025/01
    Start Date: 09/30/2000
    End Date: 04/28/2002
    Funding: $635,897
    Vehicle: Task Order Contract
    PI: Stuart Gutterman
    Awardee: Urban Institute, The
    PO: Leslie M. Greenwald, Ph.D.
    Description: The purpose of this project is to design a 
possible next generation payment methodology--currently called 
the Direct Model--for the Medicare+Choice program. This study 
will prepare a conceptual paper that describes and 
operationalizes HCFA's proposed general approach. As of January 
1, 2000, 10 percent of Medicare+Choice plans total capitated 
payments are based on the Principle In-Patient Diagnostic Cost 
Group (PIP-DCG) risk adjustment methodology. Future years will 
see an increase in the proportion of payments based on risk 
adjustment, with a comprehensive risk adjustment methodology 
due to take effect in January 2004. The movement of the 
Medicare+Choice program towards increased emphasis on health 
status risk adjusted payments--though an improvement over 
current demographic adjusted payments in terms of potential 
accuracy and ability to address selection bias--still has a 
significant drawback: it is based on FFS practice patterns and 
costs. Two possible steps could be taken to separate Medicare 
managed care payments from their traditional fee-for-service 
basis. The first could be considered an interim approach, and 
would address the problem of basing managed care payment on FFS 
practice patterns. If a full encounter data model were 
implemented, and if a complete set of data were mandated 
(sufficient to support recalibration), risk adjuster weights 
could be re-estimated using managed care encounter data (rather 
than the FFS data used in the models development). In this way, 
risk score weights and resulting predicted payments would 
reflect actual managed care practice patterns instead of FFS 
practice patterns. The remaining residual of FFS in the 
approach would be FFS prices, which would be assigned to the 
managed care encounter data in the absence of reliable 
information on actual managed care costs. In the longer term, 
HCFA could move to what could be called a direct payment model. 
Under this direct model, managed care payments would move away 
(all or in part) from their current county FFS basis. In this 
direct payment approach, risk adjustment models could be 
calibrated using either a combination of fee-for-service and 
managed care encounter data, or managed care data alone. But 
rather than converting enrollee expenditure estimates from risk 
adjustment methodologies to a risk adjustment factor (i.e. 
figures such as 1.05, indicating the estimated expenditures of 
an individual relative to others), the risk adjustment model 
would simply predict expected expenditures for that individual. 
Then, this risk based estimated expenditure (inflated to the 
payment year from the model calibration year) would be 
multiplied by a geographic price index to adjust for local 
price differences. In all likelihood, these price indexes would 
continue to be based on prices observed in fee-for-service. It 
might be possible however, in the future, to estimate both the 
risk adjusted estimated expenditures and price indexes based on 
costs/prices observed in managed care (or a combination of 
managed care and fee-for-service). These concepts, however, are 
not possible to implement today, when actual costs for managed 
care services are all but unknown, and most national health 
specific price indexes are considered weak. This model presumes 
that the risk adjuster method would account sufficiently for 
practice pattern variability. In addition, this change would 
require agreement on the extent of parity between Medicare's 
expenditures for beneficiaries enrolled in fee-for-service 
versus managed care. This direct model could be summarized as 
follows: Direct payment (Individuals Risk Based Estimated 
Expenditures) x (Geographic Price Input). This possible future 
approach for Medicare may seem extreme at first glance. But 
because BBA had mandated that county rates by blended with a 
national rate, there is already a move toward national pricing. 
The direct model is perhaps a logical extension of this policy.
    Status: In progress.
    Survey of Medicare Beneficiaries Who Were Involuntarily 
Disenrolled from HMOs that Withdrew from Medicare or Reduced 
their Service Areas
    Prj #: 500-95-0061/10
    Start Date: 09/30/2000
    End Date: 02/28/2002
    Funding: $470,000
    Vehicle: Task Order
    PI: Bridget Booske
    Awardee: University of Wisconsin--Madison/Research Triangle 
    PO: Gerald Riley
    Description: In January 1999 and January 2000 about 100 
HMOs withdrew from the Medicare program or reduced their 
service areas. Over 300,000 Medicare beneficiaries were 
disenrolled involuntarily each year, and had to enroll in 
another HMO or go to fee-for-service (FFS). Many of these 
disenrollees did not have another managed care plan available 
to them. These beneficiaries had no choice but to go to FFS. 
Most HMOs that participate in Medicare offer additional 
benefits outside the regular Medicare benefit package. Extra 
benefits commonly include low copayments, prescription drugs, 
unlimited hospitalization, and preventive services. Many 
beneficiaries have come to rely on the extra benefits they 
receive from their HMO, particularly prescription drugs. 
Replacing the benefits through Medigap insurance is usually 
very expensive, and may be unaffordable for some. Joining 
another HMO or going to FFS may also force many beneficiaries 
to change doctors, creating dissatisfaction and disrupting 
existing patterns of care. There has therefore been concern 
among policymakers about the impact of the recent HMO 
withdrawals on the beneficiary population. There have been two 
efforts to assess the impact of the January 1999 withdrawals 
and service area reductions on beneficiaries. The first, based 
on survey results indicated that although most disenrollees 
fared relatively well after their HMO withdrew from Medicare, 
many experienced a reduction in supplemental benefits, an 
increase in premiums, and/or disruption in their care 
arrangements (Kaiser Family Foundation, 1999). Problems were 
disproportionately experienced by disabled beneficiaries, 
racial and ethnic minorities, the poor and near-poor, and those 
reporting fair or poor health. The second effort covered 
enrollee notification; information and assistance in exploring 
new insurance options; what option beneficiaries selected; 
changes in benefits and costs; problems encountered; and 
satisfaction. HCFA anticipates that additional withdrawals may 
occur in 2001 and subsequent years. It is desirable to know the 
impact on beneficiaries if a significant number of additional 
withdrawals occurs in 2001. In this project we will mount a 
survey that asks about the experience of beneficiaries whose 
plans withdraw from Medicare or reduce their service areas in 
January, 2001. A draft survey instrument has been developed. 
This project will: finalize the instrument; develop an OMB 
clearance package; identify an appropriate sample from Medicare 
administrative records; administer the survey; edit and clean 
the data; analyze the survey responses; prepare a final report; 
prepare and deliver a clean data file to HCFA for use in 
further analyses. Beneficiaries will be asked what insurance 
arrangements they made after their plan withdrew from Medicare 
or reduced its service area; how their benefits and out of 
pocket costs were affected by new arrangements necessitated by 
their plan's withdrawal; and whether they had to change 
doctors. The universe from which the survey sample will be 
drawn is the Medicare population enrolled in managed care plans 
that either terminate their risk contracts or reduce their 
service areas in January, 2001. In the case of plans that 
reduce their service areas, enrollees that live in areas from 
which the plan withdraws will be eligible for the survey. The 
survey sample must be drawn from 2 strata: persons who live in 
geographic areas where at least one managed care plan is still 
available under Medicare after January, 2001; and areas where 
no Medicare managed care plans are available after January, 
2001. Approximately 1,500 completed surveys must be produced 
for each stratum. The survey must be conducted by mail with 
telephone followup, and will consist of 20-30 questions.
    Status: Research Triangle Institute is performing the work 
under this task order with over 90 percent of the funds 
assigned to their subcontract.
    Updating the Johns Hopkins University ACG/ADG Risk 
Adjustment Methods for Medicare Contracting
    Prj #: 500-00-0060
    Start Date: 09/29/2000
    End Date: 03/31/2001
    Funding: $272,902
    Vehicle: Contract
    PI: Jonathan Weiner
    Awardee: Johns Hopkins University, School of Public Health
    PO: Jesse Levy
    Description: This contract will allow HCFA to better assess 
and evaluate the Johns Hopkins University ACG/ADG model as an 
option for a potential Medicare+Choice payment system. Johns 
Hopkins will revise, extend and recalibrate the ADG/ACG model 
using recent Medicare data. They will provide HCFA with the 
updated software and a recalibration. Earlier work by Johns 
Hopkins for HCFA updated the ACG/ADG Risk Adjustment Method for 
application to Medicare risk contracting. In that project, 
Hopkins developed two diagnosis-based risk adjustor models. 
Work on these alternatives to the then existing demographic-
only risk adjustment models was concluded in 1996. In further 
work entitled AApplying JHU ACG/ADG Risk Adjustment Methods to 
Medicare Risk Contracting, Johns Hopkins further developed 
their model for Medicare purposes. This concluded in early 
    Status: This project is getting underway.
    Applying the Clinically Detailed Risk Information System 
for Cost (CD-RISC) to Medicare+Choice Payments
    Prj #: 500-95-0056/12
    Start Date: 09/29/2000
    End Date: 09/12/2001
    Funding: $245,934
    Vehicle: Task Order
    PI: Emmitt Keeler
    Awardee: RAND Corporation, The
    PO: John Robst
    Description: This project will provide technical consulting 
and analytic services to assess and evaluate the Clinically 
Detailed Risk Information System for Cost (CD-RISC) model as an 
option for a potential Medicare+Choice payment system. The 
project will calibrate the CD-RISC model on Medicare dataCwhich 
may involve the need to make adjustments to the model as it 
currently stands--and provide HCFA with the up to date software 
and calibration. During earlier work funded by HCFA CD-RISC was 
developed to potentially apply to capitation payments for the 
under-65 population. This model has not yet been calibrated or 
tested on Medicare beneficiaries and expenditures. In response 
to our mandate from the Balanced Budget Act of 1997, HCFA has 
implemented a risk adjustment method for Medicare+Choice 
payments. That method relies on inpatient data only. For a 
number of reasons, we believe methods that draw upon data from 
outpatient care delivery sites as well as inpatient sites are 
preferable to this model. We have announced that we plan to 
implement a model that draws upon diagnoses from multiple sites 
of care in 2004. We are now in the process of evaluating 
different candidates among the models that have been developed 
to see which ones perform the best. To make sure we have 
sufficient choices available, we are funding further 
development of contending models this one included.
    Status: In progress.
    Evaluation of the Competitive Pricing Demonstration--Phase 
    Prj #: 500-95-0048/07
    Start Date: 06/30/1999
    End Date: 08/29/2001
    Funding: $458,288
    Vehicle: Task Order
    PI: Gregory C. Pope & Steven Garfinkel (RTI)
    Awardee: Health Economics Research, Inc.
    PO: Brigid Goody, Sc.D
    Description: Section 4011 of the Balanced Budget Act of 
1997, which establishes authority for HCFA to test competitive 
pricing for Medicare+Choice organizations mandates that 
``...the Secretary shall closely monitor and measure the impact 
of the project on the price and quality of, and access to, 
Medicare covered services, choice of health plans, changes in 
enrollment, and other relevant factors.'' The purpose of this 
phase of the evaluation of the Competitive Pricing 
Demonstration is to provide HCFA with timely feedback on the 
implementation and operational experience of each demonstration 
site. A case study methodology will be used to develop both 
qualitative and quantitative information required to assess the 
strengths and weaknesses of the demonstration. The types of 
questions to be answered during this phase include:
          How was the bidding process implemented?
          How did the plans react to the process?
          Can the process be improved?
          How smoothly was the demonstration implemented in 
        each site?
          Were there operational problems for each of the 
        stakeholders and, if so, how were they resolved?
          How effective were the Area Advisory Committees in 
        their responsibilities to advise on implementation 
        issues? What lessons were learned that could ease 
        implementation in other sites or on a nationwide basis?
    Status: The contractor is currently completing a case study 
of the advisory committee process. Since the implementation of 
the demonstration has been delayed until January 2002, further 
evaluation activities are being delayed. This delay will force 
a change in this contract.
    Evaluation of the Medical Savings Account Demonstration
    Prj #:500-95-0057/06
    Start Date: 09/28/1998
    End Date: 09/27/2003
    Funding: $6,546,119
    Vehicle: Task Order
    PI: Ken Cahill
    Awardee: Barents Group, LLC/Westat
    PO: Renee Mentnech
    Description: This project evaluates the Medical Savings 
Account (MSA) Demonstration. It compares the experience of MSA 
enrollees with other Medicare beneficiaries. The contractor 
will also act as a coordinator between HCFA and the 
demonstration participants, including beneficiaries and health 
plans, in order to ensure that accurate, reliable, and complete 
data are collected.
    Status: In progress.
    Evaluation of the Medicare Choice Demonstration
    Prj #:500-92-0011/06
    Start Date: 09/01/1995
    End Date: 09/30/2000
    Funding: $1,591,240
    Vehicle: Delivery Order
    PI: Lyle Nelson, Ph.D.
    Awardee: Mathematica Policy Research, Inc.
    PO: Renee Mentnech
    Description: HCFA is in the process of implementing the 
Medicare Choices Demonstration to test the feasibility and 
desirability of new types of managed care plans for Medicare 
such as integrated delivery systems and preferred provider 
organizations. This evaluation project provides a detailed 
assessment of the overall demonstration project, which looks 
specifically at beneficiary experiences in the demonstration, 
cost and use of services within the demonstration sites, and 
quality of care issues. The evaluation provides some insights 
into whether the greater range of managed care options offered 
in this demonstration would be more appealing to the Medicare 
beneficiaries, and whether issues such as biased selection, 
high rates of disenrollment, and dissatisfaction exist. In 
addition, the evaluation project provides continuous monitoring 
of the demonstration sites, including a comprehensive case 
study of each of the managed care plans in the demonstration. 
This part of the evaluation activities focuses on the 
implementation experience and operational feasibility of the 
new managed care plans, as well as how plans interact with 
carriers and HCFA.
    Status: The contractor has completed site visits to assess 
the implementation difficulties the plans have encountered. The 
first and second interim implementation reports are available. 
A survey of plan enrollees and a fee-for-service comparison 
group has also been completed. The survey focuses on reasons 
for enrolling and disenrolling, enrollees' understanding of 
their plans, and the enrollees' perceptions of access, quality, 
and satisfaction. A final report is expected in the summer of 
    Department of Defense Subvention Demonstration Evaluation
    Prj #:500-95-0056/06
    Start Date: 09/03/1998
    End Date: 03/02/2002
    Funding: $1,411,439
    Vehicle: Task Order
    PI: Dana Goldman, Ph.D.
    Awardee: RAND Corporation, The
    PO: Leslie M. Greenwald, Ph.D.
    Description: Under the demonstration, enrollment in the 
Department of Defense's (DoD) Senior Prime plan is offered to 
military retirees over age 65 who live within 40 miles of the 
primary care facilities of one of the six sites, have recently 
used military health facility services, and are enrolled in 
Medicare Part B. The Senior Prime plans must meet all relevant 
requirements for Medicare+Choice plans. Medicare makes a 
capitation payment to DoD for each enrollee, and DoD must 
maintain a level of effort for health care services to all 
retirees who are also Medicare beneficiaries, whether or not 
they choose to enroll, that is based on fiscal year 1996 DoD 
experience. The evaluation seeks to answer the basic question: 
can DoD and Medicare implement a cost-effective alternative for 
delivering accessible and quality care to military-Medicare-
eligible beneficiaries? The evaluation will seek the answer by 
examining issues in four basic areas:
          Enrollment demand.
          Enrollee benefits.
          Cost of the program.
          Impacts on other DoD and Medicare beneficiaries.
    RAND is conducting a process evaluation and a quantitative 
analysis for the demonstration sites and a set of control 
    Status: The final report from the evaluation was delivered 
in April 1999. It is available from the National Technical 
Information Service (NTIS) (accession number PB 99 149056). The 
Interim Report conveying results of the process evaluation of 
the demonstration start-up period was delivered in July 1999.
    Second Generation of Social Health Maintenance Organization 
    Period: November 1996 Extended 30 months after the Report 
to Congress is submitted.
    Funding: Waiver-only.
    Grantees: See below.
    Description: In accordance with section 2344 of Public Law 
98-369, the concept of a social health maintenance organization 
(S/HMO) integrates health and social services under the direct 
financial management of the provider of services. All acute- 
and long-term-care services are provided by or through the S/
HMO at a fixed, annual, prepaid capitation sum. The Omnibus 
Budget Reconciliation Act (BBA) of 1990 authorized the 
expansion of the S/HMO demonstration. The purpose of this 
second generation S/HMO (S/HMO-II) demonstration is to refine 
the targeting and financing methodologies and the benefit 
design of the current S/HMO model. The S/HMO-II model also 
provided an opportunity to test more geriatrically-oriented 
models of care. Six organizations in the project were selected 
to participate. Only one plan is operational, The Health Plan 
of Nevada. The Balanced Budget and Refinement Act of 1999 
extended the demonstration until 18 months after the submission 
of the SHMO transition Report to Congress. The Benefits 
Improvement and Protection Act of 2000 further extended the 
demonstration another 12 months, for a total of 30 months after 
the submission of the SHMO transition Report to Congress.
    Grantee: Health Plan of Nevada, Inc., P.O. Box 15645, Las 
Vegas, NV 89114.
    Period: September 1995-December 2001
    Funding: $1,811,184
    Contractor: Abt Associates Inc, 55 Wheeler Street, 
Cambridge, MA 02138
    Investigator: Henry Goldberg
    Site Development and Technical Assistance for the Second 
Generation Social Health Maintenance Organization Demonstration
    Prj #:500-93-0033
    Start Date: 09/27/1993
    End Date: 12/30/2000
    Funding: $2,251,123
    Vehicle: Contract
    PI: Robert L. Kane, M.D.
    Awardee: University of Minnesota, School of Public Health, 
Institute for Health Services Research
    PO: Thomas Theis
    Description: In January 1995, HCFA selected six 
organizations to participate in the Second Generation Social 
Health Maintenance Organization (S/HMO) Demonstration. The 
purpose of this project is to study the impact of integrating 
acute and long-term care services within a capitated managed 
care system. It was developed to refine the targeting and 
financing methodologies and the benefit design of the current 
S/HMO model, which was initiated as a demonstration in 1985. 
Although similar services are provided under both of these 
demonstrations, the Second Generation S/HMO Demonstration 
features a greater emphasis on geriatric care and a more 
inclusive case-management system. Another distinguishing 
characteristic of the project is its risk-adjusted payment 
methodology that is based on an individual's health status and 
functioning level. The primary focus of the project's 
evaluation will be to compare beneficiaries enrolled in the 
demonstration with beneficiaries in a section 1876 HMO program. 
The University of Minnesota and its subcontractor, the 
University of California at San Francisco, are providing 
technical assistance and support in the development, 
implementation, and operation of the Second Generation S/HMO 
    Status: The developmental phase of the Second Generation S/
HMO Demonstration began in January 1995. Since that time the 
University of Minnesota and the University of California at San 
Francisco have been providing technical assistance to the 
organizations participating in the project. They have also 
developed a questionnaire that is being used to determine a 
beneficiary's capitated payment rate, a series of geriatric 
protocols is being used to help physicians identify and treat 
certain health conditions, and a care coordination assessment 
instrument is being used to assist case managers with care 
planning. These technical assistance contractors have made site 
visits during this time to review the progress of the S/HMO 
site. They are also assisting a contractor in preparing a S/HMO 
Transition Report to Congress. The Health Plan of Nevada (HPN) 
began enrolling beneficiaries in the demonstration in November 
1996. HPN enrollment at the end of 1999 was over 35,000 
    Second Generation Social Health Maintenance Organization 
Demonstration: Florida
    Prj #:99-C-90874/4
    Start Date: 05/01/1998
    End Date: 06/30/2000
    Funding: $150,000
    Vehicle: Cooperative Agreement
    PI: Charlie Liem
    Awardee: Florida Department of Elder Affairs
    PO: James Hawthorne
    Description: This Cooperative Agreement provides the 
Florida State Department of Elder Affairs (DEA) with funds to 
purchase technical assistance and to support planning 
activities for a second generation social HMO. The goal of this 
project is to study the feasibility of implementing a Second 
Generation Social HMO in Florida and, should this prove 
feasible, to develop the specifications needed for the State to 
issue an RFP.
    Status: Department of Elder Affairs staff are taking the 
lead in coordinating planning activities and have assembled a 
task force comprised of consumers, providers, and 
representatives from the Maryland State Department of Health 
and Mental Hygiene to guide the planning process. They have 
obtained Medicare and Medicaid claims data and are linking 
these data in an effort to devise a rate-setting mechanism that 
will work for plans that enroll a disproportionate share of 
frail elderly.
    Second Generation Social Health Maintenance Organization 
Demonstration: Maryland
    Prj #:99-C-90868/3
    Start Date: 04/30/1999
    End Date: 06/30/2000
    Funding: $109,211
    Vehicle: Cooperative Agreement
    PI: Martin Wasserman, MD
    Awardee: Maryland Department of Health and Mental Hygiene
    PO: James Hawthorne
    Description: This Cooperative Agreement provides the 
Maryland State Department of Health and Mental Hygiene (DHMH) 
with funds to purchase technical assistance and to support 
planning activities for a second generation social HMO. The 
state has sub-contracted this work to the Center for Health 
Plan Development and Management (CHPDM) at the University of 
Maryland in Baltimore County. The goal of this project is to 
study the feasibility of implementing a Second Generation 
Social HMO in Maryland and, should this prove feasible, to 
develop the specifications needed for the State to issue an 
    Status: The State has hired staff to coordinate planning 
activities and has assembled a task force comprised of 
consumers, providers, and representatives from the Department 
of Health and Mental Hygiene to guide the planning process. 
They have obtained Medicare and Medicaid claims data and are 
linking these data in an effort to devise a rate-setting 
mechanism that will work for plans that enroll a 
disproportionate share of frail elderly.
    Evaluation of the Evercare Demonstration Program
    Prj #:500-96-0008/02
    Start Date: 09/26/1997
    End Date: 03/25/2001
    Funding: $1,544,142
    Vehicle: Task Order
    PI: Robert L. Kane, M.D.
    Awardee: University of Minnesota
    PO: Leslie M. Greenwald, Ph.D.
    Description: For each EverCare site, of which there are 
five, two comparison groups will be selected--nonparticipating 
residents in EverCare site nursing homes and residents in 
nonparticipating nursing homes operating in EverCare 
demonstration cities.
    Status: Site visits have been made to EverCare and non-
EverCare facilities in each of the participating sites. The 
information gathered was developed into a paper that has been 
submitted to the gerontologist for review.
    Age Well Option (now referred to as TLC)
    Prj #:18-P-90748/1
    Start Date: 05/01/1997
    End Date: 04/30/2002
    Funding: $600,000
    Vehicle: Grant
    PI: Lewis A. Lipsitz, M.D.
    Awardee: Hebrew Rehabilitation Center for the Aged
    PO: Renee Mentnech
    Description: Community care and educational protocols are 
used to test the hypothesis that clients can be educated and 
empowered to more actively participate in their own health care 
planning, decisionmaking, and chronic disease management. The 
populations studied are individuals living in the Hebrew 
Rehabilitation Center for the Aged and those living in 
subsidized housing in the Boston community. Educational 
protocols are used to test the hypothesis that clients can be 
educated and empowered to more actively participate in their 
own health care planning, decisionmaking, and chronic disease 
    Status: In progress.
    On Lok's Risk-Based Community Care Organization for 
Dependent Adults: On Lok Senior Health Services
    Period: November 1983-Indefinite
    Funding: Waiver only
    Grantee: On Lok Senior Health Services, 1333 Bush Street, 
San Francisco, CA 94109 and California Department of Health 
Services, 714-744 P Street, P.O. Box 942732, San Francisco, CA 
    Description::As mandated by sections 603(c) (1) and (2) of 
Public Law 98-21, the Health Care Financing Administration 
granted Medicare waivers to On Lok SeniorHealth Services and 
Medicaid waivers to the California Department of Health 
Services. Together, these waivers permitted On Lok to implement 
an at-risk, capitated payment demonstration in which more than 
300 frail elderly persons, certified by the California 
Department of Health Services for institutionalization in a 
skilled nursing facility, are provided a comprehensive array of 
health and health-related services in the community. The 
current demonstration maintains On Lok's comprehensive 
community-based program but has modified its financial base and 
reimbursement mechanism. All services are paid for by a 
predetermined capitated rate from both the Medicare and 
Medicaid (Medi-Cal) programs. The Medicare rate is based on the 
average per capita cost for the San Francisco county Medicare 
population. The Medi-Cal rate is based on the State's 
computation of current costs for similar Medi-Cal recipients, 
using the formula for prepaid health plans. Individual 
participants may be required to make copayments, spenddown 
income, or divest assets based on their financial status and 
eligibility for either or both programs. On Lok has accepted 
total risk beyond the capitated rates of both Medicare and 
Medi-Cal. The demonstration provides service funding only under 
the waivers. Research and development activities are funded 
through private foundations.
    Section 9220 of Public Law 99-272 extended On Lok's Risk-
Based Community Care organization for Dependent Adults 
indefinitely, subject to the terms and conditions in effect as 
of July 1, 1985, with the exception of the requirements 
relating to data collection and evaluation. On Lok is continued 
to collaborative projects with other organizations in the San 
Francisco Bay area. A pilot agreement with the Institute on 
Aging (IOA) was completed and the two organizations have 
entered into a venture agreement in which IOA established an 
adult day health center, operating it under the rules of the 
program of All-Inclusive Care for the Elderly (PACE) protocol. 
The site is in the Richmond area of San Francisco. On Lok 
provides quality assurance oversight as well as marketing and 
enrollment support. IOA receives a portion of On Lok's 
capitation via the HCFA demonstration and a portion is retained 
by On Lok to cover administrative expenses. The Balanced Budget 
Act of 1997 authorized coverage of PACE under the Medicare 
program. Under the Benefits Improvement and Protection Act of 
2000, this demonstration has until November 24, 2002 to 
transition to operational
    Status:. This date can be extended one year as a State 
    Evaluation of the Program of All-Inclusive Care for the 
Elderly (PACE)
    Prj #:500-96-0003/04
    Start Date: 04/23/1997
    End Date: 06/30/2000
    Funding: $238,917
    Vehicle: Task Order
    PI: David Kidder, Ph.D.
    Awardee: Abt Associates, Inc.
    PO: Frederick G. Thomas, III, CPA, MS, MBA
    Description: The Evaluation of the Program of All-inclusive 
Care for the Elderly (PACE) consists of both qualitative and 
quantitative components. The purpose of the qualitative 
component is to examine, in detail, the structure and process 
of case management as well as to gain a better understanding of 
the factors that drive interdisciplinary team decisionmaking in 
the PACE model. Since enrollment in PACE has been lower than 
originally expected, except for On Lok, the first part of the 
quantitative part of the evaluation of PACE is examining the 
decision to participate in PACE. This is particularly important 
given the anomaly of under-enrollment in virtually all long-
term care alternatives, as well as the policy interest in 
encouraging increased use of managed care. In the evaluation, 
the process by which people come to participate in PACE is 
modeled. The ``refusers,'' or those who apply to PACE and pass 
the initial screening eligibility criteria but do not actually 
enroll in the program, serve as the comparison group for the 
evaluation of the impact of PACE. The impact evaluation of PACE 
is addressing a broad range of questions including:
          Does the government spend less on PACE clients than 
        it would have spent on them in the absence of PACE?
          Does the PACE program spend no more on PACE clients 
        than the capitation amount?
          Does PACE alter the mix of services provided?
          Does the quality of life and satisfaction with 
        services increase for participants and family members?
          Does PACE impact the presence and amount of formal 
        in-home care, formal care outside the home, informal 
        in-home care and informal care outside the home?
          How does PACE affect the health status and functional 
        status of PACE participants?
    Status: All of the data collection for this project has 
been completed and the contractor is analyzing the impact of 
PACE on Medicare costs. A final report, entitled ``The Impact 
of PACE on Participant Outcomes,'' has been received. Briefly, 
this study found that compared to the comparison group:
          PACE enrollees had much lower rates of nursing home 
        and inpatient hospital utilization, and higher rates of 
        ambulatory care.
          PACE enrollees reported better health status and 
        quality of life.
          PACE participants had lower mortality rates.
    The benefits of PACE appeared to be magnified for those 
participants with high levels of physical impairment. Work 
continues on the study of the cost effectiveness of PACE.
    Actuarial Assessment of PACE Enrollment Characteristics in 
Developing Capitated Payments
    Prj #:500-95-0061/09
    Start Date: 09/30/2000
    End Date:
    Funding: $120,460
    Vehicle: Task Order
    PI: James Robertson
    Awardee: University of Wisconsin--Madison/Research Triangle 
    PO: Frederick G. Thomas, III, CPA, MS, MBA
    Description: The purpose of this is to investigate the 
impact of a number of the Program for All-Inclusive Care for 
the Elderly (PACE) specific issues on financial risk and 
payments and then to formulate alternative payment options, 
which would result in a reasonable approach for Medicare 
payments to PACE. The BBA requires the PACE program to be paid 
using the risk adjustment method developed for Medicare+Choice 
programs, but adjusted for factors specific to the PACE 
program. PACE is expected to differ from M+C plans in a number 
of attributes: enrollment size, group bias, dual Medicaid 
capitation, and mortality rates. An actuarial assessment is 
needed to explore the risk characteristics related with these 
factors and to formulate options that use this information in a 
capitated payment system. The project will explore the 
following issues related to PACE payments: (1) The Problem of 
Small Numbers--The volatility of a PACE site's average actual 
Medicare service costs for a period depends upon the site's 
census. Enrollment size could influence: (a) setting the 
minimally viable number of PACE organizations in a geographic 
area, (b) setting the minimum enrollment size for a viable PACE 
site, and (c) establishing financial reserve requirements, 
which may be considered by licensing agencies in assessing 
financial viability. Large sites should exhibit more stable 
per-member-per-month costs from period to period than smaller 
sites. So, all else being equal, smaller sites will be more 
likely than large sites to experience significant strains on 
their financial status. In the insurance industry, this 
exposure is managed through reinsurance agreements or minimum 
surplus requirements. The actuarial topic of ruin theory may be 
applied to determine the formula for the minimum surplus level 
to assure that the probability of a site's financial ruin is 
less than some maximum tolerance. (2) Biased Groups--Related to 
the problem of small numbers, PACE organizations enroll an 
inherently biased group of beneficiaries. Available studies 
suggest that PACE enrollees are sicker, frailer, and more 
costly than the average Medicare beneficiary is. It is not 
clear whether these higher costs are driven by enrollment into 
PACE after a precipitating event, or if these costs are ongoing 
as a result of enrolling patients with chronic/persistent 
illnesses. Either bias would likely act to increase the 
financial risk assumed by PACE organizations particularly in 
light of the assumption of a random draw in Medicare+Choice, 
where payment is based on the average. However, the rate 
setting implications are different. If PACE is enrolling 
beneficiaries at a high point their expenditure pattern, then 
remaining expenditures prior to enrollment could overstate 
average costs. On the other hand, paying average cost will 
underpay given the lingering effects of the precipitating event 
and higher costs in the last year of life. What is the most 
appropriate Arisk adjuster or other method of modifying 
capitation rates to account for these biases? (3) Medicaid 
Capitation--Ignoring the adequacy of the Medicaid rates, does a 
jointly capitated payment model reduce the financial risk to a 
PACE organization? This could occur if services provided by 
Medicare result in lower Medicaid costs. (4) Higher Mortality--
PACE organizations have experienced higher mortality rates, 
estimated at roughly 20 percent per year. A prospective model 
is used in Medicare+Choice payments; however, the mortality is 
much lower, estimated at 3 percent. If a prospective risk 
adjustment model is used, payments will be adjusted in 
subsequent years only on living enrollees. Given the 
differential rates in mortality, would a prospective payment 
model adjusted for higher mortality result in lower financial 
risk to a PACE organization?
    Status: Payments for medical services furnished by PACE 
organizations are fully capitated by Medicare and Medicaid. A 
variant of this capitated approach is used by Medicare to pay 
Medicare+Choice organizations, which generally have much larger 
numbers of Medicare participants than PACE organizations. 
Because of their unique niche, total reliance on capitated 
payments (Medicare and Medicaid), lower enrollee levels, and 
higher mortality rates, PACE organizations may have a higher 
level of financial risk than Medicare+Choice plans. In order to 
assess the potential risk elements as well as to help determine 
implications for policy purposes, an actuarial evaluation and 
assessment of payment rates for PACE will be performed under 
this project. Available studies suggest that PACE enrollees are 
sicker, frailer, and more costly than the average Medicare 
beneficiary. It is not clear whether these higher costs are 
driven by enrollment into PACE after a precipitating event, or 
if these costs are ongoing as a result of enrolling patients 
with chronic/persistent illnesses. Either bias would likely act 
to increase the financial risk assumed by PACE organizations 
particularly in light of the assumption of a random draw in 
Medicare+Choice, where payment is based on the average. This 
project will assess the financial risk that PACE organizations 
incur as a result of their smaller enrollment numbers, biased 
populations, and higher mortality. Risk will be characterized 
in enrollment level tiers and compared and contrasted to the 
risk characteristics of larger health delivery organizations. 
Simulations and the actuarial theory of ruin will be used in 
this assessment. The impact of joint capitated funding streams 
(Medicare and Medicaid) also will be modeled. Available claims 
data and data sets from other studies will be analyzed under 
this contract.
    Community Nursing Organization Demonstration
    Period: September 1992--December 31, 2001
    Contractors: See below.
    Description: Section 4079 of Public Law 100-203 directs the 
Secretary of the Department of Health and Human Services to 
conduct demonstration projects at four or more sites to test a 
capitated, nurse-managed system of care. The two fundamental 
elements of the Community Nursing Organization (CNO) 
demonstration are capitated payment and nurse case management. 
These two elements are designed to promote timely and 
appropriate use of community health services and to reduce the 
use of costly acute care services. The legislation mandates a 
CNO service package that includes home health care, durable 
medical equipment, and certain ambulatory care services. Four 
applicants were awarded site demonstration contracts on 
September 30, 1992. The selected sites represent a mix of urban 
and rural sites and different types of health providers, 
including a home health agency, a hospital-based system, and a 
large multi speciality clinic. All CNO sites underwent a 1-year 
development period and began a 3-year operational period in 
January 1994. The Balanced Budget Act of 1997 extended the 
demonstration through December 31, 1999. The Balanced Budget 
and Refinement Act of 1999 extended the demonstration through 
December 2001 and inlcuded a budget neutrality requirement for 
the payment rates. The Benefits Improvement and Protection Act 
of 2000 removes the budget neutrality reqirement but will 
reduce projected payment rates by 15 percent for the New York 
site, and 10 percent for the three other sites. Actuarial 
adjustments will also be made for October through December 2000 
and for calendar year 2001. Abt Associates Inc. was selected to 
evaluate the project and to provide technical assistance to the 
sites. Abt Associates Inc also was awarded the external quality 
assurance contract.
    Contractor: Care Clinic Association, 307 East Oak, Suite 3, 
P.O. Box 718, Mahomet , IL 61853.
    Contractor:Visiting Nurse Service of New York, 107 East 
70th Street, New York, NY 10021-5087
    Aditional Analyses of Community Nursing Organization (CNO) 
Demonstration Data
    Prj #: 500-95-0062/09
    Start Date: 09/29/2000
    End Date: 01/19/2001
    Funding: $204,637
    Vehicle: Task Order
    PI: Steven Pizer
    Awardee: Abt Associates, Inc.
    PO: James Hawthorne
    Description: The Community Nursing Organization (CNO) 
Demonstration was mandated by the Omnibus Budget Reconciliation 
Act of 1987, although actual enrollment did not commence until 
12/17/93. The demonstration was originally authorized for three 
years but in 1996 it received a one-year extension from HCFA, 
followed by a two-year extension through the Balanced Budget 
Act of 1997. The demonstration was scheduled to end on 12/31/
99, but received another two year extension from Congress in 
the Balanced Budget Refinement Act of 1999 (BBRA). It is now 
scheduled to run until 12/31/01. Abt Associates was contracted 
to design and conduct an evaluation of the first phase of the 
demonstration. The Abt Phase I evaluation included 
beneficiaries randomized through September 1995. It addressed 
the experience of these beneficiaries through the beginning of 
1997. The main findings were that the CNO intervention did not 
significantly improve care and that capitation payments to the 
CNO's were significantly higher than expenditures for the same 
package of services provided to the control groups but paid for 
on a fee-for-service basis. Because of language in the BBRA, 
which requires that the remainder of the demonstration be 
budget neutral, and the findings from the Abt evaluation, HCFA 
notified the CNO sites that their capitation payments will be 
reduced. The CNO sites and Congressional staff contend that the 
payment reductions are such that the CNOs will be required to 
cease operations. As a result of requests from the CNO sites 
and Congressional staff, several meetings took place to discuss 
the future of the demonstration and the budget neutrality 
requirement. The CNO sites and Congressional staff question the 
validity of the Abt evaluation and have requested that 
additional analyses be conducted. The CNO sites and 
Congressional staff are particularly concerned about the fact 
that in a 1998 Interim Report by the evaluation contractor, the 
expenditures for the treatment and control groups were 
different than the expenditure amounts in the Final Evaluation 
Report. Several important methodological changes were made in 
the Final Report, including the elimination from the analysis 
of participants from the treatment group who enrolled after 
randomization stopped, the addition of 6 more months of data, 
and the use of an inflation adjustment that was not applied to 
the data in the Interim Report. The CNO sites and Congressional 
staff want to know the extent to which each of these 
methodological changes affected the expenditure amounts in the 
Final Report. They want to have a better understanding of the 
reasons behind the changes between the Interim and Final 
Reports. When the evaluation contractor conducted the work for 
the Final Report, they re-constructed the files from scratch, 
which means the Final Report was not simply an update of the 
analyses in the interim report. Therefore, to fully understand 
the differences between the Interim and Final Report and answer 
their questions and concerns, additional programming and 
analyses will be necessary.
    Phase II Evaluation of Community Nursing Organization (CNO) 
    Prj #: 500-95-0062/10
    Start Date: 09/20/2000
    End Date: 09/19/2002
    Funding: $246,367
    Vehicle: Task Order
    PI: Steve Pizer
    Awardee: Abt Associates, Inc.
    PO: James Hawthorne
    Description: This project is for the design and 
implementation of the Phase II evaluation of this ongoing 
demonstration. The Community Nursing Organization (CNO) 
Demonstration was mandated by the Omnibus Budget Reconciliation 
Act of 1987 although actual data collection for the project did 
not commence until 12/17/93. The demonstration was originally 
authorized for three years but in 1996 it received a one-year 
extension (from HCFA)(followed by a two-year extension 
authorized in the Section 10019 of the Balanced Budget Act of 
1997). The demonstration was scheduled to end on 12/31/99 but 
(in Section 532 of the Balanced Budget Refinement Act of 
1999(BBRA)) it received another two year extension from 
Congress and is now scheduled to run until 12/31/01. Abt 
Associates won a competitive contract to design and conduct an 
evaluation of the first phase of the demonstration. The Abt 
(Phase I) evaluation covers the operation of the demonstration 
from January, 1994 to July, 1997. In addition to extending the 
demonstration, Congress mandated a second evaluation of the 
demonstration which is this Phase II Evaluation. A final report 
of this evaluation is to be delivered to Congress no later than 
7/1/01. This new/extended evaluation will provide for longer 
term follow-up of early participants and will also include 
assessment of the effects of the CNO intervention on later 
participants whose data were not available for the Abt 
evaluation. This second evaluation will require the use of HCC 
concurrent, risk adjusted estimates of Medicare expenditures 
for Medicare beneficiaries who participated in the 
demonstration as well as for a new comparison group. The 
calculation of the risk adjuster scores is being contracted 
separately and the resulting data will be made available to 
this Phase II Evaluation.
    Study of Pharmaceutical Benefit Management
    Prj #: 500-97-0399
    Start Date: 09/28/2000
    End Date: 07/13/2001
    Funding: $299,695
    Vehicle: Contract
    PI: Michael Keagan
    Awardee: PriceWaterhouse Coopers, LP
    PO: Peri H. Iz, Ph.D.
    Description: This study is an extension of an earlier HCFA 
ORD research (500-95-0065/02). Completed in 1996, this early 
study remains valuable for its description of the industry 
functions and the origins. However, most information contained 
in the early study is no longer current. This industry has 
undergone major stages of evolution during the past five years. 
While the industry size has grown impressively in size, there 
has been an increasing concentration of market power. The 
pharmacy benefit management (PBM) industry is becoming a 
dominant player in the administration of pharmaceutical 
benefits. It seems certain that the PBM sector will play a 
significant role in administering the Medicare program in case 
a drug benefit is added to Medicare. This study will 
systematically examine this growing PBM industry from a 
potential client's perspective.
    Status: The project is in the start-up phase.
    Evaluation of Programs of Coordinated Care and Disease 
    Prj #: 500-95-0047/09
    Start Date: 09/30/2000
    End Date: 09/29/2005
    Funding: $3,018,839
    Vehicle: Task Order
    PI: Randolph Brown
    Awardee: Mathematica Policy Research
    PO: Barbara Silverman, MD
    Description: This project will design and conduct the 
evaluation of a group of Congressionally mandated demonstration 
programs and two HCFA-initiated demonstration programs. These 
programs will test various methods of managing care in the fee-
for-service Medicare environment. Attempts to demonstrate the 
effectiveness of programs of care coordination or management 
are complicated not only by wide variations in program staff, 
funding mechanisms, interventions and stated goals, but by the 
evaluator's definition(s) of effectiveness. Despite the 
widespread acceptance of the concept of care coordination, 
studies of the effectiveness of various approaches, including 
those conducted in Medicare beneficiary populations, have 
yielded mixed results. The results of a Medicare demonstration 
of case management in a fee-for-service environment carried out 
from October 1992 through November 1995 are demonstrative of 
the difficulties inherent in defining and evaluating the 
effectiveness of these programs. The three programs studied 
varied widely in their target populations and the nature of the 
interventions attempted; although all were associated with 
increased client satisfaction, none appeared to improve 
outcomes or reduce costs. A major defect in the three programs 
studied was a lack of active involvement of the primary care 
provider in the case management intervention. HCFA continues to 
investigate the potential of care coordination or case 
management to improve care quality and control costs in the 
Medicare fee-for-service program. Section 4016 of the Balanced 
Budget Act of 1997 (Public Law 105-33) required the Secretary 
to design a demonstration of approaches to coordinated care of 
chronic illnesses in up to nine separate sites. As required by 
Congress, an evaluation of best practices in coordinated care 
and a study of demonstration design options has been conducted. 
A solicitation informing interested parties of the intent to 
conduct this demonstration is expected in late Spring, 2000. 
Demonstration sites will be funded for a period of four years. 
A separate demonstration, the Medicare Case Management 
Demonstration, focuses on programs of case management specific 
to diabetes and congestive heart failure. This evaluation is to 
assess the effectiveness of various strategies for coordinating 
care in the fee for service (FFS) Medicare environment, in a 
total of 11 demonstration sites. The participating 
demonstration sites will vary considerably by a number of 
factors, including corporate structure, types of medical 
conditions addressed, scope of patient care covered, 
beneficiary eligibility, source of comparison data. However, 
the sites have in common the goal of improving quality and 
reducing cost of health care received by chronically ill 
Medicare beneficiaries through any or all of the following: 1. 
Individualized plans of care that take into account the 
beneficiaries medical and social needs. 2. Improved 
beneficiaries access to treatment and prevention services, 
including services that may not otherwise be available through 
the traditional Medicare fee-for-service program (such as 
medications, home visits, transportation, and health 
education). 3. Involvement of a care [email protected] 
or [email protected] in the beneficiary medical care 
depending on the design of the program, this individual may 
exercise considerable control over the beneficiary's medical 
care, or may function in an adjunct role, assisting patients in 
making and keeping medical appointments, complying with 
treatment recommendations and accessing other needed resources 
4. Simplified processes for contacting providers to allow for 
rapid resolution of new problems that otherwise might require 
emergency care 5. Increased beneficiaries (or where applicable, 
family members or caregivers) understanding of their medical 
problems, in order to improve compliance with treatment plans. 
6. Improved information sharing between health care providers 
in order to insure that patients receive appropriate care in a 
timely fashion, reduce duplicative or unnecessary care, and 
avoid unnecessary emergency care and hospitalizations. The goal 
of this evaluation is to identify those characteristics of the 
programs of coordinated care under study that have the greatest 
impact on health care quality and cost, and to identify the 
target populations most likely to benefit from such programs. 
The demonstration programs to be studied as a part of this 
evaluation will vary widely with respect to the demographics, 
medical and social situations of the target population, 
intensity of services offered, interventions under study, 
type(s) of health care professionals delivering the 
interventions, and other factors. Furthermore, sites may be 
added to the demonstration as it progresses. For these reasons, 
the evaluator will be required to establish a basic framework 
for analysis that can be tailored to the requirements of each 
demonstration site, and will allow for between-site comparisons 
at the intervals and at the completion of the evaluation.
    Status: In progress.
    Aging in Place: A New Model for Long-Term Care
    Prj #: 18-C-91036/7
    Start Date: 06/18/1999
    End Date: 06/17/2003
    Funding: $1,169,406
    Vehicle: Cooperative Agreement
    PI: Karen Dorman Marek, PhD, MBA, RN
    Awardee: Curators of the University of Missorui, Office of 
Sponsored Program Administration, University of Missouri--
Columbia, Sinclair School of Nursing
    PO: Barbara Silverman, MD
    Description: The goal of the ``Aging in Place'' model of 
care for frail elderly is to allow elders to remain in their 
homes as they age, rather than requiring frequent moves to 
allow for more intensive care if and when it becomes necessary. 
The University of Missouri's Sinclair School of Nursing is in 
the process of implementing such a model. Although a planned 
element of the program is a new senior housing development, the 
program currently targets elderly residents of existing 
congregate housing. The University has received a grant in the 
amount of $2 million in support of the evaluation of this model 
of care.
    Status: A first-year award was made to the applicant 
subject to revision of the study design and work plan according 
to terms and conditions established by the review panel. HCFA 
staff met with the Principal Investigator and other members of 
the research team at a kick-off meeting on September 1, 1999, 
at which time a revised work plan and budget were submitted. As 
a result of changes to the study plan, the applicant requested 
an increase in the first-year award with a corresponding 
reduction in the Years 2-4 awards and no change in the total 
budget. This change was approved.
    Study of Medicare Payments in HPSA's
    Prj #: 500-95-0056/11
    Start Date: 09/21/1999
    End Date: 07/29/2001
    Funding: $240,323
    Vehicle: Task Order
    PI: Donna Farley
    Awardee: RAND Corporation, The
    PO: William Buczko, Ph.D.
    Description:Medicare includes a number of special payment 
provisions aimed at maintaining beneficiary access to needed 
services in areas where there is a scarcity of physicians and 
providers. These areas are designated by the Health Resources 
and Services Administration and are called Health Professional 
Shortage Areas (HPSAs). This project compiles data on trends in 
payment amounts, services, and recipients that have been 
provided by Medicare over the past decade, project future 
trends, and suggests and assesses alternatives to the current 
set of special payment provisions for HPSAs. It will review the 
value of all Medicare payments to HPSAs for services provided 
in, or to residents of, such areas. The methodology used to 
designate such areas is undergoing proposed changes which are 
expected to be finalized in the year 2000. This project will 
inform HCFA about the importance of several Medicare special 
payment policies for HPSAs and aid in the assessmentof them and 
of alternatives.
    Status: In progress.
    Evaluation of Competitive Bidding Demonstration for DME and 
    Prj #: 500-95-0061/03
    Start Date: 09/30/1998
    End Date: 05/15/2003
    Funding: $2,315,249
    Vehicle: Task Order
    PI: Sarita Karon
    Awardee: University of Wisconsin--Madison/Research Triangle 
Institute/Northwestern Univ.
    PO: Ann Meadow, Sc.D.
    Description: HCFA has mounted a demonstration to test the 
feasibility and effectiveness of establishing Medicare fees for 
durable medical equipment (DME) and prosthetics, prosthetic 
devices, orthotics and supplies (POS) through a competitive 
bidding process. The fundamental objective of competitive 
bidding is to use marketplace competition to establish market-
based prices and to select DME suppliers. The Balanced Budget 
Act of 1997 (BBA) authorized competitive bidding demonstrations 
for Part B services (except physician services), and the 
current project is being conducted under that authority. The 
initial site of the demonstration is Polk County, Florida. 
Competitively bid product categories in Polk include oxygen 
supplies and equipment, enteral nutrition, surgical dressings, 
urological supplies, and hospital beds. Medicare contracts with 
winning suppliers commenced in October 1999. Section 4319 of 
the BBA specifically mandates evaluation studies addressing 
competitive bidding impacts on expenditures, quality, access, 
and diversity of product selection. This task order will study 
these and other outcomes of the demonstration. The evaluation 
will use several types of research designs, such as multiple 
time series analysis and pre-test/post-test comparisons. The 
results of the evaluation will help HCFA decide how to conduct 
any future competitive bidding activities.
    Status: Data collection activities have begun. A pre-
demonstration survey of oxygen users and users of other medical 
supplies was fielded in two Florida counties (Polk and Brevard) 
in March 1999. The results suggested beneficiaries were highly 
satisfied with the services and products delivered by their 
Medicare suppliers. A followup survey is to be conducted during 
CY 2000. Two site visits in 1999 were conducted as part of the 
evaluation's case study activities, focusing on administrative 
and market outcomes. Other evaluation activities now in the 
planning stages include claims analyses, focus groups, fee-
schedule analyses, and additional surveys. The first annual 
evaluation report is scheduled for release in early CY 2001.
    Assessment of Medicare Prescription Drugs and Coverage 
    Prj #: 500-00-0024/01
    Start Date: 09/30/2000
    End Date: 02/28/2002
    Funding: $202,527
    Vehicle: Task Order
    PI: Thomas Hoerger
    Awardee: Research Triangle Institute
    PO: Peri Iz
    Description: The purpose of this task is to assemble and 
analyze recent fee-for-service and managed care plan data on 
Medicare spending for prescription drugs, as well as comparable 
data from other public and/or private payers. Using these data, 
the project will estimate possible financial effects of 
alternative Medicare payment policies for drugs currently 
covered by statute. This study will estimate current 
expenditures and possible savings from alternative 
reimbursement policies based on different discount rate and 
price schedules used by other payers, as well as examine other 
purchasing polices including competitive bidding and rebate 
mechanisms. In fiscal year 1997, Medicare's limited 
prescription drug benefits represented approximately 5 percent 
($2.8 billion of the $56.4 billion) of the total Medicare Part 
B expenditures. The majority of this drug spending is provided 
on an inpatient basis or related to the End Stage Renal Disease 
program. While not the most significant source of spending 
under Medicare, Part B spending for these limited prescription 
drugs exceeds spending for lens surgery, ambulance services, or 
oxygen. Until recently, Medicare paid for these limited 
prescription drugs based on reasonable charge determinations 
for covered prescription drug products found in the published 
Average Wholesale Price (AWP). Medicare paid 63 percent of the 
amounts billed for prescription drug products and their 
dispensing. A recent report from the Office of the Inspector 
General (OIG) concluded, however, that Medicare's payments for 
22 drugs in 1996 had an average mark-up of 41 percent over what 
physicians and suppliers paid for the drugs. By contrast, 
Medicare recognized only 49 percent of submitted charges for 
all other billed Part B services. The Balanced Budget Act of 
1997 changed Medicare's payment amount from 100 percent to 95 
percent of the AWP. According to several OIG reports, public 
programs such as Medicare have been paying too much for 
prescription drugs relative to what pharmacies actually spend 
for brand name products. For example, the prevailing Medicaid 
discount rate has been 10 percent, whereas actual acquisition 
discounts average over 18 percent. For generic products, the 
disparity is thought to be larger. Medicaid recoups a 
substantial portion of prescription drug payments through 
rebates from manufacturers. Also, drug manufacturers frequently 
provide special discounted prices for drugs used by the 
Department of Defense, the Department of Veterans Affairs, and 
certain Department of Health and Human Services health care 
programs. In 1997, it was estimated that 68 percent of Medicare 
managed care plan benefit packages included broadened benefits 
for prescription drugs, and that some of these managed care 
options were offered at no additional premium to beneficiaries. 
Such managed care plans offering these options may receive 
substantial discounts and/or rebates from manufacturers either 
by negotiation or by use of pharmacy benefit management firms 
who conduct price negotiations on behalf of plans. Medicare 
would like to know in greater detail how its payment policy for 
prescription drugs compares with the policies of other payers 
and purchasers. But data for making such comparisons are not 
readily available. HCFA does obtain detailed, product specific 
data from state Medicaid programs that are used to calculate 
rebate obligations of manufacturers. Under the terms of the 
Medicaid rebate agreements, however, such data are held in 
confidence and could not be used for this study. Hence, the 
purposes of this study are twofold:
          Data Collection (Task 1): the contractor will seek 
        and obtain available drug payment system information 
        from other non-Medicare organizations.
          Comparative Analysis (Task 2): the contractor will 
        compare current Medicare covered prescription drug 
        reimbursement levels to those found in the data 
        gathered, and prepare an analytical report.
    Status: In progress.
    Examine the Effects of Providing a Outpatient Prescription 
Drug Benefit
    Prj #:HCFA-00-0046
    Start Date: 01/20/2000
    End Date: 02/28/2001
    Funding: $15,000
    Vehicle: Simplified Acquisition
    PI: Ralph Monaco
    Awardee: InterIndustry Economic Research Fund
    PO: Edgar Peden
    Description: This project analyzes the macro-economic 
effects related to the introduction of a new public program, 
specifically an outpatient prescription drug benefit for 
    Status: In progress.
    Evaluation of the Nursing Home Case-Mix and Quality 
    Prj #:500-94-0061
    Start Date: 09/30/1994
    End Date: 09/01/2000
    Funding: $2,980,219
    Vehicle: Contract
    PI: Robert J. Schmitz, Ph.D.
    Awardee: Abt Associates, Inc.
    PO: Edgar A. Peden
    Description: Using data from the Nursing Home Case-Mix and 
Quality (NHCMQ) Demonstration, HCFA is evaluating the new 
practice of paying skilled nursing facilities (SNF) for 
Medicare skilled nursing services on a prospective basis. Prior 
to July 1, 1998, SNFs were reimbursed on a retrospective basis 
for their reasonable costs. Since that date, however, following 
methods used in the NHCMQ demonstration, a new prospective 
methodology has been implemented. Under this methodology, 
patients are classified into resource utilization groups which 
are then used to calculate each facility's case mix. HCFA then 
pays facilities for each covered day of care, to the case mix 
of patients residing there on any given day. Though some costs 
will continue to be
    Status: Interim analyses of admitting patterns and select 
outcomes have been undertaken, and visits to demonstration and 
nondemonstration facilities have been completed which should 
help in understanding provider response to the payment 
demonstration. Data base construction and analysis of the third 
phase of the demonstration, which bundled skilled therapy 
services into the prospectively-paid routine rate has been 
completed. This primary data collection activity was completed 
in July 1999. MDS assessments were matched to Medicare SNF and 
hospital claims and to HCFA Provider-of-Service records to 
create the analytic data base for the project. Current analytic 
activities center around assessing and revising the draft final 
report. Of special interest is the analysis of primary data 
regarding the provision of professional therapy services in 
both demonstration sites and comparison sites.
    Case-Mix Adjustment for a National Home Health Prospective 
Payment System
    Prj #:500-96-0003/02
    Start Date: 07/26/1996
    End Date: 09/30/2000
    $Funding $3,416,984
    Vehicle: Task Order
    PI: Henry Goldberg
    Awardee: Abt Associates Inc.
    PO: Ann Meadow, Sc.D.
    Description: The primary focus of this study is to 
understand existing variation in home health resource patterns 
and to use this information to develop a case-mix adjustment 
system for a national home health prospective payment system 
(PPS). In this study, the Outcomes and Assessment Information 
Set (OASIS), which has been developed for outcome-based quality 
assurance and improvement for Medicare home health agencies, is 
being examined to see whether items included in this instrument 
will be useful for case-mix adjustment. Detailed information, 
including information on resource utilization and additional 
items needed for case-mix adjustment not included on OASIS, has 
been collected from participating agencies. (Arizona, 
California, Florida, Illinois, Massachusetts, Pennsylvania, 
Texas, Wisconsin.)
    Status: Ninety agencies were recruited and trained from 
eight States in the spring and summer of 1997. All agencies 
began data collection on a 6-month cohort of new admissions to 
home care beginning in October 1997. Data collection ended in 
the spring of 1999. Analysis to date has resulted in a viable, 
clinically coherent system of 80 case-mix groups that explains 
more than 30 percent of the variation in resource use on a 
development sample drawn from the cohort members. Resource use 
is measured for 60-day periods of care, to conform to the 
planned unit of payment under the forthcoming national PPS. 
Selected OASIS assessment items, collected at the start of 
care, are used in the grouping system. The case-mix items fall 
into three major domains: clinical factors, functional-status 
factors, and utilization factors. Within each domain, a 
parsimonious set of items is summarized into a score for the 
patient. In two of the domains, scores are partitioned into 
four levels corresponding to high, moderate, low, and minimal 
impact, based on the relationship of the score to resource 
utilization. In the third domain, scores are partitioned into 
five impact levels. A patient's combination of levels on all 
three domains identifies the group into which the patient is 
classified for purposes of case-mix adjusting the prospective 
payment amount. Under this system, the patient's case mix 
classification is updated at the end of the payment period to 
reflect the actual amount of home therapy services received 
during the 60-day payment period. This information is necessary 
to arrive at a final score for the utilization domain. Results 
of the study to date are described in two reports:
          Case-Mix Adjustment for a National Home Health 
        Prospective Payment System: First Interim Report, July 
        1998 (revised December 1998).
          Case-Mix Adjustment for a National Home Health 
        Prospective Payment System: Second Interim Report, 
        September 24, 1999.
    Additional reports on model validation results refinement 
related analysis and OASIS case-mix data verfication are 
expected in 2001.
    Maximizing the Cost Effectiveness of Home Health Care: The 
Influence of Service Volume and Integration with Other Care 
Settings on Patient Outcomes
    Prj #:17-C-90435/8
    Start Date: 09/01/1994
    End Date: 09/30/2000
    Funding: $1,496,245
    Vehicle: Cooperative Agreement
    PI: Peter W. Shaughnessy, Ph.D.
    Awardee: Center for Health Policy Research, University of 
    PO: Ann Meadow, Sc.D.
    Description: Home health care (HHC) is the most rapidly 
growing component of the Medicare budget in recent years. The 
rapid growth in home health use has occurred despite limited 
evidence about the necessary volume of HHC to achieve optimal 
patient outcomes and whether it substitutes for more costly 
institutional care. Little is known about integrating HHC with 
care in other settings to reduce overall health care costs. The 
central hypotheses of this study are that volume-outcome 
relationships are present in HHC for common patient conditions, 
that upper and lower volume thresholds exist that define the 
range of services most beneficial to patients, and that a 
strengthened physician role and better integration of HHC with 
other services during an episode of care can optimize patient 
outcomes while controlling costs. To test these hypotheses, a 
sample of 3,600 patient records is being analyzed from agencies 
in 20 States stratified into high, medium, and low-volume 
categories based on annual visits per beneficiary. Trained data 
collectors at each agency recorded patient health status and 
service information between HHC admission and discharge to 
assess patient outcomes and costs within the HHC episode. Long-
term, self-reported outcomes are being measured from telephone 
interview data at HHC admission and from 6-month follow ups. 
These primary data concerning patient status and outcomes will 
be combined with Medicare claims data over the episode of care 
to study the relationship between service volume in HHC and 
both patient outcomes and costs.
    Status: Study Paper 1, Research Design Update, which 
summarized the research design and its evolution from the 
original proposal, was finalized in September 1998. Primary 
data collection ended in late 1998. An interim report on a 
subsample of 1,000 patients (February 1999) described case mix 
and volume relationships. Separately for the four common 
conditions (congestive heart failure, stroke, surgical hip 
procedures, and open wounds), a high- and low-volume group was 
selected by taking the highest and lowest 45 percent of the 
arrayed cases within each condition. Two-sample tests for mean 
differences in case mix characteristics and volume were 
performed to compare the two volume groups within each 
condition. The median volume (defined as number of visits until 
discharge or first inpatient admission) differed by a factor of 
about four to nine, depending on the condition. For home health 
aide services, mean volume differed by a factor of between 30 
and 47. Many case mix indicators were measured at the start of 
care. Of these, few demographic indicators differed between the 
volume groups within condition. But limitations in activities 
of daily living (ADLs) were significantly greater for the high-
volume groups, these patients had a greater prevalence of 
chronic conditions, and their institutional utilization within 
the 14 days prior to admission was less likely to be an acute-
care hospital, indicating the more post-acute nature of the 
low-volume groups. This general case mix difference is 
consistent with the greater use of aide services for high-
volume patients. Preliminary analyses of outcomes suggested 
relatively few differences in outcomes by volume. This result 
may mean that the additional services delivered to the high-
volume group helped equalize outcomes between more severely ill 
and less severely ill patients. Risk-adjusted analyses planned 
for later in the study are necessary to further explore this 
    Evaluation of Phase II of the Home Health Agency 
Prospective Payment Demonstration
    Prj #:500-94-0062
    Start Date: 09/30/1994
    End Date: 09/30/2000
    Funding: $3,528,408
    Vehicle: Contract
    PI: Barbara Phillips, Ph.D.
    Awardee: Mathematica Policy Research, Inc.
    PO: Ann Meadow, Sc.D.
    Description: This contract is evaluating Phase II of the 
Home Health Agency (HHA) Prospective Payment Demonstration, 
under which HHAs are paid on a prospective basis for an episode 
of care reimbursed by the Medicare program. (Phase I tested 
per-visit prospective payment for HHAs.) Ninety-one agencies 
from five states--California, Florida, Illinois, Massachusetts, 
and Texas--were randomly assigned to either the treatment group 
(prospective payment system (PPS) method, 48 agencies) or the 
control group (conventional cost-based reimbursement, 43 
agencies). The agencies phased into the demonstration at the 
beginning of their 1996 fiscal year. Treatment-group agencies 
can reduce the cost of care they provide during a 120-day 
payment period by reducing visits, changing the mix of visits 
to make less costly visits a larger proportion of visits, 
reducing per-visit costs, or some combination of all three. The 
cost-reducing activities raise the possibility that quality of 
care might deteriorate under episode-based payment. Quality 
impacts, along with cost, utilization, and qualitative, 
behavioral effects, are the focus of the evaluation. The 
findings will indicate not only the overall effects of the 
change in payment methodology, but also how the effects are 
likely to vary with the characteristics of agencies and 
    Status: Interim findings from the evaluation, based 
primarily on the first 8 to 15 months of demonstration 
operations, are described in following documents:
          Transition Within a Turbulent System: An Analysis of 
        the Initial Implementation of the Per-Episode Home 
        Health Prospective Payment Demonstration, August 6, 
          Preliminary Report: The Impact of Prospective Payment 
        on Medicare Home Health Quality of Care, January 30, 
          Preliminary Report: The Impact of Prospective Payment 
        on Medicare Home Health Use--Promising Results for a 
        Future Program, July 22, 1998.
          The Impact of Prospective Payment on Medicare Service 
        Use and Reimbursement During the First Demonstration 
        Year, December 1998.
          Preliminary Report: The Impact of Prospective Payment 
        on the Cost per Episode: Striking the Balance Between 
        Decreasing Use and Increasing Cost, July 22, 1999.
    Findings from the first 2 years of the evaluation are 
described in additional reports forthcoming in calendar year 
2000. Findings from the interim analysis of cost impacts 
suggest that, on average, prospective payment reduced the cost 
of care during the 120-day episode period by $419 or 13 
percent. The impact on cost was similar across different types 
of agencies, except that small agencies (less than 30,000 
visits in year before the demonstration) exhibited a 
significantly smaller effect than large agencies. Findings from 
the utilization study suggest that the per-episode group of 
HHAs was able to reduce the number of visits provided during 
the 120-day episode period by 17 percent and the time from 
admission to discharge by 15 percent. The proportion of 
patients receiving care in each home health discipline changed 
little under episode payment. The utilization findings 
generally applied to agencies regardless of size, nonprofit 
status, affiliation status (hospital or freestanding), or use 
pattern (i.e., whether the agency provided more or less than 
the average number of visits during a base year, given its case 
    The reduction in visits has not led to compensating 
utilization in other parts of the health care system. An 
analysis of utilization and reimbursement for Medicare-covered 
services other than home health found that prospective payment 
did not affect the use of or reimbursement for such services 
during the 120-day episode period. An investigation of 
spillover effects in settings not covered by Medicare similarly 
found no compensating utilization. For example, prospective 
payment did not affect the likelihood of receiving 
nonresidential services such as personal care aides and adult 
day care, based on results from a patient survey.
    These findings suggest that a reduction in home health 
utilization at the level observed under the demonstration does 
not adversely affect care quality or shift costs to services in 
other settings. Other interimanalyses of quality impacts found 
few differences in patient outcomes between treatment and 
control agencies, and when differences were found, they were 
small. Analysis of claims data indicated that PPS patients have 
significantly lower emergency room use. There were no 
significant differences due to PPS in any other outcomes 
studied from the claims data, including institutional 
admissions for a diagnosis related to the home health care and 
mortality. Results from the first patient survey on client 
satisfaction suggested that both treatment and control group 
clients were generally satisfied. On three specific components 
of satisfaction with agency staff, treatment-group clients were 
found to be somewhat less satisfied than control group clients, 
although satisfaction levels were quite high in both groups. 
Measures of health and functional outcomes from the survey 
offered equivocal evidence for small negative effects of 
prospective payment in a few of the functional outcomes. These 
results are preliminary and require further study in a planned 
follow-up survey. Half of the treatment agencies selected for 
case study early in the demonstration reported plans for 
specific initiatives to reduce per-episode costs spurred by 
their participation in the demonstration project. From the case 
studies, the evaluators concluded that treatment agencies were 
not planning to change their behavior in ways that threatened 
access or quality of care.
    Subsequent evaluation reports will focus on utilization, 
cost, and quality effects beyond the 120-day episode period. 
There will be further case-study results on agency response to 
the demonstration and an extension of previous work on cost 
impacts to include an analysis of agencies' financial 
performance. Finally, supplementary analyses will consider the 
representativeness of the demonstration sample and the patient 
selection behavior of agencies.
    Medicare Post-Acute Care: Evaluation of BBA Payment 
Policies and Related Changes
    Prj #:500-96-0006/04
    Start Date: 09/21/2000
    End Date: 09/20/2002
    Funding: $636,557
    Vehicle: Task Order
    PI: Brian Burwell
    Awardee: MEDSTAT Group, LLC
    PO: Philip Cotterill
    Description: The purpose of this project is to study the 
impact of BBA and other policy changes on Medicare utilization 
and delivery patterns of post-acute care. Post-acute care is 
generally defined to include the Medicare covered services 
provided by skilled nursing facilities (SNFs), home health 
agencies, rehabilitation hospitals and distinct part units, 
long term care hospitals, and outpatient rehabilitation 
providers. The changes in post-acute care payment policy 
enacted in the late 1990's (mostly in the 1997 Balanced Budget 
Act (BBA) with some subsequent modifications) were made one-by-
one to most types of post-acute care. However, a beneficiary's 
post-acute care needs, can often be met in alternative provider 
settings. Hence policy changes for one post-acute care modality 
may have ramifications for other post-acute and acute care 
services. Understanding the interrelationships among post-acute 
care delivery systems is critical to the development of 
policies that encourage appropriate and cost-effective use of 
the entire range of care settings. The results of this work may 
be useful in refining policies for individual types of post-
acute care, as well as in developing a more coordinated 
approach across all settings. Medicare utilization and 
expenditures for post-acute care increased dramatically in the 
1990's prior to the passage of the BBA. Many of the changes 
enacted in the BBA were in reaction to the experience of the 
early 1990's and were aimed at controlling the decade's 
fiscally disturbing expenditure trends. Even before passage of 
the BBA, administrative actions (such as Operation Restore 
Trust (ORT)) were taken to tighten the enforcement of coverage 
guidelines and reduce abuses that were perceived to be 
significant contributory factors to the runaway growth of the 
early 1990s. Chief among the BBA changes was the mandate for 
implementation of prospective payment systems to replace 
retrospective cost-based payment for all the major post-acute 
care providers. Among the BBA policies whose impacts to be 
considered in this project are the following: the Interim 
Payment System (IPS) for home health agencies; the SNF 
prospective payment system; the revised inpatient hospital 
transfer policy for 10 DRGs; the new cost limits and rebased 
target amounts for rehabilitation hospitals and distinct part 
units; and the outpatient therapy limits. Study Overview--In 
general, the appropriate evaluation design is a Adifferences in 
[email protected] model that estimates differential 
effects over time as a function of differential degrees of 
impact. In this initial project, analyses will compare changes 
between the pre-BBA period of the 1990's and a post-BBA year, 
such as 1999. For the most part, the studies should focus on 
the interrelationships among the various post-acute care 
settings. However, in some cases, changes affecting a single 
type of post-acute care may warrant special analysis. The model 
needs to be applied flexibly to include a variety of 
beneficiary, provider, and market area analyses. In addition, 
analyses may involve data for individual years, as well as 
changes between years. Since the impacts of policy changes not 
yet implemented will continue to be of interest for many years, 
the analyses developed under this project are expected to use 
and refine methods that can be applied in future evaluation 
research. Analytically, this is a challenging project due to 
the numbers of provider types and policy changes involved. The 
staggered and overlapping temporal implementation of the 
changes further complicates the effort. The proposed analyses 
are not necessarily expected to be able to attribute causality 
to effects detected, nor are they expected to disentangle the 
effects of one policy change from the effects of another. In 
general, it will only be possible to determine net effects of 
all changes relevant to a specific analysis. However, in 
choosing time periods, attention will be paid to the policies 
that could be expected to impact behavior during the period of 
analysis. The project will utilize secondary data sources, 
primarily HCFA claims data. Claims for all relevant types of 
services will need to be linked with beneficiary enrollment 
information to create [email protected] of care by 
beneficiary. At least 2 such episode files will be required, 
one for a pre-BBA year such as 1995 or 1996 and another for a 
post-BBA year such as 1999. In addition the project will design 
a strategy for monitoring and evaluation of impacts across 
post-acute care settings. We are interested in distinguishing 
between the needs for regular monitoring of impacts across 
post-acute care settings and more detailed evaluation studies. 
We are especially interested in defining data requirements for 
monitoring sentinel events that would serve as alerts for more 
in-depth evaluation. The strategy will define data requirements 
for monitoring and evaluation activities, taking into 
consideration the data available for individual care modalities 
and the need to integrate data across modalities in as timely 
and efficient a manner as possible.
    Status: In developmental phase.
    Design of an Integrated Post-Acute Care System
    Prj #: 500-96-0008/04
    Start Date: 09/30/1997
    End Date: 10/31/2001
    Funding: $829,428
    Vehicle: Task Order
    PI: Robert L. Kane, M.D.
    Awardee: University of Minnesota
    PO: Frederick G. Thomas, III, CPA, MS, MBA
    Description: HCFA intends to create an infrastructure of 
post-acute and long-term care delivery and payment systems that 
are better integrated and more flexible in meeting the needs of 
beneficiaries with chronic illnesses and disabilities. The 
transition from our current benefit and provider-based system 
to a beneficiary-centered system requires several elements:
          An assessment tool that can be used and shared across 
        provider types.
          More flexible benefit packages.
          Funding based on beneficiary health and functional 
          Case management that involves formal and informal 
        caregivers in care planning and supports and 
        encourages, where appropriate, beneficiaries to direct 
        their own care.
    Additional work that incorporates beneficiary preferences 
into outcome measures, as well as further attempts to 
differentiate outcomes by post-acute-care modality for 
different patient conditions, is also needed. The purpose of 
this project is to design several elements needed in a more 
integrated system--an assessment tool, potential case 
management models, appropriate payment systems, and outcome 
measures that cross settings and incorporate beneficiary 
preferences, with the ultimate intent of pilot testing and 
refining these elements in a demonstration. A second purpose of 
this project is to design an optional demonstration that tests 
the feasibility and effectiveness of creating a more integrated 
post-acute-care system.
    Status: Work has begun on developing potential case-
management models, as well as an assessment instrument.
    Effects of Telemedicine on Accessibility, Quality, and Cost 
of Health Care
    Prj #:18-P-90332/5
    Start Date: 07/01/1994
    End Date: 09/30/2001
    Funding: $644,086
    Vehicle: Grant
    PI: F. W. Womack
    Awardee: University of Michigan
    PO: Joel Greer, Ph.D.
    Description: This project evaluated the effect of 
telemedicine systems on accessibility, quality, and cost of 
health care. A detailed methodology for evaluating telemedicine 
was developed by a panel of experts and implemented in existing 
telemedicine programs at the Medical College of Georgia (MCG) 
Telemedicine Center and Mountaineer Doctor Television (MDTV) at 
the Health Sciences Center, West Virginia University (WVU). 
Included in the evaluation design was a quasi-experimental 
survey study of clients and providers in selected experimental 
and control communities and a case-control study to compare the 
content, process, and outcomes of episodes of care with and 
without telemedicine. The project plan had three goals:
    Development of a detailed methodology for a comprehensive 
evaluation of the effects of telemedicine on accessibility, 
utilization, quality, and cost of health care, using a panel of 
experts on quality, economics, clinical medicine, and 
technology. Implementation and testing of the evaluation design 
at the MCG Telemedicine Center. Extending the evaluation design 
to MDTV at WVU.
    The general hypothesis guiding this research was that 
telemedicine will improve accessibility to health care, enhance 
the quality of care delivered, and contain costs.
    Status: The final report is being prepared.
    Maximizing the Effective Use of Telemedicine: A Study of 
the Effects, Cost Effectiveness, and Utilization Patterns of 
Consultation via Telemedicine
    Prj #: 18-C-90617/8
    Start Date: 09/01/1995
    End Date: 09/28/2002
    Funding: $2,198,968
    Vehicle: Cooperative Agreement
    PI: Jim Grigsby, Ph.D. and Robert E. Schlenker, Ph.D.
    Awardee: Center for Health Policy Research, University of 
    PO: Joel Greer, Ph.D.
    Description: This project is evaluating the medical 
effectiveness, patient and provider acceptance, and costs 
associated with telemedicine services, as well as their impact 
on access to care in rural areas. The demonstration involves 
ten rural hospitals, one rural referral hospital, and one urban 
hospital. Planned services for the demonstration include 
interactive video consults for teleradiology, telepathology, 
and, where available, telesonography, electrocardiography, and 
fetal monitoring strips. Payment for related physician services 
is expected to be made under a waiver of Medicare payment 
regulations. The goal of he project is to evaluate whether 
specialty telemedicine services provided by hospital networks 
produce change with respect to medical effectiveness, patient 
and provider satisfaction, cost, and access. Hypotheses include 
telemedicine improving differential diagnoses and treatment, 
patients and providers being as satisfied with telemedicine as 
with on-site services, telemedicine services being less costly 
than on-site services, and telemedicine improving access to a 
wider range of health care services.
    Status: The evaluation design has been completed and the 
instrument approved by the Office of Management and Budget. 
Data collection has begun.
    Evaluation of the Informatics, Telemedicine, and Education 
    Prj #: 500-95-0055/05
    Start Date: 09/30/2000
    End Date: 07/29/2004
    $Funding $1,419,493
    Vehicle: Task Order
    PI: Judith Woodridge/Stephen Zuckerman
    Awardee: Urban Institute, The
    PO: Carol Magee
    Description: Section 4207 of the Balanced Budget Act of 
1997 (BBA97) instructs the Secretary to establish a single, 4-
year demonstration project using an eligible health care 
provider telemedicine network. The demonstration involves the 
application of high-capacity computing and advanced 
telemedicine networks to the task of improvement of primary 
care and prevention of health complications in Medicare 
beneficiaries with diabetes mellitus. These beneficiaries must 
reside in medically underserved rural or medically underserved 
inner-city areas. The statute also mandates that the Secretary 
submit a final Report to Congress (RTC) that: AY shall include 
an evaluation of the impact of the use of telemedicine and 
medical informatics on improving access of Medicare 
beneficiaries to health care services, on reducing the costs of 
such services, and on improving the quality of life of such 
beneficiaries. Submission of the RTC is mandated by August 31, 
2004 (6 months after the conclusion of the demonstration). The 
purpose of this project is to evaluate the impact of the 
Informatics, Telemedicine, and Education Demonstration Project 
and to provide input into the RTC. The Informatics, 
Telemedicine, and Education Demonstration project is using 
specially modified home computers, or home telemedicine units 
(HTU) linked to a Clinical Information System (CIS) maintained 
by Columbia Presbyterian Medical Center. The HTUs in patients' 
homes allow video conferencing, access to health information 
and access to medical data. Computerized devices read blood 
sugar levels, check blood pressure, take pictures of skin and 
feet for signs of infection, and screen for other factors that 
affect the management of diabetes. These data are fed 
electronically to the data system at Columbia. The CIS provides 
storage of clinical data for use in the development and 
application of patient care guidelines and clinical standards. 
Full-time nurse case-managers monitor the data and intervene if 
the data from a patient vary from guidelines. Patients receive 
feedback, including clinical data such as blood glucose levels, 
care reminders and suggestions on how to maintain good health. 
Health information specific to diabetes is to intervention 
group participants on a specially developed website (under 
development) in both low literacy and regular versions in both 
Spanish and English.
    The demonstration project is being conducted as a 
randomized, controlled clinical trial. Half of the participants 
are receiving the intervention, consisting of an HTU and 
electronic services within a case-manager environment (as 
detailed above), and half continue to receive usual care for 
their diabetes. The demonstration consists of 2 components: an 
urban component conducted in northern Manhattan, and a rural 
component, conducted in upstate New York. Participants can have 
either Type I or Type II diabetes, and both males and females 
will be included. There are no racial or ethnic exclusions to 
participation. Demonstration participants are being recruited 
into the study over approximately 1 year. Once recruited and 
randomized, each participant will remain in the demonstration 
for 2 years. After completion of their time in the 
demonstration, participants will be phased out over 
approximately 1 year. Outcome data will be collected from all 
participants at three visits (visit 1 [baseline], visit 2 [one 
year follow-up], and visit 3 [two year follow-up]). The primary 
health outcome measures to be collected as part of the 
demonstration are glycosylated hemoglobin levels, blood 
pressure levels, and lipid levels. Other important outcomes 
include receipt of recommended diabetes-specific health care 
services (dilated eye exam, foot exams), other recommended 
preventive services, smoking cessation in the subset of 
participants who smoke, and satisfaction with care.
    Impact of the telemedicine intervention on health outcomes 
will be evaluated by comparing mean and adjusted mean levels of 
glycosylated hemoglobin, blood pressure, and lipids in the 
intervention and the control groups. There will be two separate 
analyses. The first is an internal analysis of the randomized 
clinical trial to be conducted by the Columbia University 
consortium analysts. The clinical trial analysis is primarily 
focused on the impact of the telemedicine intervention on 
health outcomes and clinical care of the participants. The 
second evaluation, which is the this project, is to assess the 
financial impact of the of the demonstration. This evaluation 
is independent of Columbia's internal analysis. This financial 
inpact evaluation will focus on whether the home telemedicine 
intervention can increase access to care for Medicare 
beneficiaries in medically underserved areas; whether the use 
of the intervention would reduce health care costs; and whether 
the physicians who are part of demonstration are representative 
of the physician population serving Medicare beneficiaries. 
More specifically, the questions to be addressed are:
        What is the impact of the use of telemedicine and 
        medical informatics on:
        access of Medicare beneficiaries to health care 
        reducing the costs of health care services to Medicare 
        improving the quality of life of Medicare 
        In addition, issues to be addressed may include:
        costs of the telemedicine intervention, with attention 
        to both technology and service costs of the 
        estimation of the cost-effectiveness of the 
        telemedicine interventiondifferences in the physicians 
        who participate in the demonstration from those who do 
        not participate.
    Status: This project is subcontracted to Mathematica Policy 
    Design and Simulation of Alternative Medigap Structure
    Prj #: 500-95-0059/07
    Start Date: 09/30/1999
    End Date: 07/29/2001
    Funding: $588,984
    Vehicle: Task Order
    PI: Lisa Maria Alecxih
    Awardee: Lewin Group, The
    PO: John Robst
    Description: While Medicare benefits are extensive, like 
many insurance products, the program has deductible and co-
insurance requirements as well as limitations on payments to 
providers. On average, basic Medicare benefits alone cover 
about half the personal health care expenditures of aged 
beneficiaries (Laschober and Olin, 1996). Because of these 
``gaps'' in coverage, many beneficiaries choose to purchase a 
supplemental policy, often called ``Medigap.'' The project will 
compile premium data on existing standard Medigap premiums, 
formulate alternative standard benefit packages, and estimate 
premium costs of these alternative packages. From this 
analysis, the current and alternative Medigap options will be 
    Though Medicare supplemental coverage has been available 
since nearly the inception of the Medicare program itself, 
prior to the enactment of the Social Security Disability 
Amendments of 1980, such insurance products were regulated only 
by States. Increasing concerns regarding the confusing array of 
different Medigap products, questionable marketing and sales 
practices, sales of overlapping and duplicative coverage, and 
low loss ratios prompted Congress in 1980 to establish Federal 
standards for Medigap plans. Most States adopted the standards, 
which were developed by the National Association of Insurance 
Commissioners. Continued concern regarding marketing abuses and 
confusion among beneficiaries eventually prompted Congress to 
mandate Medigap policy standards. As a result of the Omnibus 
Budget Reconciliation Act of 1990, effective in 1992, newly 
issued Medigap policies have been required to conform to one of 
ten standardized benefit packages. The law also mandated other 
standards, including minimum loss ratios and a guaranteed open 
enrollment period for new Medicare enrollees. Despite many 
changes in the Medicare programsince the early 1990s, the basic 
benefit structure of Medicare supplemental insurance has 
remained unchanged. This project will examine possible updated 
Medigap benefit structures, and compare these alternatives to 
the premiums and benefit structures of currently available 
supplementary coverage, as well as Medicare+Choice options.
    Status: In progress.
    Health status and Medical Treatment of the Future Elderly: 
Implications for Medicare Program Expenditures
    Prj #:500-95-0056/09
    Start Date: 06/30/1999
    End Date: 06/15/2001
    Funding: $1,582,650
    Vehicle: Task Order
    PI: Dana Goldman, Ph.D., and Michael Hurd, Ph.D.
    Awardee: RAND Corporation, The
    PO: Linda Greenberg, Ph.D.
    Description: This project is designed to develop 
demographic-economic models to project how changes in health 
status, disease, and disability among the next generation of 
the elderly will affect future Medicare spending. The goal of 
this task order is to enable HCFA actuaries and policymakers to 
simulate the impact of changes in health and functional status, 
as well as changes in medical technology, on future costs to 
the Medicare program. The first aim of the model will be to 
answer the question: ``If the current trends in demographics 
continue, and if the future generation of the elderly face the 
same health status and health care environment as today's 
elderly, what will future health care costs be?'' The second 
aim of the model will be to serve as the simulation vehicle for 
evaluating ``what if'' scenarios to explore how various 
assumptions about changes in the health status of the elderly 
and the health care environment will affect Medicare and non-
Medicare costs.
    The models will focus on two key determinants of health 
spending: diseases (and the medical technology to treat them) 
and health status. RAND will use literature reviews and 
technical expert panels (TEPs) to guide the model development 
effort. The literature review effort will focus on five areas:
          Health and disability trends.
          New medical treatments.
          Effects of new technologies on morbidity and 
          Diseases most likely to affect the elderly's future 
        health expenditures.
          Past efforts to model health care expenditures.
    The first TEP--consisting primarily of physicians 
knowledgeable about treatments for the elderly--will identify 
conditions likely to affect expenditures by the future elderly. 
For each condition, the TEP will identify the emerging 
technologies and estimate likely consequences on mortality and 
morbidity. The second TEP--consisting primarily of social 
scientists and modelers--will help determine appropriate health 
status measures, methodologies, and data sets for estimating 
model parameters, and the best modeling techniques.
    RAND will use a microsimulation model to estimate future 
Medicare expenditures. The modeling efforts will consist of 
three components: a ``basic'' model, a ``health status'' model, 
and a ``what if'' model. The ``basic'' model will categorize 
the future elderly population by age and sex, then iteratively 
apply a transition matrix to calculate the status of the 
population at later time periods. This will serve as a useful 
benchmark for subsequent modeling efforts. The ``health 
status'' model will augment the basic model to explicitly 
include health status so that RAND can explore the possibility 
that changes may occur in the health status of the elderly and 
the treatment of particular health conditions among the 
elderly. RAND will use longitudinal datasets to estimate the 
transition rates--the probability that a person (or persons) 
with certain demographic characteristics and known health 
status will transition to another category with a different 
demographic and health status description over some time 
period. RAND will estimate the direct costs of health 
expenditures by fitting parametric models of the distribution 
of expenditures using existing data that link health status to 
spending. Finally, the ``what if'' model will explore changing 
the parameters of the health status model to reflect possible 
changes to the health care environment, including medical 
    Status: The project is well underway. In September 1999, a 
final design report was accepted. In the fall of 1999, project 
staff consulted with nationally-recognized geriatricians to 
discuss which disease groups and specific medical conditions 
should be covered by the medical TEPs. Members have been 
appointed to the medical and social science TEPs. Preliminary 
reviews of the literature are expected prior to theTEP 
meetings. Work on devising a micro-simulation model to estimate 
future Medicare expenditures is underway. Final project results 
are expected by December 2001.
    Retiree Health Benefits
    Prj #:500-95-0061/08
    Start Date: 09/30/2000
    End Date: 06/30/2002
    Funding: $249,971
    Vehicle: Task Order
    PI: Lauren McCormack
    Awardee: University of Wisconsin--Madison/Research Triangle 
    PO: Brigid Goody, Sc.D.
    Description: This project examines current employer-based 
health  insurance  coverage  for  Medicare-eligible  retirees,  
the prospects for continuation of this coverage and possible 
implications for the restructuring of the Medicare fee-for-
service and Medicare+Choice (M+C) programs. Although 
approximately one-third of aged Medicare beneficiaries have 
coverage under an existing employer-sponsored health insurance 
policy, the prevalence of coverage has declined and retiree 
cost-sharing requirements have increased in recent years. If 
current trends continue, the future of employer-sponsored 
coverage of Medicare eligible retirees is not encouraging. 
Declining employer-sponsored coverage could result in more 
Medicare beneficiaries purchasing individual Medigap policies, 
joining Medicare+Choice plans or going without supplemental 
coverage. As Medicare beneficiaries face paying more for 
services previously covered by retiree health insurance, the 
Medicare Program may come under increasing pressure to offer 
additional benefits, most notably outpatient prescription 
    The project will consist of two parts. The first part will 
analyze existing secondary data to describe the types of 
coverage offered to Medicare-eligible retirees, the funding for 
this coverage and recent trends in coverage. The second part 
will be comprised of interviews aimed at understanding the 
prospects for future employer-sponsored coverage of this 
population, possible impacts of Medicare reform initiatives on 
this coverage and how the Medicare Program, both fee-for-
service and managed care, might be restructured to encourage 
continued coverage. Interviewees would, at a minimum, include 
employers, unions, business coalition/purchasing groups and 
outside consultants (insurance agents/brokers, third party 
administrators and professional benefits consultants).
    Status: Research Triangle Institute will perform this 
project under a subcontract
    Health Disparities: Longitudinal Study of Ischemic Heart 
Disease Among Aged Medicare Beneficiaries
    Prj #:500-95-0058/12
    Start Date: 09/22/2000
    End Date: 01/21/2002
    Funding: $282,157
    Vehicle: Task Order
    PI: Jerry Cromwell
    Awardee: Health Economics Research, Inc.
    PO: Linda Greenberg, Ph.D.
    Description: The purpose of this task order contract is to 
assess the use of Medicare covered services among Medicare 
beneficiaries with ischemic heart disease based on 
sociodemographic characteristics (e.g., race/ethnicity, sex, 
age, socioeconomic status). During the past few years, the 
Health Care Financing Administration (HCFA) has undertaken 
several efforts to strengthen the base of knowledge of health 
disparities among racial/ethnic groups. This project is one 
part of a larger HCFA and Department of Health and Human 
Services effort to address health disparities among Medicare 
beneficiaries. This will be done using a longitudinal database 
that links Medicare enrollment and claims data with small-area 
geographic data on income (e.g., U.S. Census data or other 
private data sources). Such information will be useful to 
compare the incidence of disease and the outcomes of diagnostic 
and surgical procedures for ischemic heart disease (IHD) across 
racial/ethnic groups, socioeconomic status, and geographic 
areas. The advantage of a longitudinal database is that it 
provides data at multiple time points during a person's life. 
Due to recent expansions in the race/ethnic coding in the 
Medicare enrollment database (EDB), it is now possible to 
examine health care access, utilization, and outcomes among 
minority groups.
    Status: In progress.
    Patterns of Injury in Medicare and Medicaid Beneficiaries
    Prj #:500-95-0060/04
    Start Date: 09/29/2000
    End Date: 09/30/2001
    Funding: $715,991
    Vehicle: Task Order
    PI: Deborah Garnick
    Awardee: Brandeis University
    PO: Rosemary Hakim, Ph.D.
    Description: This project is a descriptive study of the 
extent and impact of injuries in the Medicare and Medicaid 
populations, and to conduct in depth analyses on specific types 
of injuries. Unintentional injuries accounted for more than 
90,000 deaths in the US in 1997, making this the fifth leading 
cause of death overall. Intentional injuries, suicide and 
homicide, have resulted in more than 50,000 deaths annually 
since 1985. The impact on health care costs, income and 
productivity is significant. Injuries may be an even more 
important cause of mortality and morbidity among persons in 
vulnerable populations, which include the populations served by 
Medicare and Medicaid. While mortality data for injuries are 
available, data addressing the prevalence of morbidity due to 
injuries and the expenditures for related care are not 
available. The Medicare and Medicaid data are particularly well 
suited to assess morbidity due to injuries that are severe 
enough to come to medical attention.
    Status: In progress.
    Examining Gender and Racial Disparities Among Medicare 
Beneficiaries with Chronic Diseases
    Prj #:500-95-0058/15
    Start Date: 09/29/2000
    End Date: 09/28/2001
    Funding: $177,442
    Vehicle: Task Order
    PI: Deborah Dayhoff
    Awardee: Health Economics Research, Inc.
    PO: Marsha G. Davenport, M.D., M.P.H.
    Description: The purpose of this task order is to develop 
and complete an analytic study using the Medicare 
administrative claims files to expand HCFA's knowledge base in 
the area of women's health and chronic diseases. Chronic 
diseases contribute significantly to the morbidity and 
mortality of older Americans. Diseases such as arthritis, 
asthma, chronic obstructive pulmonary disease (COPD) and other 
respiratory conditions, cancers, diabetes, heart disease, 
hypertension, osteoporosis, and stroke comprise the major 
categories of chronic conditions affecting persons age 65 and 
older. Cardiovascular diseases (CVD), primarily heart disease 
and stroke, are the leading cause of death irrespective of 
gender or racial origin. However, for women, cardiovascular 
disease is responsible for more deaths than almost all of the 
leading causes of death, including cancer. The general category 
of cardiovascular diseases (CVD) includes not only heart 
diseases such as coronary heart disease, but also hypertension 
or high blood pressure and stroke. Until recently, death rates 
for coronary heart disease had declined. However, with the 
growing aged population, the slope of this decline has begun to 
level off.
    Another cardiovascular disease with a major impact on the 
aged population is stroke. Stroke is the third leading cause of 
death. Recent studies have identified disparities in treatment 
for heart disease both by gender and race/ethnicity. There are 
a growing number of racial and/ethnic groups in this country 
who appear to be disproportionately sharing the burden of these 
chronic diseases. Just as cardiovascular disease can result in 
disabilities, arthritis and osteoporosis are also diseases that 
cause disability and lost work days. As the population ages, 
the impact of this disease may have major ramifications for 
society as more and more persons become disabled. Osteoporosis 
is a potential cause of disabilities because this disease 
increases the risk of fracture. Data from the Medicare Current 
Beneficiary Survey (MCBS) showed that the percentage of 
Medicare beneficiaries reporting osteoporosis increased with 
increasing age. The study also found that a higher percentage 
of whites reported having had a hip fracture than nonwhites. A 
final category of diseases are the respiratory diseases. Asthma 
and COPD are among the 10 leading chronic conditions. It has 
been found that deaths due to asthma are more likely to occur 
in African Americans and Hispanics than among whites. In 
summary, chronic diseases are quite prevalent in the aged 
population. Little is known about the gender and racial 
differences in patterns of utilization and health outcomes for 
the Medicare population. Findings from this project will assist 
HCFA in targeting policies, programmatic changes, education, 
outreach, research and demonstration projects to achieve 
improved health outcomes for our female Medicare beneficiaries.
    Status: In progress.
    Health status and Quality of Life for Women with Diabetes: 
Data from the Medicare Current Beneficiary
    Prj #:500-96-0516/13
    Start Date: 09/30/2000
    End Date: 09/29/2001
    Funding: $92,490
    Vehicle: Task Order
    PI: Celia H. Dahlman [Fu Assoc's, Sub]
    Awardee: CHD Research Associates, Inc.
    PO: Marsha G. Davenport, M.D., M.P.H.
    Description: This task order will develop a database, 
create analytic files, and provide programming and analytic 
support for studies on beneficiaries with diabetes from the 
Medicare Current Beneficiary Survey (MCBS). These studies will 
focus on gender and racial/ethnic differences for respondents 
in the MCBS who reported having had a diagnosis of diabetes. 
Chronic diseases contribute significantly to the morbidity and 
mortality of older Americans. Diabetes is the seventh leading 
cause of death in this country. However, the true burden of 
diabetes is actually not known, because diabetes frequently 
goes undiagnosed. The Centers for Disease Control and 
Prevention (CDC) estimate that the number of persons with 
undiagnosed diabetes to be over 5 million. At the present time, 
it has been estimated that 10.3 million people have been 
diagnosed with diabetes in the United States. HCFA's Women's 
Health Workgroup developed an initiative on diabetes in 
response to the Department's interest in proposals for the 
Women's Living Long, Living Well and the Prevention 
Initiatives. Diabetes was identified as a disease that affected 
our beneficiaries across the life span and scope of all HCFA's 
programs (Medicare, Medicaid, and the State Children's Health 
Insurance Program). This project is designed to provide a 
mechanism for on-going analyses from the Medicare Current 
Beneficiary Survey (MCBS) and the Medicare administrative files 
that are linked for these survey participants. Through creating 
a database and analytic files, studies on Medicare 
beneficiaries with diabetes can be conducted using several 
years of data from the MCBS. Important issues related to 
health, health status, co-morbid conditions, functional status, 
disability, quality of life as well as costs and utilization of 
health care services can be examined. We plan to study at a 
          Demographic characteristics of beneficiaries who 
        report a diagnosis of diabetes (age; gender; race/
        ethnicity; income; education; marital status; etc.)
          Health and functional status (activities of daily 
        living; instrumental activities of daily living)
          Health care services variables (usual source of care; 
        doctor and emergency room visits)
          Co-morbid health conditions ( heart disease; stroke; 
        blindness; amputations; etc.)
          Utilization of services from the link to the Medicare 
        administrative files for outpatient services; inpatient 
        hospitalizations; etc.
          Use of preventive services appropriate for diabetics 
        (immunizations; eye exams; foot care; etc.)
          Costs associated with preventive care and treatment 
        of Medicare beneficiaries with diabetes.
          Changes in coverage policies for diabetic treatment 
        and care.
    Status: In developmental phase.
    Improving Quality in Long-term Care
    Prj #:HCFA-99-0100
    Start Date: 04/01/1999
    End Date: 03/31/2001
    Funding: $50,000
    Vehicle: Purchase Order
    PI: Janet Corrigan, Ph.D.
    Awardee: National Academy of Sciences, Institute of 
Medicine, Board on Health Care Services
    PO: Sydney P. Galloway
    Description: HCFA provided funds to support a portion of an 
ongoing project in the National Academy of Sciences/Institute 
of Medicine (IOM). Our funding would sponsor an additional 
meeting of the project committee to further explore and 
deliberate on its findings and recommendations related to the 
definition and enforcement of regulatory standards, work-force 
problems, organizational capacity for quality improvement, and 
quality measurement/information strategies in long-term care 
    In 1986, IOM issued the report, Improving the Quality of 
Care in Nursing Homes, which was to serve as a foundation for 
the Nursing Home Reform Act of 1987. Since then, much has 
changed including attitudes about those using long-term care, 
ways of providing care, and strategies for assessing and 
improving the quality of care. In 1997, with primary funding 
from the Robert Wood Johnson Foundation, the IOM appointed an 
expert committee to examine a broader range of long-term care 
services, recipients, and quality improvement strategies than 
those considered in the 1986 report. Questions being 
investigated include:
          What are the demographic, health, and other 
        characteristics of individuals requiring long-term care 
        and how are they changing?
          What are the roles of the various long-term care 
        settings, and how do they relate to other components of 
        community care systems?
          What are the strengths and limitations of existing 
        methods and tools to measure, oversee, and improve 
        quality of care and the outcomes of long-term care?
          How can these methods and tools be improved?
          What is known about the current quality of long-term 
        care in different settings and the extent to which care 
        has improved or deteriorated in the last 10-15 years?
          What is known about the impact of long-term care 
        regulation, especially the Nursing Home Reform Act of 
    After working for over a year, the IOM committee concluded 
that an additional meeting was needed given the complexity of 
the topics being considered and a number of recent developments 
in long-term care, including various initiatives by the 
Department of Health and Human Services. In particular, the 
committee directed that additional report text be drafted 
related to payment issues and research directions. This HCFA 
project provides the support to make this last portion of the 
work possible.
    Status: The final report is completed.
    Direct and Indirect Effects of the Changes in Home Health 
Policy and an Analysis of the Skill Mix of Medicare Home Health 
Services Before and After the Balanced Budget Act of 1997
    Prj #:HCFA-00-0108
    Start Date: 03/16/2000
    End Date: 03/23/2001
    Funding: $24,298
    Vehicle: Simplified Procurement
    PI: Nelda McCall
    Awardee: Laguna Research Associates
    PO: Sydney P. Galloway
    Description: This project provides partial support for a 
project primarily funded by the Robert Wood Johnson Foundation 
(RWJ). As part of this larger project, HCFA supplies needed 
data and receives the results of a special study. The major 
(RWJ) project examines three areas where impacts of the 
Balanced Budget Act (BBA) might fall B the Medicare 
beneficiary, home health care agencies, and the overall medical 
and long-term care system. Analysis based on the data HCFA 
supplies under this award, taken together, will help understand 
the overall pattern of impacts and be useful in formation of 
future reimbursement policy. The special study for HCFA looks 
at beneficiary access. This will analyze pattern of Medicare 
home health use before and after the implementation of the BBA. 
There is a focus on assessing whether changes occurred in the 
skill mix of types of visits received by home health users. It 
will examine whether differential effects have occurred for 
different categories of home health users and in different 
geographic areas.
    Status: The data have been accessed and the analysis are 
being prepared.
    Assessing Readiness of Medicare Beneficiaries to 
Participate in Informed Health Care Choices
    Prj #:17-C-90950/1
    Start Date: 08/17/1998
    End Date: 06/16/2000
    Funding: $63,192
    Vehicle: Cooperative Agreement
    PI: James O. Prochaska, Ph.D.
    Awardee: Pro-Change Behavior Systems
    PO: Sherry A. Terrell, Ph.D.
    Description: This study will adapt the investigator's 
transtheoretical model of health behavior change using the 
Medicare Current Beneficiary Survey (MCBS) data to predict a 
Medicare beneficiary's readiness to make an informed decision 
about his/her Medicare health insurance plan choice. The model 
is a mathematical algorithm that assigns/classifies a case to a 
stage of readiness to make a decision.
    Status: The research team has received MCBS data for 1995-
1997 from HCFA and prepared related analytic files. Once 1998 
MCBS files are available, the transtheoretical model can be 
    Analysis of Medicare Beneficiary Baseline Knowledge Data 
Using MCBS
    Prj #:500-95-0061/04
    Start Date: 06/16/1999
    End Date: 06/15/2002
    Funding: $229,123
    Vehicle: Task Order
    PI: James M. Robinson, Ph.D.
    Awardee: University of Wisconsin--Madison/Research Triangle 
    PO: Sherry A. Terrell, Ph.D.
    Description:The purpose of this project is to analyze 
Medicare beneficiary baseline knowledge data which have been 
previously collected through the Medicare Current Beneficiary 
Survey (MCBS). The program objective is to evaluate National 
Medicare Education Program (NMEP) print material (Handbook: 
1999 and Bulletin) and selected information distribution 
channels (print, Internet, 1-800-MEDICARE). The policy 
objective is to support HCFA strategic plan initiatives, 
contribute to Government Performance and Results Act program 
performance reporting, and provide feedback for monitoring and 
continuous quality improvement of NMEP informational materials 
directed to the Medicare population over time.
    Status: The project is in the first of two phases. An 
analysis plan has been approved for Phase I, MCBS data user 
agreements executed, and MCBS Access to Care files for 1995-
1997 and associated supplemental files have been received. 
Phase I data analyses have begun and several working measures 
of knowledge constructed. A report entitled ``A Knowledge Index 
Technical Note'' using Phase I data has been received and is 
under review. Phase II will extend Phase I analyses using MCBS 
1998 Access to Care files including special supplements--Round-
23 (beneficiary knowledge) and Round-24 (beneficiary needs).
    Survey and Evaluation of New Medicare Members of 
Medicare+Choice Plans
    Prj #:500-95-0047/07
    Start Date: 09/08/1999
    End Date: 09/07/2001
    Funding: $657,583
    Vehicle: Task Order
    PI: Merrile Sing, Ph.D.
    Awardee: Mathematica Policy Research, Inc
    PO: Peri Iz, Ph.D.
    Description: The purpose of this project is to design a 
survey for and collect data from Medicare beneficiaries who are 
new members of Medicare+Choice (M+C) plans and to evaluate the 
effectiveness of the National Medicare Education Program (NMEP) 
for these beneficiaries. The objective is to understand the 
special information needs of new Medicare members, their 
sources of information (who/where), their preferred 
distribution channels (how), their understanding of the basic 
(standard) Medicare program, their understanding of their 
particular M+C plan, and the impact NMEP activities may have on 
new members' decision to choose an M+C plan or change their 
plan. This project does not include the disenrollee population. 
The project will support HCFA strategic plan initiatives, 
contribute to Government Performance and Results Act program 
performance reporting, and provide feedback for monitoring and 
quality improvement to NMEP informational materials directed to 
the M+C population over time.
    Status: This project is in the start-up phase.
    Evaluation of the Home & Community-based Services Waiver 
    Prj #:500-96-0005/03
    Start Date: 09/30/1998
    End Date: 03/29/2002
    Funding: $2,308,371
    Vehicle: Task Order
    PI: Lisa Maria Alecxih
    Awardee: Lewin Group, The
    PO: Renee Mentnech
    Description: The Home and Community-Based Services (HCBS) 
Waiver Program has been operating since 1981 and has 
experienced tremendous growth in recent years. The percent of 
Medicaid long-term care spending devoted to HCBS has increased 
from 10 percent to 19 percent (between the financial and 
beneficiary-level impacts of the program) in over a decade. The 
aim of this task order is to gain a better understanding of the 
broader HCBS waiver program and determine what programmatic 
mechanisms have been successful.
    Status: The project is ongoing.
    Study of the Impact of Boren Amendment Repeal on Medicaid 
Skilled Nursing Facilities
    Prj #:Other/CF-1999-1
    Start Date: 01/01/1999
    End Date: 12/31/2000
    Funding: $280,000
    Vehicle: Grant
    PI: Christine Bishop, Ph.D.
    Awardee: Brandeis University, Heller Graduate School, 
Institute for Health Policy
    PO: Paul J. Boben, Ph.D.
    Description:This project examines the impact of the repeal 
of the Boren Amendment through a study of the relationship 
between States' Medicaid payments to nursing homes and quality 
and access to care for Medicaid recipients. The results of this 
research will assist HCFA in preparing a report to Congress on 
the effects of Boren Amendment repeal, as mandated by the 
Balanced Budget Act of 1997. HCFA's participation in this 
project is primarily to supply the needed data and to supervise 
its use.
    Status: The research team has just begun looking at data 
from the Online Survey Certification and Reporting system and 
Skilled Nursing Facility Cost Report data bases maintained by 
HCFA. A report examining the relationship between State 
Medicaid reimbursements for skilled nursing facilities and 
access and quality of care for Medicaid eligibles is expected 
    Study of the Impact of Boren Amendment Repeal on Nursing 
Facility Services for Medicaid Eligibles
    Prj #:500-95-0060/03
    Start Date: 09/29/2000
    End Date: 10/10/2001
    Funding: $268,875
    Vehicle: Task Order
    PI: Christine Bishop
    Awardee: Brandeis University
    PO: Paul J. Boben, Ph.D.
    Description: The purpose of this project is to study of the 
impact of repeal of the Boren Amendment on Medicaid eligibles= 
access to Nursing Facility (NF) services and the quality of 
care available to them in those facilities. The results of the 
study will enable HCFA to submit the required Report to 
Congress. The Balanced Budget Act of 1997 (BBA) effected the 
repeal of a provision of Medicaid commonly known as the ABoren 
Amendment. The Boren Amendment provided lower limits on the 
amounts states could pay three types of institutional 
providers: hospitals, nursing facilities and intermediate care 
facilities for the mentally retarded (ICF/MR). State payments 
had to be sufficient to cover the cost of Aefficiently and 
economically operated facilities. The BBA also required HCFA to 
study the effect of this repeal of the Boren Amendment on 
access to care and quality of care provided to Medicaid 
eligibles in these facility types. A Report to Congress must be 
submitted by August 7, 2001. To partially fulfill this 
statutory requirement, HCFA entered into a collaborative 
arrangement with The Commonwealth Fund and Brandeis University 
to study the relationship between state Medicaid reimbursement 
policy and access to care and quality of care for Medicaid 
eligibles in NFs. The Commonwealth Fund provided financial 
support through a grant to Brandeis. HCFA's contribution has 
been technical guidance and data, and in exchange was promised 
a report that would have provided the basis for the Report to 
Congress. The research plan of the Brandeis/Commonwealth 
project relies on a number of strategies. First, survey data 
collected under a HCFA contract by Wichita State University and 
the University of California, San Francisco are used to track 
changes in states NF reimbursement policies in the aftermath of 
Boren Amendment repeal. Data from other sources--HCFA's OSCAR 
and Medicare SNF cost reports databases--are used to construct 
other variables that measure the relevant policy outcomes: 
access to NF services and quality of care in those facilities. 
Statistical methods are then used to determine what 
relationships exist (if any) between the outcome variables and 
state Medicaid reimbursement policy variables. Finally, 
additional qualitative information on state responses to Boren 
Amendment repeal is drawn from parallel research conducted by 
an independent researcher also working under a Commonwealth 
Fund grant and the Urban Institute through their Assessing the 
New Federalism Project. Phase I of the project (November 1998 
to December 2000) consists of a cross-sectional study of the 
relationship between state payment policy and the relevant 
outcome variables using data from 1996 (prior to Boren 
Amendment repeal). Phase II (January through December 2001) 
will expand the analysis to include data from 1999, allowing a 
study of changes since the repeal of the Boren Amendment. In 
November 1998, The Commonwealth Fund approved grant funding for 
Phase I, and Brandeis University researchers began work shortly 
thereafter. In January 1999 a Memorandum of Understanding was 
signed formalizing the collaborative relationship between HCFA 
and Brandeis University. On June 12, 2000, however, The 
Commonwealth Fund informed HCFA that they would not provide 
financial support for Phase II of the research. In order for 
the Report to Congress can be submitted in a timely fashion 
HCFA must now bring the research to completion.
    Status: This project is underway.
    Mauli Ola (Spirit of Life) Project
    Prj #:18-C-91142/9
    Start Date: 09/28/2000
    End Date: 09/27/2005
    Funding: $704,055
    Vehicle: Cooperative Agreement
    PI: Charman Akina
    Awardee: Waimanalo Health Center
    PO: Stephanie Monroe
    Description: A significant number of Native Hawaiians do 
not access medical services on a timely basis, even when such 
services are made available and affordable. Of those who do, 
their continues to be a significant rate of continued medical 
non-compliance. This appears to be the case even where patients 
demonstrate a basic understanding of the medical basis and 
management strategy of their illness. Simple, straightforward 
medical information and instruction are not, it seems, 
sufficient as behavior motivators to effect long-standing 
behavioral change in the Native Hawaiian population. It is this 
underlying behavioral motivation that the Waimanalo Health 
Center proposes to address in an integrated and comprehensive 
outreach and preventive health demonstration project. The 
Center proposes to significantly increase the number and 
intensity of personal and culturally relevant motivators to 
effect positive lifestyle changes. The Center would provide 
culturally relevant and medically sound outreach, screening, 
educational, and preventive health services for its entire 
service area.
    Status: This project is underway.
    State of Minnesota ``Senior Health Options (MSHO) Project
    Prj #:11-W-00024/5
    Start Date: 04/01/1995
    End Date: 12/01/2000
    Funding: $0
    Vehicle: Waiver-only Project
    PI: Pamela Parker
    Awardee: Minnesota, Department of Human Services
    PO: Linda Frisch
    Description: In April 1995, the State of Minnesota was 
awarded Medicare and Medicaid waivers for a 5-year 
demonstration designed to test delivery systems that integrate 
long-term care and acute-care services for elderly dual 
eligibles. The State targeted the elderly dually-entitled 
population that resides in the seven-county metro area and St. 
Louis county. Elderly Medicaid eligibles now required to enroll 
in the State's current section 1115 Prepaid Medical Assistance 
Program (PMAP) Demonstration are being given the option to 
enroll in the Senior Health Options (SHO) Project, which in 
essence adds long-term care and Medicare benefits to basic PMAP 
benefits. Under this demonstration, the State is being treated 
as a health plan that contracts with HCFA to provide services, 
and provides those services through subcontracts with various 
appropriate providers. The State is continuing its current 
administration of the Medicaid-managed care program while 
incorporating some Medicare requirements that apply directly to 
the health plans with which the State would subcontract for 
SHO. HCFA's direct oversight functions will continue to apply 
to the overall demonstration and managing entity, which will be 
the State.
    Status: The State implemented the project in March 1997. It 
is currently ongoing.
    Multi-state Evaluation of Dual Eligibles Demonstrations
    Prj #:500-96-0008/03
    Start Date: 09/30/1997
    End Date: 09/29/2002
    Funding: $2,155,854
    Vehicle: Task Order
    PI: Robert L. Kane, M.D.
    Awardee: University of Minnesota
    PO: Noemi V. Rudolph
    Description: This evaluation is designed to assess the 
impact of dual eligible demonstrations in the States of 
Minnesota, Colorado, Wisconsin and New York. Analyses will be 
conducted for each State and across States. The quasi-
experimental design will utilize surveys, case studies, and 
Medicare and Medicaid data for analysis. Major issues to be 
examined include the use of a capitated payment strategy to 
expand services while reducing/controlling costs, the use of 
case management techniques and utilization management to 
coordinate care and improve outcomes and the goal of responding 
to consumer preferences while encouraging the use of 
noninstitutional care. A universal theme to be developed is the 
difference between managing and integration.
    Status: Beneficiary surveys have been completed in the 
Minnesota demonstration. Beneficiary surveys for the Wisconsin 
demonstration are planned to be conducted in early 2000. Two 
case study reports and the First Annual Report have been 
submitted to HCFA. The New York demonstration received its 
waivers in September 1999 and increased evaluation activities 
will soon be underway.
    Wisconsin Partnership Program
    Prj #:11-W-00123/05
    Start Date: 10/16/1998
    End Date: 12/31/2004
    Funding: $0
    Vehicle: Waiver-only Project
    PI: Steve Landkamer
    Awardee: Wisconsin Division of Health and Family Services, 
Department of Health and Family Services
    PO: James Hawthorne
    Description: The State submitted an application t in 
February 1996 for Medicare and Medicaid demonstration waivers 
to establish a ``Partnership'' model of care for dually-
entitled nursing home-certifiable beneficiaries who are either 
under age 65 with physical disabilities or frail elders. This 
project is utilizing Centers for Independent Living in Madison 
and Eau Claire. This is believed to be the first site in the 
nation offering fully capitated Medicare and Medicaid services 
for people with physical disabilities. Waivers were approved on 
October 16, 1998 and one site (Elder Care--Madison) became 
operational on January 1, 1999. Community Care for the 
Elderly--Milwaukee expected to become operational on March 1, 
1999. Community Living Alliance--Madison and Community Health 
Partnership--Eau Claire expected to become operational in the 
spring of 1999. The ``Partnership'' model is similar to the 
Program for All-inclusive Care for the Elderly (PACE) model in 
the use of multidisciplinary care teams, prepaid capitation, 
and sponsorship by community-based service providers. Rather 
than the physician being co-located with the multi-disciplinary 
team, the Partnership program will enable participants to use a 
physician of their choice in the community who agrees to 
participate as a contractor with the Partnership plan. This 
model utilizes nurse practitioners and other multidisciplinary 
team members to provide continuity and coordination with the 
physicians who elect to participate. The Partnership also will 
rely less on adult day care centers than do PACE sites as the 
organizing focus for the provision of care. The model is 
proposed as a fully voluntary enrollment model for 1,200 
beneficiaries. All Medicare and Medicaid covered benefits are 
offered under full capitation for eligible participants who 
elect to enroll. Partnership sites for the frail elderly are 
the existing PACE sites in Milwaukee and Madison. The 
Partnership model for people with disabilities will utilize 
Centers for Independent Living in Madison and Eau Claire. The 
model for people with disabilities is believed to be the first 
site in the nation for fully capitated Medicare and Medicaid 
services for people with physical disabilities. Partnership 
sites for the frail elderly are the existing PACE sites in 
Milwaukee and Madison.
    Status: The four sites became operational in early 1999 and 
by the end of the year had a combined enrollment of over 700. 
An evaluation of the Partnership, under separate contract, 
began in mid-1999.
    Continuing Care Network Demonstration, Technical Assistance 
and Third Party Assessments
    Prj #:18-C-91101/2
    Start Date: 09/30/1999
    End Date: 03/05/2005
    Funding: $437,994
    Vehicle: Cooperative Agreement
    PI: Helena Temkin-Greener, PhD
    Awardee: Community Coalition for Long Term Care
    PO: Noemi V. Rudolph
    Description: This initial award is part of a multi-year 
technical assistance and third party assessment for the 
Continuing Care Network (CCN) demonstration project in Monroe 
County. Specific objectives include: (1) to analyze and compare 
the proposed HCFA Medicare+Choice capitation methodology with 
the CCN demonstration risk-adjusted payment model, (2) to 
assure the collection of assessment data and administer a 
subcontract with the independent assessor, (3) to design and 
empirically test a Medicare and Medicaid risk/savings sharing 
model, and (4) to examine CCN strategies for outreach/
education, marketing, and enrollment especially as it pertains 
to the frail and dual eligibles. Data sources will include: the 
Monroe County Medicare and Medicaid Database and the CCN 
demonstration database, surveys, assessments conducted by the 
independent assessor and by care plan nurses, interviews, and 
focus groups.
    Status: In progress.
    Continuing Care Network Demonstration
    Prj #:11-W-00126/2
    Start Date: 09/30/1999
    End Date:
    Funding: $0
    Vehicle: Waiver-only Project
    PI: Linda Gowdy
    Awardee: New York State Department of Health, Bureau of 
Continuing Care Initiatives
    PO: Noemi V. Rudolph
    Description: Medicare waivers were approved for this 
demonstration on September 1999. The CCN project, a 5-year 
demonstration, is designed to test the efficiency and the 
effectiveness of financing and delivery systems that integrate 
primary, acute and long term care services under combined 
Medicare and Medicaid capitation payments based on functional 
status. The CCNs will enroll, over a five-year period, at least 
10,000 Medicare-only and dually eligible beneficiaries who are 
65 or older in Monroe County, New York. This population will 
include those residing in nursing facilities, the nursing home 
certifiable living in the community, and the unimpaired. This 
is a voluntary program for both Medicare and dually eligible 
beneficiaries. The approval is the first to combine the 
authority under Section 402 of the Social Security Amendments 
with the authority of Sections 1915(a) and 1915(c). The State 
will amend the (Medicaid) State Plan to include a new class of 
managed care organizations that will allow them to capitate 
Medicaid service costs with home and community-based services 
and to pay the CCNs one capitated payment for each Medicaid 
enrollee. The State will also apply a parallel 1915(c) waiver 
to support case management and invoke spousal impoverishment 
protection for nursing home certifiable enrollees living in the 
community. A limited chronic care benefit of up to $2,600 per 
year (and not to exceed a $6,000 lifetime maximum) will be 
available to all that join the CCN as community-based 
unimpaired participants on enrollment. The DMS-1 assessment 
instrument, which is normally employed to assess nursing home 
certifiability in New York State, will be used to place 
enrollees who are nursing home certifiable in the community 
into one of the three rate cells based on level of impairment. 
An independent third party assessor will conduct initial and 
subsequent DMS-1 assessments, since the result of this 
assessment will be used for both care planning and rate cell 
    Status: In progress.
    Demonstration Project for Institutionalized Dually Eligible 
    Prj #:99-C-90869/3
    Start Date: 04/30/1999
    End Date: 06/30/2000
    Funding: $59,538
    Vehicle: Cooperative Agreement
    PI: Martin Wasserman, MD
    Awardee: Maryland Department of Health and Mental Hygiene
    PO: James Hawthorne
    Description: This Cooperative Agreement provides the 
Maryland State Department of Health and Mental Hygiene (DHMH) 
with funds to purchase technical assistance and to support 
planning activities to develop two demonstration projects to 
assist persons with physical disabilities who are under age 65 
to move from nursing facilities to community-based settings. 
The demonstrations would provide care coordination on a 
capitated basis and would emphasize consumer choice and 
direction. The demonstrations would depend on existing Medicare 
Managed Care Organizations (MCOs) to enroll eligible 
beneficiaries and to provide their medical care. The MCO's 
would sub-contract with community based organizations, such as 
Centers for Independent Living, to assist participants in 
obtaining appropriate support services in the community and to 
facilitate coordination of these services and the beneficiaries 
medical care. DHMH has sub-contracted the developmental work 
for this demonstration to the Center for Health Plan 
Development and Management (CHPDM) at the University of 
Maryland in Baltimore County.
    Status: DHMH has subcontracted the developmental work for 
this demonstration to the Center for Health Plan Development 
and Management at the University of Maryland in Baltimore 
County. The project has hired staff to coordinate planning 
activities and has assembled a task force comprised of 
consumers, providers, and representatives from DHMH to guide 
the planning process. The project is on schedule for the 
projected completion date of June 30, 2000.
    Multi-state Dual Eligible Data Base and Analysis 
    Prj #:500-95-0047/03
    Start Date: 09/30/1997
    End Date: 09/30/2001
    Funding: $2,135,418
    Vehicle: Task Order
    PI: Don Lara
    Awardee: Mathematica Policy Research, Inc.
    PO: William D. Clark
    Description: This project will use available Medicare/
Medicaid-linked statewide data in 10-12 States to develop a 
uniform database that can be used by States and the Federal 
Government to improve the efficiency and effectiveness of the 
acute- and long-term-care services to persons eligible for both 
Medicare and Medicaid (dual eligible). It will also conduct 
analyses derived from these data to strengthen the ability to 
develop risk-adjusted payment methods and deepen the 
understanding of Medicare-Medicaid program interactions as they 
relate to access, costs and quality of service. Finally, it 
will recommend longer-range options that will improve the 
usefulness of the database for operational and policy purposes.
    Status: The project is constructing a multistate dual 
eligible database and using these data for analyses.
    Case Studies of Managed Care Arrangements for Dual Eligible 
    Prj #:500-95-0048/08
    Start Date: 08/26/1999
    End Date: 02/25/2001
    Funding: $367,135
    Vehicle: Task Order
    PI: Edith Walsh
    Awardee: Health Economics Research, Inc.
    PO: William D. Clark
    Description: The purpose of this project is to obtain 
greater knowledge of the dynamics of Medicare and Medicaid 
coordination of eligibility, benefits, and services at the 
health plan level. It will provide preliminary identification 
of issues that the Health Care Financing Administration, 
States, health plan contractors and beneficiaries should 
prioritize and address. It will identify exemplary and routine 
approaches implemented by health plans for further 
consideration and potential adoption by others. This project 
examines health plans including their provider networks, care 
management activities and beneficiary experiences. It will 
identify exemplary and routine approaches implemented by health 
plans for further consideration and potential adoption by 
others. In 1997, an estimated 6.7 million Medicare 
beneficiaries received some level of additional benefits 
through Medicaid buy-in at some point during the year. These 
dual eligible beneficiaries are estimated to represent 17 
percent of all Medicare beneficiaries in 1997, and are 
estimated to account for at least 28 percent of total Medicare 
expenditures. For Medicaid, enrollment and expenditure 
experience is strikingly similar. Dual eligible beneficiaries 
are estimated to represent 19 percent of total enrollment and 
35 percent of Medicaid expenditures, of which 57 percent is 
Federal match to States. The growing importance of the dually 
eligible population is magnified by the fact that the 
population of Americans over 80+, those most likely to become 
dually eligible due to frailty and impairment, is expected to 
grow by 100 percent for men and 50 percent for women by the 
year 2025. Beneficiaries dually entitled for Medicare and 
Medicaid obtain health insurance coverage from these programs 
in many combinations. They may be entirely in traditional fee-
for-service, Medicare+Choice risk contract plans with Medicaid 
benefits in fee-for-service, Medicaid managed care arrangements 
of varying definitions with Medicare fee-for-service, or in 
combinations of Medicare and Medicaid contractual arrangements 
within the same health plan organization. Some Federal 
demonstration health plans more consciously attempt to 
integrate Medicare and Medicaid financing at the plan level. It 
is believed that, through improved contractual arrangements, 
additional efficiencies in the organization and delivery of 
services may lead to improved health plan performance. The 
combined financing is intended to facilitate the integration of 
medical care, hospitalization, and post-acute services with 
community and/or residential supportive services and other 
benefits, including prescription drugs. The availability of 
this array of options varies considerably in health plans 
across the United States. Even though total enrollment and 
costs for services used by dual eligible beneficiaries in 
Medicare and Medicaid represents a substantial figure, the 
bifurcation of responsibility for this population results in a 
consideration of dual eligibility as a subset of each program 
subject to the statutory requirements of each. Rarely has a 
lens been applied to program changes mandated in either program 
that considers the impact of changes in one program and 
resulting consequences on the other. The Balanced Budget Act 
changes in Medicare home health payment and consequences for 
State Medicaid illustrates this point. Similarly, research that 
illuminates dual eligible issues often is focused on either 
Medicare or Medicaid, but rarely both. There are many reasons 
for this including data incompatibility, source of funding, and 
primary purpose of the research. This task order is one of a 
number of efforts intended to apply a lens to dual eligible 
issues as the central point of focus. In this study the 
dynamics of Medicare and Medicaid interactions at the health 
plan level are to be investigated. Given the difficulty in 
seeking to change both Medicare and Medicaid programs by 
Statute or through demonstration and program waivers in order 
to improve service delivery systems for dual eligible 
beneficiaries, it is essential to develop a more complete 
understanding of the way these programs interact at the 
provider and beneficiary level. While it is important to 
determine exemplary solutions to common problems that may have 
potential for replication by others, it is equally important to 
obtain a realistic portrait of the abilities and limitations of 
health plans in working with the Medicare and Medicaid programs 
to accomplish the facilitation, coordination, and integration 
of health and supportive services for dual eligible 
    Status: The project is in the start-up phase.
    Factors Associated with Low Mammography Rates among Elderly 
    Prj #:20-P-90895/4
    Start Date: 09/27/1998
    End Date: 09/26/2000
    Funding: $240,035
    Vehicle: Grant
    PI: Alma R. Jones
    Awardee: Morehouse School of Medicine
    PO: Richard Bragg
    Description: The overall objective for the research is to 
provide information that will ultimately lead to reductions in 
breast cancer mortality among African American Medicare 
beneficiaries, 65 years old and older in Fulton County and 
DeKalb County, Georgia, by increasing the percentage of this 
population that is screened for breast cancer annually. The 
project will address the low mammography screening rates for 
African American, nonhealth-maintenance-organization Medicare 
beneficiaries in Fulton and DeKalb counties. The study will 
develop, field test, evaluate, and disseminate a model for 
identifying barriers to test breast cancer screening among 
various populations. The proposed study will build upon 
research previously performed by the breastcancer prevention 
research group at Morehouse. In this instance, a trial to 
increase the rate at which inner-city African American women of 
various ages obtain breast and cervical cancer screening was 
designed. Hence, the Principal Investigator wants to: Increase 
the knowledge of breast cancer and improve the attitude toward 
breast cancer screening. Increase the rate at which annual 
screening mammograms are secured in the study population.
    Status: This project, which was awarded under HCFA's grant 
program for Historically Black Colleges and Universities, is in 
    Health Promotion in the African American Community: A 
Computer-Based Nutrition Program
    Prj #: 20-P-91120/6
    Start Date: 09/25/2000
    End Date: 09/24/2001
    Funding: $120,754
    Vehicle: Grant
    PI: JoAnn Blake
    Awardee: Prairie View A&M; University
    PO: Richard Bragg
    Description: The purpose of the study is to investigate the 
effectiveness of a computer-based nutrition education program 
on the use of health promotion behaviors by African American 
adults in community settings as compared to traditional methods 
of instruction. An interactive multimedia computer program will 
be used to teach nutrition to African American adults. A 
research team of faculty and nursing students will implement 
project activities. The investigators plan to validate the 
feasibility of computer based intervention strategies and 
materials that are designed to teach African American adults 
about nutrition in a community setting when compared to 
traditional methods of instruction. The project goals are: (1) 
to form collaborative partnerships within minority communities 
in need of health promotion focusing on nutrition, (2) to 
examine the difference in outcomes of health education using a 
computer based delivery method when compared to traditional 
methods, and (3) to determine the feasibility of using a 
computer-based education program to teach health promotion to 
African American adults in urban community settings. A study 
population of 200 individuals will be recruited from the 
community. A two group pretest (Nutrition Survey and Health 
Promotions Lifestyle Program (HPLP) behavior rating scale)--
posttest design will be used. The software program will present 
information in a cultural relevant way that may be 
individualized to the subject. A panel of experts will review 
the program.
    The experimental group will complete the pretest that 
consists of a questionnaire on nutrition and the Health 
Promotion Lifestyle Profile. The pretest instruments are 
designed to determine baseline knowledge and use of health 
promotion behaviors. After the baseline data is collected, the 
experimental group will complete a multimedia interactive 
computerized nutrition program developed by the investigators. 
Instruction on nutrition in the areas of need identified by the 
computer program will be provided. The control group will 
complete the baseline data collection process, receive printed 
information in the form of pamphlets and will be provided with 
group instruction on nutrition. The researchers will be 
available to assist with use of the computers and completion of 
the data collection instruments. A body mass index will be 
calculated for all participants and the posttest will be 
administered 3 months and 6 months after the start of the 
project. The applicant will develop and test the computer 
program before using it with the experimental group.
    Status: Study is in development phase.
    Increasing Breast Cancer Screening in African American 
Women: A Community Pilot Project
    Prj #: 20-P-91123/4
    Start Date: 09/25/2000
    End Date: 09/24/2001
    Funding: $124,990
    Vehicle: Grant
    PI: Margaret Hargreaves
    Awardee: Meharry Medical College
    PO: Richard Bragg
    Description: The study seeks to determine the extent to 
which breast cancer screening can be increased among low income 
and elderly African-American women living in the Nashville area 
(more specifically, around the East Nashville Family Health 
Care Group Practice -ENC), using a combination of culturally 
appropriate strategic approaches that are implemented through a 
coordinated community effort. The main goal is to develop, 
implement, and evaluate a culturally-sensitive multi-faceted 
pilot program that seeks to improve breast cancer screening 
knowledge (K), attitudes (A), and practices (P) in a high risk 
population of poor and elderly African American women. The 
specific objectives are: (1) to increase breast cancer 
knowledge (K) in the targeted risk groups by 20 percent above 
baseline; (2) to improve attitudes toward cancer screening (A) 
by at least 1 standard deviation above baseline values; (3) to 
increase the number of mammograms completed (P) among the 
targets risk groups by 20 percent above baseline rates; and (4) 
to improve the rate of early detection in the targeted risk 
groups by 20 percent above baseline levels. This 2 year project 
will involve a collaborative venture between Meharry's Cancer 
Control Research Unit, the East Nashville Family Health Care 
Group, the Community Coalition for Minority Health, the Middle 
Tennessee Breast and Cervical Cancer Screening Coalition, and 
other selected organizations and individuals in the East 
Nashville Community who have an interest in breast cancer 
prevention and control. The study has three phases: Phase 1: 
Planning, 1-6 months; Phase 2: Implementation, 7-22 months; and 
Phase 3: Evaluation, 9-24 months. Under Phase I four main 
activities are proposed to be conducted: These activities are: 
(1) Working with community organizations (becoming 
knowledgeable with how the East Nashville community is 
organized). (2) The development of an intervention program: (a) 
cluster profiling methodology, (b) social marketing 
methodology, and (c) stages of change methodology. (3) Training 
health educators for the project. (4) Baseline data collection 
KAP and barriers questionnaires administered. Random sample of 
at least 100 women selected from cluster profiles around the 
target area. Questionnaires will be administered by telephone.
    Status: Project is underway.
    Efficacy of a Culturally Sensitive Health Promotion Program 
To Improve Exercise and Dietary Behaviors in African American 
Elders with Hypertension
    Prj #: 20-P-91130/7
    Start Date: 09/25/2000
    End Date: 09/24/2001
    Funding: $98,838
    Vehicle: Grant
    PI: Lucille Davis
    Awardee: Southern University and A&M; College, School of 
    PO: Richard Bragg
    Description: The project is to test the efficacy of a 
culturally sensitive health promotion program that seeks to 
improve exercise and diet, two behaviors important in 
controlling hypertension in African American elders with 
hypertension. The project will compare the impact of outcomes 
of; (1) knowledge, (2) efficacy expectations and outcomes 
(beliefs about performing exercise and dietary behaviors), and 
(3) stages of change on exercise and dietary behaviors of 
elders who participate in one of two versions of a health 
promotion program. One version would use a culturally sensitive 
health promotion videotape (HPV) and the other, a culturally 
sensitive health promotion self-care manual (HPM). These tools 
have already been developed under a previously funded project. 
The project will have a quasi-experimental design to test the 
efficacy of using culturally sensitive videotapes and self care 
manuals as part of a health education program to improve 
hypertension knowledge, efficacy, stages of change, and 
exercise behaviors in African American elders with 
hypertension. The first year will be conducted in Baton Rouge, 
LA and the second year in Jackson, MS, under the coordination 
of the two participating universities. The intervention will be 
conducted at public housing complexes and involve resident 
coordinators who would serve as liaison between participants 
and researchers. In Louisiana, the study population will be 
drawn from 6 housing complexes involving approximately 700 
units with a large proportion of older African Americans. In 
Mississippi, 498 units including 152 units exclusively for the 
elderly, and 346 units for multi-generational families will 
comprise the target population. The sample size will consist of 
150 African Americans, 50 individuals in each of the 3 groups. 
Buildings will be randomized to one of the three groups. 
Recruitment will involve meeting with staff and residents in 
the designated buildings. Strategies to prevent attrition will 
include weekly classes. Group one will use the videotape as 
part of a lecture-discussion and skill building class. Elders 
will also be given a copy of the videotape and instructions on 
its use between classes. This group will be given a copy of the 
manual and instructed on its use between classes. The control 
group will not receive the intervention.
    Provisions and incentives are incorporated into the design 
to assure retention of subjects and to control for potential 
intervention variability across sites. For example, a small 
stipend will be paid for each interview. Inclusion criteria for 
participating in the study are explicit and appropriate to the 
goals and objectives of the study. Data will be collected at 
baseline and remeasured at 3 and 6 months on 9 variables.
    Status: Project is in development
    A Population-Based Case Control Study of Ethnic Differences 
in the Utilization of Elective Hip or Knee Replacement Surgery 
for Arthritis
    Prj #: 25-P-90948/6
    Start Date: 09/30/1998
    End Date: 09/29/2000
    Funding: $250,000
    Vehicle: Grant
    PI: Agustin Escalante
    Awardee: University of Texas Health Science Center at San 
    PO: Richard Bragg
    Description: This project examines the utilization of 
elective hip or knee replacements for arthritis among Hispanics 
and non-Hispanics in Bexar County, Texas. It directly assesses 
persons hospitalized for these procedures between February 1999 
and January 2000. The objectives of the project are to: Compare 
ethnic background between persons hospitalized for elective 
arthritis-related hip/knee replacement surgery and persons 
hospitalized for other reasons. Examine the association between 
socioeconomic status and acculturation and the likelihood of 
recipients of hip/knee replacements being Hispanics compared to 
others. Measure age-adjusted rates of elective replacement 
surgery. Investigate to what extent Bexar County residents who 
are Medicare and Medicaid beneficiaries undergo these elective 
procedures outside the county. First, a case-control study will 
be conducted comparing the ethnic background of recipients of 
an elective arthritis-related hip or knee replacement surgery 
against the ethnic background of age- and gender-matched 
controls hospitalized for other reasons. Second, population-
based utilization rates will be developed for these elective 
procedures using census-derived demographic information as the 
denominator population. Finally, the completeness of these 
estimates will be assessed using Medicare and Medicaid claims 
data to measure the extent to which Bexar County residents 
selected these elective procedures in hospitals outside their 
county of residence.
    Status: This project, which was awarded under the Hispanic 
Health Services Research Grant Program, is in progress.
    Cervical and Breast Cancer Screening for Post-Reproductive 
Age Hispanic Women Residing Near the U.S.-Mexico Border
    Prj #: 25-P-91062/9
    Start Date: 09/20/1999
    End Date: 09/19/2001
    Funding: $263,281
    Vehicle: Grant
    PI: Francisco A.R. Garcia, MD, MPH
    Awardee: University of Arizona, Arizona Board of Regents
    PO: Richard Bragg
    Description: The U.S.-Mexico border area in general and the 
Arizona (U.S.)-Sonora (Mexico) border area in particular has 
had a history of economic ties and the sharing of physical, 
economic ties, cultural, and health characteristics. The 
proposed study, which focuses on the border community of 
Douglass/Sulphur Springs Valley in Arizona, highlights the 
immense and unique health problems that plague the U.S.-Mexico 
border region. Some of the main contributing factors associated 
with the myriad of health problems in the region include: 
poverty, unavailability, and accessibility of preventive health 
and treatment services. Because there is a sparsity of research 
in the area that addresses the health of the population, as 
well as the dynamics associated with the etiology of prevalent 
diseases, there may very well be an underestimation of the 
incidence and prevalence of various diseases that seemingly 
disproportionately afflict the population. Of particular 
interest to the researchers is the preventive value of 
screening for cervical and breast cancers associated with 
Hispanic women who live in a border community (Douglass) on the 
U.S.,-Mexico border. Reports suggest that breast and cervical 
cancers may be two to three times higher for Mexican Americans 
than for non-Hispanic whites.
    The study proposes to address these problems by providing 
information on : (1) the prevalence of breast and cervical 
cancers, (b) barriers that affect access to and utilization of 
health care, including screening services; and (c) successful 
intervention strategies (involving health workers or 
promotoras) that increase participation in and and sustained 
involvement with breast and cervical cancer screening services. 
To achieve this, the researchers propose to develop culturally 
competent health promotion activities that will: (a) increase 
rates of routines breast and cervical disease screening, (b) 
promote disease prevention strategies, and (c) address the 
significant cultural and structural barriers faced by these 
women. This study will allow the researcher to address these 
problems by using a 2-year community-based cohort intervention 
study. Using data collected from a population-based cross-
sectional survey involving 600 women who will be interviewed, 
the study seeks to gather information relating to utilization 
and barriers to utilization of breast and cervical cancer 
screening services. Following the completion of the interview, 
the interviewer will assist the participant in scheduling a 
clinic visit to have a variety of screening tests (e.g., pelvic 
examination, including a pap smear; telecolposcopy; sampling 
for HPV infection; and breast examination. Instruments or 
questionnaires to be used in the study will be built from 
previous or existing questionnaires associated with earlier and 
ongoing projects that the PI and his research team are 
associated with.
    Status: In progress.
    Understanding the Role of Culture in the Access and 
Utilization of Telemedicine Health Services Among Hispanic, 
Native Americans and White Non Hispanic Populations
    Prj #: 25-P-91143/9
    Start Date: 09/25/2000
    End Date: 09/24/2001
    Funding: $124,594
    Vehicle: Grant
    PI: Ana Maria Lopez
    Awardee: University of Arizona Cancer Center
    PO: Richard Bragg
    Description: This project will provide a profile of 
telemedicine service utilization by Mexican American, Navajo 
and Non Hispanic white patients. The study focuses on the 
health needs of rural Arizona residents, including some who 
live near the U.S. border. These residents face geographic 
barriers (distance) and supply barriers (lack of specialty 
care) to access to care. These problems are compounded by 
environmental hazard along the U.S. border and the lack of 
economic opportunity in rural areas in Arizona. The applicant 
provided a clear and compelling
    Description: of these problems through the use of 
statistics and multiple academic citations on health care in 
Arizona. The objectives of the study are to: (1) identify if 
telemedicine increases or decreases the number of clinic 
encounters between patient and clinician at the same rate for 
Mexican American, Navajo, and non-Hispanic White populations, 
(2) examine if telemedicine alters the type or complexity of 
the clinical encounter at the same level for these populations, 
(3) assess if telemedicine affects the cost of providing 
clinical services for the management of chronic and/or 
rehabilitative conditions at the same amount for these 
populations, (4) examine if telemedicine affects patient 
compliance (e.g., taking medications as prescribed, doing 
exercise as instructed, etc) at the same level for these 
populations, (5) assess if minority patients perceive that 
cultural competency is an important factor in the delivery of 
telemedicine services such that it may impact utilization of 
these services, and (6) examine how telemedicine impacts the 
quality of life for these populations.
    There are two goals that are offered for this study: (1) To 
provide a profile of telemedicine service utilization, and (2) 
to deepen and broaden the understanding of the role of culture 
in access and utilization of telemedicine health services. 
These goals will be achieved via the development and 
implementation of a patient satisfaction survey, a provider 
survey, and chart review. The project has access to a cohort of 
200 patients stratified by location. This research is tracking 
individuals within an existing service project. The enrollment 
is constrained by the scope of current services. It is 
estimated that 50 participants will be studied at each of the 
four sites for a total of 200 individuals. The ethnic 
distributions are assumed to be as follows: the population of 
Springerville is 100 percent non Hispanic white, the populaton 
of Ganado is essentially 100 percent Navajo, and the 
populations of Douglass and Nogales are approximately 80 
percent Mexican-American and 20 percent non Hispanic white. 
These population distributions result in an expectation for 
enrollment Mexican-Americans, 70 non Hispanic whites, and 50 
Navajo. The first three objectives will be evaluated from 
direct patient chart review and assessment of the discharge and 
billing code data. The compliance objective will be assessed 
using a simple survey technique. The final two objectives will 
be assessed via patient surveys. These surveys are based on an 
existing self-administered questionnaire that serves to measure 
patient satisfaction with telemedicine services in terms of 
quality of care.
    Status: Project is in development phase.
    A Systematic Approach to Improving Pap Smear Screening 
Rates Among
    Prj #: 25-P-91150/9
    Start Date: 09/25/2000
    End Date: 09/24/2001
    Funding: $124,450
    Vehicle: Grant
    PI: Helda L. Pinzon-Perez/Vera Kennedy
    Awardee: California State University, Fresno Foundation, 
College of Health and Human Services, Grants and Research
    PO: Richard Bragg
    Description: This project will identify barriers to Pap 
smear screening facing Hispanic/Latino women within a Medicaid 
managed care system. The American Cancer Society (ACS) criteria 
for Pap smear screening will be used: testing with the onset of 
sexual activity and repeat pap smears every 1-3 years at the 
physician's discretion. Hispanic/Latina populations are the 
ethnic groups with the highest incidence of cervical cancer, 
and it is increasing. Cervical cancer rates in the San Joaquin 
Valley are 10.6 new cases and 3.3 deaths per 100,000 women, 
i.e., 10 percent and 50 percent higher, respectively, than the 
state as a whole. A major reason for these high rates is under-
utilization of Pap smear screening. The goals of this project 
are: to identify the alterable barriers to Pap smear screening 
facing Hispanic/Latino women within a Medicaid managed care 
system; to measure the proportion of Latina women within a 
Medicaid managed care system who are screened for cervical 
cancer; and to design a comprehensive community-based outreach 
and health education intervention strategy to improve the 
cervical cancer screening rates among the Hispanic/Latina 
population. The results from this study will be used in the 
training of medical residents at the University of California 
San Francisco in Fresno and it will be shared and disseminated 
to other health care providers, which will enhance the ability 
of service providers to provide culturally competent training 
and services as well. The study will focus on the major aspects 
of care affecting Pap smear screening. The participants will be 
recruited from 4 large community health centers (urban vs. 
rural) that serve predominately Hispanics in the Central Valley 
and the Blue Cross Managed MediCaid system. The study design 
involves structured interviews (covering the above aspects of 
care) with a random sample of 300 with 100 from each of three 
groups of women: (1) seen by a physician + Pap smear within 3 
years, (2) seen by a physician + No Pap smear within 3 years, 
and (3) Not seen by a physician + No Pap smear within 3 years. 
A pilot study will be done with 30 women. A comprehensive 
community-based outreach and health education intervention 
strategy and prevention program will be compared (involving 
strategies such as call and recall system with incentives, 
``Consejeras'' community health workers, mailed reminders, 
discussion groups in native language, use of female providers 
and interpreters, provision of transportation, etc.) to improve 
pap screening rates among the target group of Hispanic women.
    Status: Project is in develpment phase.
    MassHealth: Senior Care Options Medicare Enrollment Broker
    Prj #: 500-00-0038
    Start Date: 09/28/2000
    End Date: 09/28/2001
    Funding: $170,289
    Vehicle: Contract
    PI: Marion E. Reitz
    Awardee: Maximus, Inc.
    PO: William D. Clark
    Description: This project involves demonstration-specific 
design development in Phase I. If awarded Phase II, the project 
will provide operational support for features being implemented 
in the MassHealth: Senior Care Options research/demonstration 
initiative sponsored by the Health Care Financing 
Administration (HCFA) and the Massachusetts Division of Medical 
Assistance (DMA). The Phase I consists of a developmental 
design phase culminating in the preparation of an Enrollment 
Broker Operations Protocol and the performance of operational 
system pilot tests. Phase II will implement the operational 
support activities. A decision to award
    Phase II is to be based on the feasibility of the proposed 
enrollment broker operational activities as described in the 
Enrollment Broker Protocol and the readiness of the contractor 
to perform such activities. Award of
    Phase II also is to be determined by the separate approval 
by HCFA and DMA of MassHealth: Senior Care.
    Status: Project is in development phase.
    Readmission and Access
    Prj #: 30-P-91022/7
    Start Date: 01/10/1999
    End Date: 01/09/2000
    Funding: $21,600
    Vehicle: Grant
    PI: Cindy Hornberger
    Awardee: University of Kansas Medical Center
    PO: Carl Hackerman
    Description: The primary aim of this study is to determine 
the relationship between access to health services and heart 
failure outcomes among Kansans aged 65 years and older who were 
discharged with DRG 127 during 1995. Heart failure is the only 
major cardiovascular disorder that is increasing in incidence 
and prevalence as the population ages. Heart failure is the 
most common diagnosis related grouping billed to Medicare. A 
significant portion of these costs are due to repeated 
readmissions. Readmission rates for heart failure within the 
first 14 days to 1-year range from 12.5 to 47.5 percent. 
Readmission frequency and mortality are related to access, 
which includes (a) availability of services, such as distance 
to health care services, (b) individual and community social 
determinants of well being, such as income and educational 
levels, and (c) actual utilization of health services. The 
project will use Individual-level and ecological-level analyses 
to examine the relationships between the dependent variables of 
readmission rate and mortality, and the independent access 
variables using merged data sets. The access variables will 
include the availability of emergency and/or community 
hospitals. emergency transportation, specialty and/or primary 
care providers; the number of home health care visits; and 
county-level social determinants. The Medicare data come from 
the Kansas and Missouri peer review organizations. Other data 
sources include the Area Resource File; Kansas Kids Coalition, 
Inc.; the Kansas Hospital Association; and the Kansas Health 
Institute. Validity concerns regarding readmission rates, as an 
unbiased indicator of disease severity will be addressed. 
Statistical methods will include descriptive statistics, 
correlational studies, analyses of variance, and linear 
regression techniques.
    Status: In progress.
    Home Care Services: The Effect of Unmet Need on Health Care 
    Prj #: 30-P-91010/9
    Start Date: 01/10/1999
    End Date: 01/09/2000
    Funding: $21,600
    Vehicle: Grant
    PI: Lisa G. Matras-Schmidt
    Awardee: University of California, Department of Health 
    PO: Carl Hackerman
    Description: The main objective of this study is to examine 
how the need for home care services and the service delivery 
mechanism itself affect the use of health care services among a 
population of Medicare-eligible elderly and disabled persons 
receiving home care. Home care is one of the fastest growing 
components of personal health expenditures. However, among 
persons receiving home care, there is still a considerable 
amount of unmet need--either a lack of, or insufficient help 
with, activities of daily living and instrumental activities of 
daily living. Moreover, different models of service delivery 
have been developed to provide home care. Both of these 
factors, unmet need and service delivery mechanism, can have 
significant impacts on costs of home care, as well as quality 
of life for home care recipients. However, the effect of these 
factors on the utilization of health services has not been 
included in past studies of home care programs. This research 
addresses the following: (1) Do persons with more unmet home 
care personal assistance needs utilize more health services 
than those with fewer unmet personal assistance needs and (2) 
Does the service delivery method of home care (client self-
directed versus home care agency model) affect health care 
utilization? Data come from two sources which will be linked 
together, (1) a survey of individuals receiving home care 
services through the California In-Home Supportive Services 
program and (2) Medicare claims data. Multiple regression 
analysis will be utilized to examine the effects of service 
delivery mechanism and unmet personal assistance needs on use 
of health services. In addition, a stratified analysis based on 
level of disability will be done in order to determine if the 
effects vary by degree of disability.
    Status: In progress.
    Customer Utilization of Prescription Drugs
    Prj #: 30-P-91007/5
    Start Date: 01/10/1999
    End Date: 01/09/2000
    Funding: $19,171
    Vehicle: Grant
    PI: Julie M. Ganther
    Awardee: University of Wisconsin--Madison, School of 
    PO: Carl Hackerman
    Description: The main objectives oft this study are to: (1) 
examine the effect of insurance on prescription drug 
utilization, (2) examine the effect of medical care preferences 
on prescription drug utilization, and (3) explore the 
interaction between medical care preferences and insurance 
coverage. The expansion of insurance coverage for prescription 
drugs may be one factor in the large growth in prescription 
drug expenditures over the past two decades. However, consumer 
preferences for treating health problems also may effect 
prescription drug utilization. Some consumers prefer to see a 
doctor and/or take a prescription drug almost any time they 
have a health problem while other consumers prefer to self-
treat most health problems. In addition to directly affecting 
prescription drug utilization, these preferences may influence 
the effect of insurance coverage on prescription drug 
utilization. For example, it is unlikely that consumers who 
prefer to avoid using prescription drugs would increase their 
utilization dramatically just because they had insurance 
coverage. Data will be collected via mail survey from a random 
sample of Wisconsin consumers age 50 and over. A two-part 
econometric model will be used to examine whether health 
insurance coverage and medical care preferences effect the 
number of prescriptions and the cost of prescriptions used in a 
30 day reference period. Medical care preferences will be 
measured using a 10--item scale. In order to account for 
possible selection bias in insurance choice, consumers will be 
asked to report the source of their prescription drug 
insurance. The analysis will be done separately for the 
respondents who received their insurance from a large employer. 
These insurance coefficients will be compared to the insurance 
coefficients for the entire sample to determine the magnitude 
of the selection bias.
    Status: In progress.
    Factors of and Variations in Hospitalization Rates among 
Elderly Nursing Home Residents: Searching for Indicators of 
Appropriate Levels of Acute Care
    Prj #: 30-P-91009/1
    Start Date: 01/10/1999
    End Date: 01/09/2000
    Funding: $21,561
    Vehicle: Grant
    PI: Mary Ellen Whelan
    Awardee: University of Massachusetts-Boston
    PO: Carl Hackerman
    Description: This project aims to further the understanding 
of the interface between nursing homes and hospitals. It will 
closely examine one aspect of this care continuum, 
hospitalization among nursing home residents. The project 
involves an empirical investigation of the relative explanatory 
contribution of individual patient risk factors, facility-level 
structural factors and area market health delivery factors in 
explaining variations in hospital utilization rates among 
dually-eligible, nursing home residents in the state of 
Massachusetts. Using longitudinal data, all hospitalizations 
will be analyzed via multivariate regression techniques to help 
disentangle the influence of practice style differences from 
medical needs among nursing homes and to determine whether 
variations in transfer rates are associated with high (low) 
discretionary and/or certain ambulatory care sensitive 
conditions. In an attempt to curb burgeoning Medicaid 
expenditures associated with nursing home care, various state 
Medicaid cost containment strategies for nursing homes have 
been implemented. By and large, the payment policies enacted 
reflect prospective rate setting methodologies, meaning that 
Medicaid reimbursement to nursing homes is based on a capitated 
system, often with case-mix adjustment allowances, rather than 
an individual based or flat-rate cost strategy. Although 
research suggests that these changes in Medicaid reimbursement 
polices succeeded in improving access to nursing homes for 
certain heavy-care residents, policy concerns remain regarding 
the overall effects of these payment systems on health care 
    Status: In progress.
    Effect of Competition on Quality of Medicare
    Prj #: 30-P-91016/5
    Start Date: 01/10/1999
    End Date: 01/09/2000
    Funding: $21,596
    Vehicle: Grant
    PI: Tiffany Radcliff
    Awardee: University of Minnesota
    PO: Carl Hackerman
    Description: This research examines the relationship 
between market structure and quality of care using data that 
defines quality with conformity to accepted clinical practice 
guidelines. This project explores the role of competition in 
the provision of appropriate care once patients are admitted to 
hospitals with acute myocardial infarction.
    Price regulation within the U.S. health system is 
increasing. For example, during the 1980s the Health Care 
Financing Administration implemented the Prospective Payment 
System with predetermined and fixed hospital payment rates 
based on diagnosis codes. Movement from cost-based payment to 
external price regulation for health services has consequences. 
What happens to quality of care across different types of 
competitive environments when the price of health services is 
fixed by external regulation? Descriptive statistics and 
multivariate regression are used to test the following research 
hypotheses: 1. Under price regulation, quality of care will 
increase with the level of market competition. 2. Other 
factors, including whether the market is rural, will affect 
quality of care. Quality of care for urban residents will be 
higher than for rural residents. In this work the sample 
includes the majority of Medicare patients hospitalized with 
acute myocardial infarction during 1994-95. The quality 
indicators were abstracted from inpatient medical charts by 
Peer Review Organizations as part of the Health Care Financing 
Administration's Cooperative Cardiovascular Project. 
Competition will be measured using various definitions of 
market areas and measures of market competition.
    Status: In progress.
    Post Acute Care Use and Early Hospital Readmission of 
Hospitalized Elderly Medicare Patients
    Prj #: 30-P-91018/5
    Start Date: 01/10/1999
    End Date: 01/09/2000
    Funding: $21,596
    Vehicle: Grant
    PI: Wen-Chieh Lin
    Awardee: University of Minnesota
    PO: Carl Hackerman
    Description: The objective of this project is to 
investigate the variation in hospital discharge location and 
subsequent early hospital readmission attributable to patient, 
hospital, and market area characteristics for elderly Medicare 
patients. The Balanced Budget Act of 1997 (BBA) expanded the 
prospective payment system to post-acute care. The BBA also 
expanded the definition of transfer cases by treating discharge 
to post-acute care as hospital transfers (for selected 
Diagnostic Reimbursement Groups.) These expansions are likely 
to result in new patterns of post-acute care choice and 
utilization. Understanding the attributable variations of will 
provide information for reforming post-acute care services and 
policy options for bundling post-acute care payments in the 
future. The specific aims for this study are: (1) investigate 
patient, hospital, and market factors affecting hospital 
discharge location (a two-level (patient and hospital) 
hierarchical model will be established to investigate the 
variation in the probability of receiving a specific type of 
post-acute care for patients (a) within hospital-market and 
then (b) across hospital-market. The hospital and market area 
(county) characteristics are attached to the hospital.) (2) To 
investigate quality of care using early hospital readmission as 
the indicator (the similar structure of the two-level 
hierarchical model will be used to investigate this issue by 
including the post-acute care choice in the model.)
    Status: In progress.
    Improving Health Outcomes Using New Psychosocial Screens
    Prj #: 30-P-91025/2
    Start Date: 01/10/1999
    End Date: 01/09/2000
    Funding: $21,595
    Vehicle: Grant
    PI: Deborah N. Peikes
    Awardee: Princeton University
    PO: Carl Hackerman
    Description: This study addresses a central challenge faced 
by the Medicare program, to control costs by reducing the 
demand for health services. This study characterizes critical 
sociodemographic, psychological, and social factors, which 
place people at risk for later illness so that appropriate 
interventions can be made to reduce those risks. It will 
identify key protective factors that contribute to the 
maintenance of long term health -information critical to 
increasing the number of disability-free years enjoyed by the 
population. The project uses the Wisconsin Longitudinal Survey 
(WLS), an extensive set of longitudinal data collected on 
roughly 10,000 Wisconsin high school graduates born in 1939. 
This cohort precedes the bulk of the baby boom generation by 
about a decade. The ``boomers'' are expected to tax the 
Medicare system in the coming years.
    Hence lessons gained from this sample can be used to target 
preventive efforts to reduce the amount of ill health faced by 
the younger baby boomers, and, in the process. lower Medicare 
expenditures. The project will isolate constellations of 
factors in the Wisconsin respondents' life histories, which 
predict health outcomes in later life. To do so, it will 
construct life histories which incorporate extensive survey 
information about adversity and advantage across multiple 
domains, occurring throughout life (e.g., early background and 
starting resources, educational and occupational attainment, 
job conditions, marriage and parenting, social support and 
participation in voluntary organizations). The integration of 
these multiple domains, organized around the person as the unit 
of analysis, constitutes a novel approach to explicating later 
life health status. It will then apply Boolean-logic analytic 
methodology to isolate key factors affecting health outcomes 
and utilization patterns.
    Status: In progress.
    Economic Impact of Outpatient Prescription Drug coverage on 
Total and Specific Health Expenditures and Service Use of 
Medicare Beneficiaries
    Prj #: 30-P-91017/5
    Start Date: 01/10/1999
    End Date: 01/09/2000
    Funding: $21,579
    Vehicle: Grant
    PI: Margaret Artz
    Awardee: University of Minnesota
    PO: Carl Hackerman
    Description: This research investigates the economic impact 
of outpatient prescription drug coverage for Medicare 
beneficiaries in terms of health care expenditure and service 
use. Prescription medications play a significant role in the 
health care regimens of the elderly and represent a significant 
portion of their out-of-pocket health care expenses. Medicare 
does not cover outpatient prescription drugs, yet little more 
than half of Medicare beneficiaries who purchase a supplemental 
insurance policy choose one with a prescription drug benefit. 
Specifically, this research will determine if those elderly 
possessing Medicare supplemental insurance with prescription 
coverage have lower total and specific health care expenditures 
 and/or  specific  health  care  use  compared  to elderly  
possessing either Medicare supplemental insurance without 
preseciption coverage or Medicare alone. Estimation of per 
capita differences in annual expenditures and service use will 
also be calculated. Generosity of the outpatient prescription 
drug coverage in terms of cost sharing is figured to play an 
important role in the expenditures spent and/or service used by 
the elderly.
    Status: In progress.
    Nursing Home Quality of Care: Time, Competition and Demand
    Prj #: 30-P-30238/4
    Start Date: 01/03/2000
    End Date: 01/02/2001
    Funding: $30,669
    Vehicle: Grant
    PI: Virender Kumar
    Awardee: University of North Carolina at Chapel Hill, 
Office of Research Services, for Department of Health Policy 
and Administration
    PO: Carl Hackerman
    Description: The project assesses how competition and its 
influence on the chronic health care market, and the OBRA 87 
regulations affect the quality of nursing home care. Variation 
in competition over a twelve year time period and variation 
across the country will be used to identify how competition 
affects quality. Measures of quality will be health outcomes of 
individuals assessed through claims data. Three waves of the 
National Long-Term Care Survey will be used as a basis to 
identify individuals admitted to a nursing home for the study 
sample. The analysis will use simultaneous equation methods to 
derive consistent estimates of the Medicaid reimbursement rate, 
competition, and OBRA 87 effects on quality and accessibility 
of nursing home care. In this time of concerns about limited 
funds and the quality of nursing home care and accessibility to 
care for Medicaid beneficiaries, the topic is of great 
    Status: In progress.
    Access to Medicare Home Health Care in the Wake of the 
Balanced Budget Act
    Prj #: 30-P-30245/3
    Start Date: 01/03/2000
    End Date: 01/02/2001
    Funding: $32,390
    Vehicle: Grant
    PI: Joan F Davitt
    Awardee: Bryn Mawr College, Graduate School of Social Work 
and Social Research
    PO: Carl Hackerman
    Description: Recent changes to the Medicare home health 
benefit have altered the way that home health care agencies 
will be reimbursed. It has been estimated that the new 
reimbursement system, referred to as the Interim Payment 
System, will reduce agency revenues by 15-22 percent. Such 
reductions may encourage agencies to alter the amount, duration 
or type of benefits provided to certain types of home health 
care patients. This study will investigate whether certain 
types of patients are experiencing reductions in access to care 
or in service receipt including: (1) not being admitted to home 
health services; (2) being discharged early; (3) receiving less 
services; or (4) receiving less expensive services. This study 
consists of a secondary analysis of data from the Medicare 
Current Beneficiary Survey (MCBS) Access to Care, Public Use 
File and HCFA claims files for the years 1996 and 1998. These 
will comprise the primary data sources for this study. The 
researcher will also obtain the Provider of Services Extract 
File from the OSCAR data base. The researcher will also conduct 
qualitative interviews with home health agency staff in an 
attempt to enhance the depth of understanding of these issues.
    Statistical analyses will allow the researcher to: 
determine whether this particular policy change is affecting 
access to care; to test hypotheses regarding utilization 
patterns; to understand which factors (such as patient 
characteristics, agency characteristics, and supply-side 
factors) are more predictive of specific utilization patterns; 
and to understand the explanatory power of sets of independent 
variables. Qualitative interview data will allow the researcher 
to understand agency practices post-IPS, providing greater 
sensitivity to contextual elements and provider perspectives. 
These interviews will also be used to check for validity in the 
interpretation of quantitative data and to identify provider 
practices that may not be reflected in the claims files. 
Information from this study will be shared with policy makers 
and home health agency providers and may be utilized to improve 
the design of the prospective payment system or to design 
necessary clinical criteria for reimbursement limit exemptions 
in home health care.
    Status: In progress.
    Outcomes and Reimbursement of Stroke and Hip Fracture 
    Prj #: 30-P-30247/2
    Start Date: 01/03/2000
    End Date: 01/02/2001
    Funding: $32,400
    Vehicle: Grant
    PI: Anne Deutsch
    Awardee: State University of New York at Buffalo, Sponsored 
Programs Administration, for School of Nursing
    PO: Carl Hackerman
    Description: Inpatient rehabilitation services for Medicare 
beneficiaries may be delivered in either rehabilitation 
hospitals/units or in skilled nursing facilities (SNF) and the 
distinctions between services provided in these 2 settings has 
narrowed in recent years. Given the differences in costs, it is 
of interest to compare functional outcomes of beneficiaries who 
have received rehabilitation services in comprehensive versus 
SNF-based settings after experiencing a hip fracture or stroke. 
The study sample will include Medicare beneficiaries who 
recently experienced a hip fracture or a stroke and were 
discharged from either a rehabilitation hospital/unit or a SNF 
that subscribed to the Uniform Data System for Medical 
Rehabilitation. This data system includes both admission and 
discharge measurements of functional status. The study will 
compare ability to perform motor functions, Medicare 
reimbursement data, rehabilitation length of stay; and total 
length of stay between beneficiaries in the 2 settings while 
adjusting for admission functional ability, age, co-morbid 
conditions, and a number of other demographic, diagnosis-
related, and health system related variables.
    Status: In progress.
    Healthy Aging Project
    Prj #: 500-98-0281
    Period: 10/30/1998-9/29/03
    Funding: $3.7 million
    Award: Cost reimbursement contract
    PI: Larry Rubenstein, M.D.
    Awardee: RAND, 1700 Main Street, Santa Monica, CA 90401
    PO: Pauline Lapin, Office of Clinical Standards and Quality
    Description: A key challenge to the health care system will 
be to determine how to prevent or slow the progression of 
disability in the senior population. There will be a total of 
76 million seniors living in the United States in 2030--a 
dramatic increase from the 35 million today. This population 
surge will substantially increase the demand for health care by 
older people, who experience much higher rates of morbidity and 
mortality than younger people. The Health Care Financing 
Administration (HCFA) developed the Healthy Aging Project to 
identify, test and disseminate evidence-based approaches to 
promote health and prevent functional decline in older adults. 
HCFA awarded RAND a five-year contract to produce reports 
synthesizing the evidence on how to improve the delivery of 
Medicare clinical preventive and screening benefits. RAND is 
also exploring how behavioral risk factor reduction 
interventions, such as smoking cessation, might be incorporated 
into Medicare.
    The first evidence report, Interventions that Increase the 
Utilization of Medicare-funded Preventive Services for Persons 
Aged 65 and Older, is an important guide for providers and 
health care systems seeking to improve the use of influenza 
immunizations, pneumococcal vaccinations, mammography, Pap 
tests and colon cancer screening. A key finding from this 
report is that organizational changes are effective in 
improving the delivery of preventive services. Standing orders 
are a type of organizational change that allow appropriate non-
physician staff to offer services, usually vaccinations, 
without an individual physician prescription. HCFA and the 
Centers for Disease Control and Prevention (CDC) are 
collaborating on a demonstration project to implement standing 
orders to increase influenza immunization rates in all of the 
nursing homes located in nine states. Medicare's quality 
improvement contractors, the peer review organizations or PROs, 
are working on this initiative.
    Another demonstration being conducted under the Healthy 
Aging Project tests the feasibility of implementing a smoking 
cessation benefit in Medicare. Three benefit options, including 
telephone counseling, are being compared to assess their 
effectiveness in promoting smoking cessation. HCFA commissioned 
an evidence report on smoking cessation, and this demonstration 
is based on that report and the U.S. Public Health Service 
clinical practice guideline on smoking cessation.
    HCFA is interested in comprehensive and systematic 
approaches to health promotion, which address both clinical 
prevention and behavioral risk factor reduction. Health risk 
appraisals with tailored feedback and follow-up are a promising 
tool for doing just that. HCFA has commissioned an evidence 
report on health risk appraisals, as well as chronic disease 
self-management, physical activity and falls prevention. RAND 
is synthesizing the evidence on these strategies and addressing 
the Medicare program and policy implications involved in 
testing them in Medicare demonstrations in its reports.
    HCFA coordinated the development of the Healthy Aging 
Project with the Agency for Healthcare Research and Quality 
(AHRQ). This project was designed to complement other 
Departmental initiatives, such as Healthy People 2010, and the 
U.S. Preventive Services Task Force. HCFA is conducting the 
Healthy Aging Project in collaboration with the AHRQ, the CDC, 
the Administration on Aging, and the National Institutes of 
    Status: Two evidence reports are currently available--
Interventions that Increase the Utilization of Medicare-funded 
Preventive Services for Persons Aged 65 and Older and 
Interventions to Promote Smoking Cessation in the Medicare 
Population. A pilot project testing the implementation of 
standing order interventions in nursing homes is being 
conducted in nine states. A demonstration to test the 
feasibility of implementing a Medicare benefit for smoking 
cessation will be conducted in seven states. Final revisions 
are being made to the evidence report on health risk appraisals 
and targeted interventions; this report should be available in 
the next few months. Reports on chronic disease self-
management, physical activity and falls prevention are 
currently in various stages of the evidence review process.


    Older Americans are generally better off healthier and 
wealthier than ever before.\1\ A combination of factors, 
including the translation of critical research advances into 
prevention and treatment strategies and the advent of health 
and social welfare programs, have dramatically improved the 
quality of life for older people. Average life expectancy in 
the United States has at least doubled over the past century, 
from an average of 49 years in 1900 to age 76 at the turn of 
the century. The rate of disability among people age 85 and 
older substantially declined from the 1980s through the mid-
1990s, and currently a majority of people age 65 and older rate 
their health as good or excellent. Programs such as Social 
Security and Medicare have improved the fiscal well-being of 
older people in the United States, enabling many individuals to 
enjoy a healthy and active retirement.
    \1\ Federal Interagency Forum on Aging Related Statistics. Older 
Americans 2000: Key Indicators of Well Being 2000.
    Although the news is promising, good health is far from a 
universal reality for older Americans. The latest national 
surveys indicate that about one-fifth of people age 65 and 
older, more than 7 million people, report some disability. 
Chronic disease, memory impairment, and depressive symptoms 
affect large numbers of older people and the risk of such 
problems significantly rises with age. Nearly half of those age 
85 and older suffer from Alzheimer's disease.\2\ These millions 
of less fortunate older people struggle with daily activities 
as simple as bathing and dressing, with families and friends 
taking on the difficult and often costly role of caregiver. The 
outlook for aging minority groups is particularly troublesome 
given the obvious health disparities that research has shown 
exists between older white Americans and their minority 
    \2\ Evans, DA, Funkenstein HH, Albert MS, et al. Prevalence of 
Alzheimer's disease in a community population of older persons; higher 
than previously reported. JAMA 262: 2551-2556, 1989.
    An increasing interest in aging research is driven in part 
by a projected dramatic increase in the older population. 
According to the United States Census Bureau, by 2030 the 
population of people 65 years and older will double. The over-
85 group, often referred to as the ``oldest old,'' is the 
fastest growing segment of the older population and is 
projected to comprise 20 million people by the middle of this 
century. The implications of this dramatic increase in the 
aging population are numerous and research has an important 
role to play in providing solutions to the challenging issues 
posed by an aging society.
    Understanding the difference between advanced years that 
are active and independent and those that are characterized by 
frailty and dependence is at the heart of research supported by 
the National Institute on Aging (NIA), a component of the 
National Institutes of Health (NIH). The NIH is the principal 
biomedical research arm of the Federal government. The NIA, 
which was established by Congress in 1974, sponsors biomedical 
and behavioral research on the aging process and diseases and 
conditions affecting the elderly. NIA also leads the Federal 
research effort on Alzheimer's disease. Through independent, as 
well as collaborative, research efforts, the NIA and the other 
Institutes and Centers that comprise the NIH are working to 
reduce disability and disease and promote healthy lifestyles 
for older people.
    This report highlights a number of significant aging-
related research advances and activities supported or conducted 
by the NIH in 1999 and 2000. Section I of this report outlines 
key advances reported by the NIA for 1999 and 2000 in four 
major areas of research. Section II provides selected findings 
from some of the other NIH institutes involved in aging 
research. They are: National Institute on Mental Health (NIMH); 
National Eye Institute (NEI); Office of Research on Women's 
Health (ORWH); National Institute of Diabetes and Digestive and 
Kidney Diseases (NIDDK); National Institute of Arthritis and 
Musculoskeletal and Skin Diseases (NIAMS); National Center for 
Complementary and Alternative Medicine (NCCAM); National 
Institute on Deafness and Other Communication Disorders 
(NIDCD); National Heart, Lung and Blood Institute (NHLBI); 
National Institute of Nursing Research (NINR); National Center 
for Research Resources (NCRR); National Institute of Child 
Health and Human Development (NICHD); National Library of 
Medicine (NLM); National Institute of Allergy and Infectious 
Diseases (NIAID); and National Institute of Neurological 
Disorders and Storke (NINDS).

            Section I--National Institute on Aging 1999-2000

    For 25 years, the NIA has led a national scientific effort 
to understand the mechanisms of aging and to extend healthy, 
active years of life for all Americans. This enterprise has 
rapidly expanded knowledge about the biological, behavioral, 
and social changes that occur with advancing age. Many of these 
advances have saved lives and prevented disability by 
contributing to improvements in public health and health care 
and enhancing physical and cognitive abilities in old age. 
Other discoveries have provided exciting insights into the 
secrets of aging and longevity. Through its support of training 
programs and research infrastructure, the NIA has provided 
critical tools to the next generation of investigators entering 
the field of aging research. Also, the NIA has maintained a 
variety of programs, including the Alzheimer's Disease 
Education and Referral Center and the NIA Information 
Clearinghouse, to communicate the results of aging research and 
related health information to the research community, health 
care providers, patients, and the general public, providing 
guidance on health care, health promotion and disease 
prevention for older people.
    Recent significant advances reported by the NIA can be 
categorized under four major headings: 1) Alzheimer's Disease 
and the Neuroscience of Aging; 2) Biology of Aging; 3) Reducing 
Disease and Disability and 4) Behavioral and Social Research.

           Alzheimer's Disease and the Neuroscience of Aging

    Alzheimer's disease (AD), the most common cause of dementia 
among older persons, is the result of abnormal changes in the 
brain that lead to a devastating decline in intellectual 
abilities and changes in behavior and personality. Tragically, 
as many as four million Americans now suffer from AD,\3\ and 
that number is expected to increase significantly as the baby 
boom generation reaches the age of greatest risk. Scientists do 
not yet fully understand what causes AD, but it is clear that 
the disease develops as a result of a complex cascade of 
events, influenced by genetic and non-genetic factors, taking 
place over time inside the brain with age being the most 
prominent risk factor. These events cause the brain to develop 
beta amyloid plaques and neurofibrillary tangles and lose nerve 
cells and the connections between them in a process that 
eventually interferes with normal brain function.
    \3\ Small, GW, Rabine, PV, Barry, PP, et. al. Diagnosis and 
treatment of Alzheimer's disease and related disorders. JAMA 16:1363-
1371, 1997.
    In the last decade, researchers have made tremendous 
strides toward solving the mystery of AD, improving 
understanding of its underlying molecular processes, developing 
innovative diagnostic tools, devising effective treatments, and 
testing prevention strategies. For example, the convergence of 
evidence from basic laboratory science and epidemiology studies 
has led to the identification of candidate interventions, such 
as vitamin E, estrogen, and anti-inflammatory agents, that may 
treat or prevent AD. In addition, advances in basic research 
have uncovered enzymes called secretases that are involved in 
the clipping of a normal cell surface protein to produce the 
amyloid peptide that forms the senile plaques found in the 
brains of AD patients. Identifying and understanding how these 
enzymes work will accelerate the development of interventions 
to specifically block their action and stop the development of 
AD plaques.
    As a result of these and other scientific discoveries, in 
1999, the NIA kicked off the NIH Alzheimer's Disease Prevention 
Initiative. The goals of this Initiative are to: invigorate 
discovery of new treatments, identify risk and preventative 
factors, enhance methods of early detection and diagnosis, 
advance basic science to understand AD, improve patient care 
strategies, and alleviate caregiver burdens. In 1999, the NIA 
launched the first large-scale AD prevention clinical trial 
supported by the NIH, the Memory Impairment Study (MIS). This 
study is evaluating vitamin E and donepezil (Aricept) over a 
three-year period for their effectiveness in slowing or 
stopping the conversion from mild cognitive impairment (MCI), a 
condition characterized by a memory deficit without dementia, 
to AD. It will be taking place at more than 70 sites in the 
U.S. Other ongoing or upcoming AD prevention trials will 
examine whether treatment with a variety of agents, such as 
anti-inflammatory drugs, estrogen, aspirin, vitamin E, 
antioxidants, or combined folate/B6/B12 supplementation can 
prevent development of AD. The effects of each of these agents 
on normal age-related decline will also be evaluated. 
Information about ongoing AD clinical trials supported by the 
NIA is now available on the Alzheimer's Disease Education and 
Referral Center home page, a service of the NIA, at: http://
    Advances in the field of AD research also have implications 
for other neurodegenerative disorders, such as Parkinson's 
disease. For example, advances in imaging techniques may one 
day enhance the ability of practitioners to detect early 
changes in the brain and intervene before symptoms of diseases 
progress. Building on the progress of NIA-supported research in 
the area of Alzheimer's disease and the neuroscience of aging, 
efforts will continue to identify critical diagnostic, 
treatment and prevention strategies for AD as well as other 
neurodegenerative diseases.

                   1999 Selected Scientific Advances

           Alzheimer's Disease and the Neuroscience of Aging

    Age-associated memory loss might be reversible.--
Researchers have identified a process by which the normal 
primate brain degenerates with aging, and were able to show 
that this degeneration can be reversed by gene therapy. They 
found that cholinergic neurons in a specific area of the brain 
are most dramatically affected by aging. An actual count of 
brain cells in rhesus monkeys showed that very few cells are 
actually lost in the cerebral cortex with advancing age. In 
contrast, cholinergic neurons in another part of the brain (the 
basal forebrain) were found to shrink in size and to stop 
making regulatory chemicals, a change that seriously affects 
the ability to reason and store memories. Using skin cells from 
each individual monkey, researchers inserted a gene that makes 
human nerve growth factor (NGF) and then injected the modified 
cells into the brains of these monkeys. After three months, the 
cholinergic neurons of the monkeys with the NGF injections had 
an almost youthful appearance. The number of cells detected was 
restored to about 92 percent of normal for a young monkey, and 
the size of the cells was restored to within 3 percent of 
normal young values. Such gene transfer  approaches  restoring  
cellular  function  have  important implications for the 
treatment of chronic age-related neurodegenerative disorders, 
such as AD.
    Brain atrophy measured by imaging techniques predicts 
progression from MCI to AD.--Mild cognitive impairment (MCI) is 
characterized by a memory deficit, but not dementia. Compared 
to normal memory changes associated with aging, memory loss 
associated with MCI is more persistent and troublesome. Each 
year, 12-20 percent of people over age 65 with MCI develop AD, 
compared with 1-2 percent of people in this same age group 
without MCI. A study found that MCI can reliably be clinically 
defined and diagnosed. The ability to differentiate patients 
with MCI from healthy control subjects and persons with very 
mild AD hopefully will lead to useful, practical, and cost-
effective means to test drug interventions for AD. To help make 
these distinctions, researchers recently used magnetic 
resonance imaging (MRI) to determine volume measurements of the 
hippocampus, a region of the brain important for learning and 
memory, in patients with a clinical diagnosis of MCI. The 
hippocampus was selected for imaging because this brain 
structure plays a central role in memory function. Patients 
were assessed annually for approximately three years using both 
clinical and cognitive assessments. In older individuals with 
MCI, the smaller the hippocampus at the beginning of the study, 
the greater the risk of developing AD later. Imaging studies 
such as these can actually identify deviations from normal 
cerebral function or normal anatomy before a clinical diagnosis 
can be made. The ability to detect early disease will enable 
researchers to test the effectiveness of treatments or 
interventions designed to stop brain changes before clinical 
deterioration sets in.
    Normal cellular enzyme becomes a marker for AD.--
Researchers examining the brains of people who had died from AD 
found abnormally large amounts of a normal enzyme called casein 
kinase-1 (CK-1) in nerve cells inside cellular sacs (vacuoles) 
called granulovacuolar degeneration (GVD) bodies. Previous 
research had shown that these vacuoles tended to accumulate in 
the hippocampus. Looking for an enzyme that adds phosphate to 
tau molecule, a key protein in the development of dementia, the 
investigator found a 30-fold increase in one form of CK-1 
inside GVD bodies in the hippocampus. This finding enables 
researchers to use CK-1 as a molecular label for studying the 
vacuoles and forges a link between them and the plaques and 
tangles commonly studied in AD brains. Analysis of GVD bodies 
could provide valuable clues useful both for the diagnosis of 
AD and for gaining a better understanding of the disease.
    Study results show promise for developing treatment of 
early-onset AD.--Most early-onset AD is the result of mutations 
in one of two human presenilin genes, PS-1 and PS-2. Mutations 
in PS-1 are found in about 40 percent of people with familial 
(early onset) AD. Every known presenilin mutation affects the 
processing of amyloid precursor protein (APP) into smaller 
fragments, such as beta-amyloid peptide, the primary 
constituent of the distinctive plaques that accumulate in the 
brains of Alzheimer's patients. When scientists altered the 
amino acid sequence of the presenilin protein from its normal 
sequence in two critical locations, amyloid formation was 
reduced. Evidence indicates that mutated PS-1 protein may be 
able to clip the beta-amyloid fragment from APP. If true, the 
identification of the long-sought enzyme involved in producing 
neuritic plaques associated with AD should hasten development 
of drugs that inhibit the enzyme, blocking production of 
amyloid-beta in much the way cholesterol-lowering drugs work. 
These studies have implications for the treatment of AD and 
related disorders of amyloid accumulation. The challenge will 
be to develop drugs that reduce or alter the activity of 
presenilin, but do not completely eliminate it, since complete 
elimination of presenilin is lethal in mice, and presenilin is 
likely to have a similar essential function in humans.
    Gene causing a form of familial dementia may yield clues to 
AD.--A form of dementia that spans seven generations of members 
of the same family in England has been linked to a newly 
discovered, dominant gene, BRI, on chromosome 13. Familial 
British dementia (FBD), which has an onset at approximately age 
50, is characterized by progressive dementia, muscle 
spasticity, and loss of muscle tone due to disease of the 
cerebellum. The predominant pathological lesions are abnormal 
protein deposits in the brain, plaques in the vicinity of blood 
vessels, and neurofibrillary tangles. FBD is similar to AD 
because in both disorders the production of a small insoluble 
protein is a key feature. Further, the neurofibrillary 
pathology observed in both FBD and AD is identical. While much 
remains unknown about the BRI gene and the function of the 
protein that it produces, understanding how the gene defect 
causes the disease will lead to insights into the pathogenesis 
of other neurodegenerative diseases characterized by amyloid 
``deposition.'' Understanding how the genetically distinct 
disorder FBD develops will contribute to efforts to understand 
the development and progression of the more prevalent AD. 
Further, insights gained in FBD may aid the design and 
development of treatments intended to disrupt peptide 
aggregation and prevent the ensuing neurodegeneration not only 
in FBD and AD but also in other diseases such as those caused 
by infectious particles called prions.
    One form of the ApoE gene protects brain cells from 
injury.--The protein apolipoprotein E (ApoE) participates in 
the transport of serum  lipids  (fats)  and the  redistribution 
 of lipids  among  cells. Although the mechanism through which 
it works is unknown, the only accepted risk factor for sporadic 
late-onset AD is the ApoE4 structural  variant  of the  ApoE 
gene.  To test  the  hypothesis that ApoE3, but not ApoE4, 
protects against age-related neurodegeneration, researchers 
analyzed mice expressing similar levels of human ApoE3 or ApoE4 
in the brain. It was determined that ApoE3 protected the brain 
against excitotoxic injury but that ApoE4 did not. ApoE3, but 
not ApoE4, also protected against age-dependent 
neurodegeneration. This study presents compelling evidence to 
suggest that the presence or absence of a particular ApoE 
structural variant or isoform affects the way neurons respond 
to injury. These differences in the effects of ApoE isoforms on 
neuronal integrity may relate to the increased risk of AD and 
to the poor outcome after head trauma and stroke in humans. The 
significance of this finding is that it may help to explain how 
ApoE4 functions as a risk factor for the development of AD, 
and, if confirmed, might suggest useful therapeutic strategies 
that could be started in advance of any cognitive impairment in 
at-risk individuals.
    New mouse model produces tangles similar to those in AD.--
Developing mouse models with features of human AD is vital in 
helping researchers gain insights into the etiologies, 
mechanisms, and progression of AD. Mice implanted with human 
genes for beta-amyloid, the precursor to neuritic plaques, were 
developed in 1997. Now, for the first time, researchers have 
developed a transgenic mouse strain that expresses human tau 
genes and develops AD-like tau tangles. Unlike their litter-
mates that lack the tau gene, these genetically altered mice 
developed masses of abnormal tau filaments in nerve cells 
within the spinal cord, cerebral cortex, and brainstem, and in 
three other critical regions of the central nervous system, as 
well as undergoing nerve cell degeneration as they aged. While 
this new strain of transgenic mice does not completely model 
AD, they closely resemble human diseases that accumulate AD-
like tau deposits in the brain. The development of this mouse 
model will help researchers understand how tau produces disease 
in the brain, and together with other partial models of AD will 
move closer to developing effective preventive or treatment 
interventions against AD.
    Study finds that the hormone melatonin does not decrease 
with age.--Melatonin, a natural sleep inducer, is secreted by 
the pineal gland located deep within the brain. The hormone is 
produced at high levels during a person's normal sleeping hours 
and is lowest during the day. A number of factors, including 
light and many common medications, such as aspirin, ibuprofen, 
and beta-blockers, can affect melatonin secretion. In the past 
two decades, more than 30 reports have suggested that the level 
of night-time melatonin peak declines progressively with age. 
These reports have led to a proliferation of over-the-counter 
supplements aimed at augmenting melatonin levels in the 
elderly. A five-year study was recently completed that measured 
serum melatonin levels in 120 healthy men and 24 women aged 18-
81. The analysis found no statistically significant difference 
in night-time melatonin concentrations between the younger and 
older study participants. This outcome means that in most 
healthy people, concentration of melatonin probably does not 
decline with age, and aging probably does not affect the 
regulation of melatonin secretion.

                   2000 Selected Scientific Advances

           Alzheimer's Disease and the Neuroscience of Aging

    Use of Positron Emission Tomography (PET) Imaging to 
Identify Pre-symptomatic Decline in Brain Function.--The gene 
APOE- has been associated with increased risk of AD. 
Scientists have been increasingly interested in whether the 
brain and brain function of people who carry one or more copies 
of APOE-4 are different from those of individuals who 
do not carry the gene to ultimately see whether AD-like 
symptoms can be identified before the disease is diagnosed 
clinically. PET imaging can provide information on metabolic 
function of specific brain regions. Recent studies using PET 
show that, despite similarities in age, gender, education, 
family history of dementia, and baseline performance on memory 
and other cognitive tasks, individuals with the APOE-
4 gene(s) have reduced cerebral glucose metabolism in 
several areas of the brain compared to people who have none. 
The differences in metabolism were even greater two years after 
initial evaluation. Lower baseline metabolism at the start of 
the study predicted a greater cognitive decline in subjects at 
genetic risk for AD. Though longer follow-up studies are needed 
to determine how many of the APOE-4 carriers actually 
develop AD, these findings suggest that a combination of 
cerebral metabolic rate and genetic risk factors may be one way 
to help detect AD pre-clinically.
    In Vivo Detection of Amyloid Plaques.--Scientists have been 
searching for a marker to be used in living patients (in vivo) 
to identify amyloid plaques that may be present in brain long 
before clinical diagnosis of the disease. A new molecular probe 
has recently been developed that sensitively labels plaques in 
post mortem AD brain sections. This probe now has been shown as 
well to label plaques throughout the brain after intracerebral 
injection in living transgenic mice. This probe is a prototype 
for molecules that could be used for radiological imaging of 
plaques in the brains of living people, permitting monitoring 
of the development and progression of AD as well as the 
clearance of plaques in response to anti-amyloid therapies.
    Standardized Clinical Information Can Predict Conversion to 
AD.-- Researchers have identified components of a standardized 
clinical assessment instrument that also appear to predict 
which individuals with very mild impairment (symptoms) or 
``questionable'' AD have a high likelihood of converting to AD 
over time. The assessment instrument was the Clinical Dementia 
Rating (CDR), a clinical interview which stages AD from normal 
to severe based on six functional categories. After receiving a 
CDR rating of normal or questionable, participants were 
followed for three years to determine who converted to probable 
AD. Likelihood of progression to AD during follow-up was 
related to the sum of the scores in the six CDR categories. 
This score, combined with selected clinical interview 
questions, identified 89 percent of those questionable 
individuals who converted to AD in the study. These findings 
provide guidelines for using a clinical assessment to identify 
patients most likely to convert from questionable AD to AD, 
improving the possibility of earlier diagnosis and earlier 
implementation of available interventions.
    Identification of the Amyloid Forming Enzymes Offers New 
Targets for Drug Development.--Amyloid is a small peptide 
fragment produced as a result of snipping (cleavage) of the 
much larger amyloid precursor protein (APP) by two enzymes 
known as beta () and gamma () secretases. For 
years, scientists knew that something was snipping the APP into 
fragments and they even went so far as to name the suspect 
secretases. But no one had been able to physically and 
precisely identify the enzymes that did the actual clipping of 
APP until the past year, when the identities of the  
and  secretases at last were revealed.
    The identity of secretase was discovered simultaneously by 
several drug companies. However,  secretase has proven 
more elusive. Its activity was known to be affected by 
mutations in one of the genes (presenilin 1 or PS1) that cause 
AD in early onset families. PS1 was identified several years 
ago and structural evidence suggested it might actually be the 
 secretase. To test this possibility, scientists 
identified a radioactive molecule that binds tightly to the 
active site of the enzyme, thus labeling the enzyme molecules. 
They found that PS1 was the labeled protein, strongly 
suggesting that it itself is the  secretase. It is 
believed this line of research could lead to the discovery of 
drugs that inhibit the production of amyloid without inhibiting 
other essential functions these secretase enzymes might have. 
Ultimately, clinical trials on such secretase-inhibiting drugs 
will show whether this approach will work.
    Immunization Against Amyloid- Can Reduce Brain 
Amyloid- Deposition.--Recent studies in animal models 
have been important in understanding the etiology of AD and in 
testing potential new therapies. In transgenic mouse models 
showing extensive plaque formation with advancing age, 
researchers are now evaluating plaque-reducing drugs. The 
results of this research have been promising. In one 
breakthrough, pharmaceutical company scientists showed that 
repeated long-term injections of an amyloid vaccine can cause 
an immune response in test mice, nearly eliminating amyloid 
plaques and associated neuropathology, with no obvious 
toxicity. A number of NIH-funded scientists have confirmed and 
extended these observations. In a novel approach, one group 
administered the vaccine to mice nasally, and also induced an 
immune response. In that study, when young transgenic mice were 
repeatedly given the human amyloid- via the nasal 
route, the mice had a much lower amyloid burden at middle age 
than animals not receiving the vaccine. Interest in the vaccine 
approach heightened upon recent preliminary reports that 
amyloid vaccination prevents cognitive decline in another 
transgenic mouse model of AD, suggesting that a vaccine might 
indeed make a difference in the clinical symptoms of AD. Human 
trials are only now beginning to test both the safety and the 
efficacy of these vaccines as a possible therapy for people 
with AD.
    A New Model of Parkinson's Disease (PD).--There are many 
similarities among neurodegenerative diseases such as AD, PD, 
and other dementias, and research on one can provide valuable 
clues about the others. PD is a common age-related and 
progressive neurodegenerative disorder characterized by death 
of neurons that make the neurotransmitter dopamine. Loss of 
these neurons results in rigidity, tremor, slowed movement, and 
impaired gait. Another hallmark of PD is the formation of 
fibrous protein deposits, called Lewy bodies, in neurons. 
Mutations in the -synuclein gene have been linked to 
some forms of inherited PD and insoluble -synuclein 
accumulates in Lewy bodies, as well as in plaques in AD. A new 
-synuclein transgenic model has been developed, using 
the fruit fly Drosophila, that exhibits many essential features 
of human PD including age-dependent onset, progressive loss of 
dopamine neurons and motor function, and development of Lewy 
body-like pathology. This model will be useful in identifying 
underlying mechanisms mediating -synuclein toxicity 
and in identifying genes that modify the -synuclein 
mediated neurodegeneration, and which may play a role in the 
pathogenesis of PD. These transgenic flies may also be valuable 
in screening potential drugs affecting the onset and 
progression of PD.
    Ongoing Research Highlights Importance of Testing 
Interventions.--REACH (Resources for Enhancing Alzheimer's 
Caregiver Health) is a multi-site intervention trial, at six 
sites and a coordinating center, to conduct social and 
behavioral research on interventions designed to help 
caregivers of patients with AD and related disorders. REACH 
projects are testing such interventions as educational support 
groups, behavioral skills training programs, family-based 
interventions, environmental modifications, and computer-based 
information and communication services. Some 1,222 caregivers 
and care recipients have participated in the study, which 
includes large numbers of African Americans, Cuban Americans, 
and Mexican Americans. Data from the REACH study are just being 

                            Biology of Aging

    Research on the biology of aging has led to a revolution in 
aging research. This new gerontology investigates the 
progressive, nonpathological biological and physiological 
changes that occur with advancing age and the abnormal changes 
that are risk factors for or accompany age-related disease 
states. Progress is being made in understanding the gradual 
changes in structure and function that occur in the brain and 
nerves, bone and muscle, heart and blood vessels, hormones, 
nutritional processes, immune responses, and other aspects of 
the body. Research has begun to reveal the biologic factors 
associated with extended longevity in humans and animal models, 
such as fruit flies, roundworms and rodents. The ultimate goal 
of this effort is to develop interventions to reduce or delay 
age-related degenerative processes in humans. Areas of research 
include the effects of calorie restriction on various 
organisms, the identification of genes and genetic mutations 
that may be related to longevity, and the study of cellular 
function in human and animal models.

                   1999 Selected Scientific Advances

                            Biology of Aging

    Mitochondrial DNA mutations increase with aging.--One 
hypothesis of the cause of aging is the accumulation of 
mutations in mitochondrial DNA (mtDNA). Although earlier 
research has shown that a particular deletion mutation of 
mitochondrial DNA increases with age, it appeared that this 
mutation only occurred in less than 4 percent of mtDNA 
molecules. However the methods used to quantitate the level of 
this mutation would not have detected other deletions, so it 
was argued by some that the common deletion mutation 
represented the ``tip of the iceberg'' of mitochondrial 
mutations. Skeptics responded that this unproven hypothesis 
represented wishful thinking. By use of a sensitive method to 
look at point mutations in mitochondrial DNA, researchers found 
hard evidence that mtDNA point mutations increase with aging 
and mitochondria deteriorate as people age. These scientists 
show that one particular point mutation in the control region 
of the mtDNA occurs in a high proportion of the mtDNA molecules 
of more than 50 percent of people over the age of 65, but is 
absent in younger individuals. Because the mitochondria are the 
cellular sites for energy metabolism, deterioration of 
mitochondria could deprive cells of the energy they need to 
function and ultimately could lead to premature cell death.
    Caloric restriction prevents age-associated changes in gene 
expression.--Most multicellular organisms exhibit a progressive 
and irreversible physiologic decline during the aging process. 
The only intervention known to slow the intrinsic rate of aging 
in mammals is caloric restriction. Given 30 to 40 percent fewer 
calories than in usual feeding schedules, but fed all the 
necessary nutrients, rodents and other non-primate laboratory 
animals studied not only have lived far beyond their normal 
life spans but have reduced rates of several diseases, 
especially cancers. In a new study, the gene expression profile 
of the aging process was analyzed in skeletal muscle of mice. 
Of the 6347 genes surveyed by new micro-array techniques, only 
58 (0.9%) displayed a greater than twofold decrease in 
expression. Thus, the aging process is unlikely to be due to 
large, widespread alterations in gene expression. The major 
effect of caloric restriction seems to be to heighten animals' 
stress response in response to damage to proteins and other 
large molecules. Caloric restriction also completely or 
partially suppressed age-associated alterations in expression 
of a large proportion of genes. This is the first global 
assessment of the aging process in mammals at the molecular 
level. Potentially, gene expression profiles can be used to 
assess the biological age of mammalian tissues, providing a 
tool to evaluate experimental interventions.
    Link established between telomeres and mammalian aging.--
Telomeres are highly repetitive DNA sequences located at the 
end of chromosomes. They are essential for the stability of 
chromosomes and cell survival in a wide variety of organisms. 
In human cells grown in culture, telomere length shortens with 
each cell division and the progressive telomere shortening 
ultimately limits the ability of cells to divide. To test the 
possibility of a link between telomere shortening and aging of 
an organism, investigators have created genetically altered 
mice lacking telomerase, an enzyme that adds new telomeric DNA 
sequences to existing telomeres. In this transgenic model, 
telomeres progressively shortened throughout the lifespan, 
providing a unique opportunity to understand the cellular 
consequences and aging significance of telomere shortening in 
the living animal. Although loss of telomeres did not elicit a 
full spectrum of the classical symptoms of aging, age-dependent 
telomere shortening was associated with a shortened life span, 
reduced capacity to respond to physiological stress, slow wound 
healing, and an increased incidence of spontaneous cancers. As 
individuals age, older organs show a markedly diminished 
capacity to cope with acute and chronic stress. The telomerase-
deficient mouse provides a valuable model to study the role of 
telomere maintenance in cellular stress responses in the aging 

                   2000 Selected Scientific Advances

                            Biology of Aging

    Extension of Average Life Span of Nematodes by 
Pharmacological Intervention.--It is widely accepted that 
oxidative stress is a factor in aging. To date, however, it has 
not been demonstrated convincingly that natural anti-oxidants 
such as vitamins C and E or b-carotene extend life span in 
model experiments with mice, fruit flies, or nematodes (a kind 
of worm). Varied results have been obtained in genetically 
altered fruit flies over-expressing either superoxide dismutase 
(SOD) or SOD and catalase, enzymes that reduce oxidative 
damage. Now, an artificial compound, EUK-134, which mimics both 
SOD and catalase activity, has been shown to increase the 
average life span of nematodes by about 50 percent. EUK-134 
also reversed premature aging in a nematode strain subject to 
elevated oxidative damage. These results strongly suggest that 
oxidative stress is a major factor in rate of aging in the 
nematode, and that this rate can be slowed by pharmacological 
intervention. It may be that similar compounds could lessen 
oxidative stress in humans and delay or reduce age-related 
    Cell Transplantation and Aging.--An alternative to tissue 
or organ transplantation that appears to have great potential 
is formation of functional tissue from cell transplants. Recent 
research has shown that isolated cow or human adrenal gland 
cells inserted into immunodeficient mice formed functional 
adrenal tissue that resembles normal adrenal gland. This 
approach may potentially be used for any organ, either to study 
its functional regeneration in a living organism with age or to 
therapeutically regenerate lost function as in a case, for 
example, when defective genes might be replaced in cells 
isolated from a patient and then placed back into the same 
patient for tissue regeneration. This technique can also reduce 
the need for immunosuppressive therapies and offers an 
alternative to stem cell therapies.
    Genetically Mimicking Caloric Restriction (CR) 
Significantly Extends Yeast Life Span.--CR has been shown to 
significantly extend life span in a variety of organisms. In 
organisms studied to date (yeast, nematodes, fruit flies, mice 
and rats), CR increased both mean and maximum life span, as 
well as significantly reducing signs of disease. In all species 
examined, the extended longevity and health of the animals was 
accompanied by changes in the regulation of energy metabolism. 
Recent research has determined that genetic manipulation of 
glucose availability, metabolism, and signaling pathways can 
mimic the longevity-extending effects of CR in the yeast model. 
This discovery makes the yeast model of aging and longevity a 
powerful tool for uncovering the underlying cellular and 
molecular mechanisms responsible for increased longevity and 
health span, with a view to developing effective interventions.
    CR Increases Neurotrophic Factor Production in the Brain 
and Protects Neurons.--Beyond extending life span, CR also 
reduces development of age-related cancers, immune and 
neuroendocrine alterations, and motor dysfunction in rodents. 
Recent animal model studies of neurodegenerative disorders 
provide the first evidence that CR can also increase resistance 
of neurons to age-related and disease-specific stresses. One 
possible mechanism is that the mild metabolic stress associated 
with CR induces cells to produce proteins that increase 
cellular resistance to disease processes. Indeed, CR increases 
production of one such protein, a neuronal survival factor, 
BDNF. BDNF signaling in turn plays a central role in the 
neuroprotective effect of CR. This work suggests that CR may be 
an effective approach for reducing neuronal damage and 
neurodegenerative disorders in aging, providing insight into 
the design of approaches that might mimic CR's beneficial 
    Use of Gene Expression Microarrays in Aging Research.--
Aging is normally accompanied by changes in expression, or 
activity, of a large number of genes, but it is not clear which 
of these changes are critical in the aging process. Gene 
expression microarrays, which allow profiling the activity of 
many thousands of genes at once, provide an opportunity to 
obtain a more complete picture of what these changes are, and 
to design tests of whether these changes are causally 
associated with aging. In three recent studies, investigators 
looked at differences in gene expression patterns in young and 
old mouse skeletal muscle, liver, and brain tissue and also 
made several observations on changes brought about by caloric 
restriction. Though the data analyses are complex, some initial 
observations are: 1) aging results in lower levels of activity 
of metabolic and biosynthetic genes; 2) aging is accompanied by 
patterns of gene expression that are indicative of stress 
responses, including inflammatory and oxidative stress; 3) 
many, but not all, age-related changes in gene expression in 
mouse liver and skeletal muscle are slowed by caloric 
restriction; and 4) caloric restriction appears to increase 
expression of genes for repairing and/or preventing damage to 
cellular macromolecules. Microarray technology is proving to be 
an efficient approach to answering long-standing important 
questions about molecular mechanisms of aging and how these may 
be manipulated, for example, by calorie restriction. Profiling 
changes in gene activity may eventually provide useful 
biomarkers of the aging process itself, markers that might be 
important in assessing the effectiveness of strategies to 
retard aging-related processes.

                    Reducing Disease and Disability

    As life expectancy increases, there is an ever greater need 
to keep these additional years disease and disability-free. 
Research has shown that life-style and other environmental 
influences can profoundly impact outcomes of aging, and that 
remaining healthy and emotionally vital until advanced age is a 
realistic expectation. NIA-supported investigators at 
institutions across the nation, including those that are the 
recipients of Claude Pepper Older Americans Independence 
Centers awards, are helping to define optimal needs regarding 
diet, diet supplements, exercise, safety, and other factors. 
The goals are to ensure that endurance, strength, and balance 
are kept at the highest possible level and that the risks of 
disease, such as osteoporosis, cancer, and cardiovascular 
disease, and disability are kept to a minimum. In addition to 
its support of biomedical and behavioral research, the NIA is 
committed to helping reduce disease and disability by 
translating research findings into effective interventions, 
such as exercise, for the public. Toward this end, in 1999, the 
NIA published a free manual, Exercise: A Guide from the 
National Institute on Aging, the cornerstone of the Institute's 
ongoing campaign to encourage older people to exercise. The 
Guide is based on scientific evidence and is intended to help 
people design their own exercise program. Information about the 
Guide, and other NIA publications, is available on the NIA home 
page at:

                   1999 Selected Scientific Advances

                    Reducing Disease and Disability

    Delirium can be prevented in hospitalized older patients.--
Delirium, an acute confusional state, in older hospitalized 
older patients is associated with poor outcomes, and is a 
common, serious, and potentially preventable source of both 
prolonged illness and early death. Between 20-30 percent of all 
hospitalized elderly patients have episodes of delirium, 
resulting in treatment costs exceeding $4 billion per year in 
the U.S. Previous studies of delirium focused on the treatment 
of delirium rather than on primary prevention. A recent study 
done by researchers evaluated the effectiveness of a multi-
component strategy for the prevention of delirium. Study 
participants received either usual, standard hospital care or 
care under a multidisciplinary team of specialists that 
included staff nurses, recreational therapists, physical 
therapists, geriatricians, and trained volunteers. Patients in 
this study had one or more of six risk factors for delirium, 
including cognitive impairment, sleep deprivation, immobility, 
dehydration, or impaired vision or hearing. To address these 
risk factors, team members were trained to recognize and 
counteract the danger signs before confusion, agitation, and 
hallucinations set in. Interventions include making sure 
patients got enough fluids, taking them for walks, and 
providing warm drinks at bedtime to promote sleep. While 15 
percent of patients receiving standard hospital services 
experienced at least one episode of delirium, only 9.9 percent 
of those receiving the team approach experienced an episode. 
Once an initial episode of delirium had occurred, however, the 
intervention had no significant effect on the severity of 
delirium or the likelihood of recurrence. This study holds 
substantial promise for the prevention of delirium in 
hospitalized older patients. Further evaluation is needed to 
determine the cost effectiveness of intervention to prevent 
delirium and its effects on related outcomes, such as 
mortality, re-hospitalization, institutionalization, use of 
home health care, and long-term cognitive functioning.
    Predictors of healthy aging can be identified and 
interventions can reduce risk of disability.--There is a need 
to understand whether there are modifiable risk factors that 
can decrease the risk of disability and death with aging. A 
long-term study with Japanese-American men in Hawaii has shown 
that these men have one of the highest life expectancies of all 
Americans. Because a number of baseline measurements were taken 
of these men in midlife, from 45 to 68, it was possible to 
explore predictors of long life expectancy and prevention of 
physical disability. Among over 6500 healthy men at baseline, 
about 60 percent remained free of major illness and were not 
physically or cognitively impaired over the next 25 years. Data 
from mid-life that proved to be predictive of healthy aging 
included optimal blood pressure, low blood sugar and 
cholesterol levels, lack of obesity, lack of smoking, and 
strong hand grip. At an older age the men were examined to 
determine the presence of functional limitation and disability. 
Of various factors considered, mid-life hand grip strength was 
associated with less physical disability and faster walking 
speed. In a clinical trial, participants were randomized into 
intervention and control groups. At the end of one year after a 
regimen of increased physical activity and chronic-illness 
self-management, the intervention group experienced fewer 
hospitalizations and fewer total hospital days. Factors leading 
to a long and active life are of prime importance as the 
population ages worldwide. This study suggests that preventive 
and/or therapeutic interventions are most effective when 
initiated at younger ages, although the clinical trial results 
suggest that successful intervention can occur at older ages. 
Researchers will need to work with clinicians to develop 
strategies to address modifiable risk factors in order to 
promote healthy aging.
    Testosterone replacement men may have protective effects 
against age-related diseases.--Many older men have blood levels 
of testosterone well below the normal range for younger men. 
Earlier studies have shown that low testosterone levels may 
increase risk factors for disease and disability, including 
loss of bone (leading to osteoporosis and fractures), loss of 
muscle (causing decreased strength), and increases in body fat 
(increasing risks for diabetes and heart disease). In a 
recently completed clinical trial of men over 65 years old with 
low serum testosterone, study participants were given a 
testosterone or placebo skin patch for three years. Levels of 
testosterone in the treatment group rose to those generally 
found in younger men. Men with the lowest endogenous serum 
testosterone (3 micrograms per liter or less) prior to 
beginning the trial had significant increases in bone density 
in response to testosterone replacement. The testosterone 
treatment also increased lean body tissue and significantly 
decreased body fat. Study participants were monitored for 
possible adverse treatment effects, particularly on the 
prostate. Testosterone treatment did not increase symptoms of 
an enlarged prostate, such as impaired urinary function, nor 
was there statistically significant evidence that the 
administered testosterone increased the incidence of prostate 
cancer. The results of this study suggest that testosterone 
replacement could help protect many older men with low 
testosterone levels against common diseases of aging such as 
diabetes, heart disease, and osteoporosis. However the 
possibility that testosterone replacement could increase 
adverse events such as prostate diseases, though not observed 
in this small study, reinforces the need for well-designed 
larger studies as well as the development of strategies to 
minimize risks of testosterone therapy while still providing 
    Postmenopausal estrogen use is associated with decreased 
arterial stiffness.--Arterial stiffness has been identified as 
a potential risk factor for cardiovascular disease. Earlier 
research has shown that estrogen may improve blood vessel 
pliability by altering the structure and function of vascular 
tissue, including smooth muscle cells. This study, conducted at 
examined the influence of age and current estrogen replacement 
therapy (ERT) on stiffness in the common carotid arteries (the 
main arteries that pass up the neck and supply blood to the 
head). The common carotid arteries of 172 women, 37 of whom 
were current users of ERT, were examined by ultrasound, and the 
degree of arterial stiffness was measured. Arterial stiffness 
was found to increase linearly with age, and was modestly 
related to other cardiac risk factors. The degree of stiffness 
was lower in women using ERT than in postmenopausal nonusers. 
Furthermore, the effects of age and ERT on the stiffness 
persisted after adjustments for other cardiovascular risk 
factors. Carotid stiffness was similar in ERT users, whether or 
not they also took progesterone. This study suggests that the 
cardiovascular protection seen in women using ERT may involve 
overall reduction of age-associated arterial stiffening.
    Chronic inflammation in the elderly predicts disability and 
early death.--Inflammation is a normal biologic response of the 
immune system to a number of different stimuli, including 
infections, allergens, and physical trauma. However, 
inflammation can become chronic and increase the onset and 
severity of a number of age-related disabilities and diseases. 
An indicator of this process is the elevation of a pro-
inflammatory protein, interleukin-6 (IL-6), which plays a 
central role in inflammation and increases with age. High 
circulating levels of IL-6 are associated with such diverse 
conditions as depression, heart failure, and arthritis. One 
study of nearly 1,700 men and women, ages 70 or greater living 
in North Carolina, measured IL-6 levels against a standardized 
test for depression. After controlling for age, race, and 
gender, IL-6 levels remained the only biologic variable 
significantly associated with depression. In another study in 
men and women 71 years or older, participants with the highest 
levels of interleukin-6 were almost twice as likely to develop 
mobility-disability and were about twice as likely to die 
within 5 years of the beginning of the study. It is known that 
IL-6 stimulates the synthesis of C-reactive protein, an 
indicator of systemic inflammation. When levels of both IL-6 
and C-reactive protein were elevated simultaneously, there was 
a 3-fold increased risk of mortality. Further studies are 
needed to improve our understanding of the complicated system 
of stimulus and response with regard to inflammation. These 
findings may broaden our understanding of the health correlates 
and consequences of chronic inflammation, as well as provide a 
new way to identify high-risk individuals to determine whether 
they would benefit from anti-inflammatory intervention.
    Behavioral training is more effective than drug therapy for 
urge urinary incontinence.--Approximately 15 million Americans 
adults have urinary incontinence (UI) with associated health 
costs estimated in a range of $16- $26 billion dollars 
annually. Urinary incontinence is especially a problem for 
women. Nearly 40 percent of community dwelling women age 60 
years and older suffer from some form of UI. While behavioral 
training and drug therapy have both been previously 
demonstrated to be effective treatments for urge urinary 
incontinence in older adults, drug therapy is commonly used as 
the first course of treatment. A recent clinical trial directly 
compared behavioral training (instrument-assisted pelvic muscle 
exercises to improve bladder control) to drug treatment for 
urge UI in older women and demonstrated that behavioral 
training was significantly more effective than drug therapy in 
reducing the episodes of accidental urine loss. Thus, 
behavioral training should be considered the first treatment 
option given the potential side effects of drug therapy, and to 
avoid further problems with drug interactions among older 
persons taking multiple medications.

                   2000 Selected Scientific Advances

                    Reducing Disease and Disability

    Fitness Affects Mortality Risk Regardless of Body Fat.--
Both obesity and being unfit increase risk for chronic disease 
and death. However, the interrelationship between fitness, body 
fat, and mortality has not been clear. Recent research suggests 
that it is fitness, not fat, that may count most. In one study, 
investigators followed men 30-83 years of age for an average of 
eight years, classifying participants according to body fat as 
well as relative fitness based on exercise testing. Not 
surprisingly, the study showed that the higher the level of 
fat, the lower the level of fitness. But what intrigued 
researchers most were data showing that, within each category 
of body fat, ``fit'' men were at lower risk of death. Most 
strikingly, among those more fit, obesity was not significantly 
related to risk of death. In another study, low fitness 
increased mortality risk in men approximately fivefold for 
cardiovascular disease, and threefold for all-cause mortality. 
These findings suggest that, beyond interventions focusing on 
weight-loss to prevent and treat obesity-associated conditions, 
there may also be important benefits for the obese from 
improved fitness.
    Stress Testing May Not Be Needed for Starting an Exercise 
Program.--The role of exercise stress testing and safety 
monitoring for older people who want to start an exercise 
program is unclear. Current guidelines for routine exercise 
stress testing may deter older people from beginning an 
exercise program, either because of the cost of testing or 
because it may lead people to believe that exercise poses 
higher risks than it actually does. The latest research 
suggests that, in the absence of cardiovascular 
contraindications, the benefits of exercise for the elderly, 
balanced against a somewhat minor increase in risk, may be 
sufficient for starting an exercise program without prior 
exercise stress testing.
    Commonly Prescribed Diuretic Protects Against 
Osteoporosis.--The lifetime risk of osteoporotic fracture in 
the U.S. is 40 percent in women and 13 percent in men. Because 
age-related bone loss increases susceptibility to fracture, 
strategies aimed at preserving bone mass are important. Large 
observational studies have consistently shown that the use of 
thiazide diuretics, usually prescribed to treat high blood 
pressure, is associated with higher bone density and about a 30 
percent lower risk of hip fracture. Investigators recently 
completed a clinical trial to directly test the effect of 
taking thiazides on bone density in older men and women with 
normal blood pressure. Among healthy older adults, low-dose 
hydrochlorothiazide did preserve bone density at the hip and 
spine. The modest effects observed over three years, if 
accumulated over 10-20 years, may explain the 30 percent 
reduction in hip fracture risk associated with thiazides in the 
earlier observational studies. The results of this trial 
suggest that low-dose thiazide therapy may have a role in 
strategies to prevent osteoporosis.
    Regulation of TGF- Type II Receptor and 
Atherosclerosis.--Atherosclerosis or narrowing of the arteries 
is the major risk factor for both heart disease and stroke and 
is a major complication after arteries have been surgically 
enlarged by balloon angioplasty. Throughout life, artery wall 
cells successfully repair injuries related to smoking, high 
blood pressure or cholesterol, making new cells to replace 
damaged ones. But constant exposure to such stresses eventually 
causes the artery wall cells to lose control of their 
replication. The growing mass of cells forms plaque, which 
eventually clogs the vessels and causes reduced blood flow. New 
research is helping to identify the complex series of cellular 
events causing cells to lose control of their division. In 
normal circumstances, a protein called TGF- prevents 
excessive cell division. It acts on the cells through binding 
to a protein receptor on the cell surface, the TGF- 
receptor, causing intracellular changes that stop cells 
dividing. In atherosclerotic lesions, it has been shown, 
unrestricted growth in some cells is caused by mutations in 
this receptor, inactivating it. Another way of preventing 
normal receptor function is to make too little TGF- 
receptor to be effective. One protein that inhibits the 
production of TGF- receptor is called Egr-1. This 
protein is found at very high levels in plaques, perhaps being 
induced by artery injury. Finding drugs to repress the activity 
of Egr-1 may be one way of keeping the key TGF- 
receptor functioning effectively to stop excessive cell 
division and prevent atherosclerosis.
    Exendin-4 as a Treatment for Type 2 Diabetes.--Type 2 
diabetes mellitus (DM) is caused by an inability of the beta 
cells of the pancreas to compensate for increasing insulin 
demands; consequently, blood glucose levels rise. Scientists 
are searching for compounds that act on the pancreatic beta 
cells to prevent this progressive rise in blood glucose. GLP-1, 
a gut peptide, can stimulate beta cells to produce more insulin 
even in type 2 DM; however, its biologic half-life is short and 
its effects quickly wear off. Exendin-4, a newly studied 
peptide analog of GLP-1, is long-lived and more potent than 
GLP-1, and has been shown to reduce blood glucose levels in 
rodents. A recent study conducted by researchers in the NIA 
intramural research program with small numbers of diabetic and 
non-diabetic humans demonstrated Exendin-4's efficacy in 
inducing insulin and normalizing blood sugar, even in 
diabetics. In the near future, an exendin-like drug possibly 
may become an effective treatment for type 2 DM.

                     Behavioral and Social Research

    A goal of NIA behavioral and social research is to maintain 
or enhance the health and well-being, including physical and 
cognitive function, of older individuals throughout the life 
span. For example, new interventions are being developed to 
encourage long-term changes in health behaviors that will lead 
to a reduced risk of disease and disability. Cognitive 
interventions are being tested to maintain cognitive function 
and retain independence. Components of the physical environment 
are being redesigned to match the skills and abilities of older 
persons, thus helping to prevent injuries and to improve 
performance of daily activities. Such human factors research 
has produced new and improved medical devices and treatment 
regimens, instructional designs, and product labeling. As the 
number of older people who are able and willing to work well 
into late adulthood increases, researchers are studying the 
physical and social barriers to their sustained participation 
in the workforce and the factors needed to enhance their skills 
and productivity. A related body of demographic research 
documents trends in health, disability, retirement, long-term 
care, and the economic aspects of aging, and uncovers their 
causes and inter-relationships.
    A major focus of ongoing research supported by the NIA 
Behavioral and Social Research (BSR) program involves tracking 
the declining chronic disability rate in the elderly U.S. 
population. First reported in 1997, researchers at Duke 
University found that between 1982 and 1994, the prevalence 
rates for chronic disability in the U.S. elderly population, 
age 65 and older, declined 3.6 percentage points, based upon 
data from the 1982, 1989, and 1994 National Long Term Care 
Surveys. The decline is highly significant statistically and 
occurred at nearly all levels of disability. In absolute terms, 
the differences in prevalence suggest that there were 
approximately 1.2 million fewer disabled people in 1994 than 
would have been predicted if the 1982 rates had remained the 
same; that is, 7.1 instead of 8.3 million people. Subsequent 
waves of the survey revealed that disability rates for older 
people have continued this downward movement. The NIA BSR 
program is supporting research to understand the dynamics of 
this trend with the goal of accelerating it in future years.

                   1999 Selected Scientific Advances

                     Behavioral and Social Research

    Social and productive activities confer survival advantages 
to the elderly.--When previous studies found that older people 
who remained active lived longer, scientists assumed that the 
survival advantage resulted from improved cardiopulmonary 
fitness attributable to physical activity. A new study from a 
research team suggests that social activities (church 
attendance, travel, etc.) and productive activities (gardening, 
community work, etc.) involving little or no enhancement of 
fitness lowered the risk of all-cause mortality over a 13-year 
period to a degree similar to that achieved by fitness 
activities (e.g., swimming, and walking). This study suggests 
that a wider range of mechanisms, both psychological and 
psychosocial, may be involved in the association between 
activity and mortality than had been previously thought. The 
finding has important implications for public policy and 
clinical practice. If confirmed, it suggests that clinicians 
might consider recommending a broader range of activity options 
for older patients.
    Centenarians live most of their lives in good health.--
Scientists have found preliminary evidence that many 
centenarians remain functionally independent for the vast 
majority of their lives and then experience a relative rapid 
decline near the end of their lives. Relative to others in the 
older population, they also appear to either experience a 
marked delay in the onset or, in some cases, escape diseases 
such as cancer and Alzheimer's disease. Scientists also find a 
strong familial component to extreme longevity. Siblings of 
centenarians tend to live longer compared to siblings of 
individuals who died in their mid-70's. This may be due in part 
to shared genetic traits among family members. Understanding 
the genetic and environmental factors responsible for 
centenarians' prolonged good health could provide insights for 
improving the health of all older people. Further work is 
needed to elucidate the genetic and environmental factors that 
contribute to centenarians' extreme longevity.
    Socioeconomic status and health disparities are strongly 
related over the life course.--There is a striking and well-
documented relationship between socioeconomic status, health, 
and longevity. People with higher incomes and more wealth tend 
to be healthier and to live longer. The causes of this 
relationship are largely unknown, but may be related to health 
behaviors and access to care. In a recent study done by 
researchers, African-American men were found to have lower life 
expectancy in disparate income groups than did white men in the 
same income groups for the years 1979 to 1989. African-American 
men with family incomes below $10,000 averaged 7.4 fewer years 
of life than black men in families with more than $25,000; 
among white men, the differential between the two income groups 
was 6.6 years. Less work has been focused on the effect of 
health events on subsequent income and wealth. The strong 
inter-relationship between health and wealth at older ages may 
be due, in large part, to the adverse economic impact of major 
health events. One major reduction in wealth appears to be 
reduced earnings that stem from taking early retirement or 
otherwise decreasing work. People who have heart attacks, 
strokes, or other acute health events are especially likely to 
reduce their work levels. There are equally large reductions in 
wealth among those with and without health insurance (although 
those with health insurance have lower out-of-pocket medical 
expenses), suggesting that health insurance does not fully 
protect people from the economic costs of major illnesses. This 
finding demonstrates how differences in health status can cause 
differences in economic circumstances. These results also 
suggest some direction for policy. They show, for example, that 
health insurance deals with only a small part of the economic 
cost of declining health. The much larger economic costs of 
decreased work and lost earnings might be more effectively 
addressed in other ways. To aid in understanding this causal 
relation between health and wealth, future clinical trials 
could include more economic content so that the impacts of 
health on economic status can be measured.
    Neighborhood and socioeconomic characteristics hamper 
progress in fitness.--Physical inactivity is a leading cause of 
both death and disability among older adults. Recent analyses 
from the Alameda County Study, which was conducted by 
investigators, show that socioeconomic variables such as 
neighborhood characteristics affect physical activity levels 
and thus may contribute to health disparities. Living in a poor 
neighborhood is associated with a decline in physical activity, 
even adjusting for age, individual income, education, smoking 
status, body mass index, and alcohol consumption. Other survey 
analyses reveal that poor weather and fear of crime were major 
barriers to exercise among low-income urban older adults, as 
was the lack of information from physicians and family/friends 
regarding the safety and benefits of exercise. These studies 
demonstrate the importance of designing physical activity/
exercise programs that can counter the negative effects of 
disadvantaged social conditions.

                     2000 Selected Science Advances

                     Behavioral and Social Research

    Mortality Continues to Decline in Industrialized 
Countries.--During the twentieth century, mortality rates have 
shown steady and significant declines in the G7 countries of 
Canada, France, Italy, Germany, Japan, the United Kingdom, and 
the U.S. Mortality decline has occurred most significantly in 
older populations due to decreases in deaths from heart attack, 
stroke, and cancer. Examining mortality data of the G7 
industrialized countries over the last five decades, 
researchers found that long-term patterns in mortality rates 
have continued to decline exponentially at a remarkably 
constant rate, without evidence of slowing. Therefore, official 
estimates of longevity in the G7 countries underestimate life 
expectancy and also understate the ratio of people 65 and older 
to working age people (20-64 year olds). By the year 2050, 
these ratios may be between 6 percent (UK) and 40 percent 
(Japan) higher than official projections. These findings have 
significant implications for public policy regarding future 
demands on health care, long-term care, retirement support, and 
other services.
    Emotional Vitality is associated with lower Mortality and 
Progression of Disability in Disabled Older Women.--Using data 
from the Women's Health and Aging Study, a longitudinal study 
of community-dwelling disabled women aged 65 years and older, 
researchers examined whether emotional vitality protects 
against progression of disability and mortality. At the start 
of this study, a substantial proportion of even the most 
disabled older women were identified as emotionally vital. 
Three years later, results showed that these upbeat, positive 
women did better than women who were not emotionally vital in 
maintaining physical function over time. These results suggest 
that helping older people maintain a high level of emotional 
vitality might play an important role in slowing or preventing 
a downward spiral in health status. Further study may be 
warranted of why and when positive emotions protect against 
health decline in older people.
    The Influence of Stereotypes on Cardiovascular Health and 
Cognitive Function.--Recent research indicates that exposure to 
negative beliefs about aging can contribute to adverse health 
outcomes, even when an individual is not consciously aware of 
such exposure. In this study, exposure to negative stereotypes 
elicited heightened cardiovascular stress (increased blood 
pressure and heart rate in older adults) in response to 
mathematical and verbal challenges designed to elicit a stress 
response. Positive messages about aging protected participants 
from a stress response. The older adults exposed to positive 
stereotypes also exhibited more confidence in their ability to 
perform computations than those exposed to negative 
stereotypes, and then outperformed them as well. These 
preliminary findings suggest that further research is need to 
examine the potentially powerful influence of stereotypes not 
only on the physical well being of older adults but also on 
their performance in tasks known to become progressively more 
difficult with age. Perhaps positive age-related stereotypes 
could be used to reduce cardiovascular responses to stress and 
to improve cognitive performance and daily function.

        Section II.--Research Sponsored by Other NIH Institutes

                  National Institute of Mental Health

    The National Institute of Mental Health (NIMH) program of 
research on aging includes studies in the basic sciences as 
well as research in neurobiology and brain imaging, clinical 
neuroscience, treatment assessment, psychosocial and family 
studies, and service systems research. Studies involve mental 
disorders with initial occurrence in late life as well as 
illnesses that begin in early adulthood but continue throughout 
the life course. Major areas of research focus are the 
psychiatric aspects of Alzheimer's disease and related 
dementias, depressive disorders, schizophrenia, anxiety 
disorders, and sleep disorders.

Alzheimer's Disease

    An estimated 4 million Americans age 65 and older suffer 
from Alzheimer's disease or other forms of dementia. An 
important area of NIMH research on Alzheimer's disease focuses 
on genetic factors. NIMH-supported researchers recently 
identified a new gene mutation strongly associated with the 
risk of developing late-onset Alzheimer's disease, the most 
common form of the brain disorder. Using the NIMH Genetics 
Initiative Alzheimer's disease sample (a collection of DNA 
samples and clinical information from hundreds of families in 
which more than one individual has Alzheimer's), and new 
methodology, the researchers found that a particular gene 
mutation, alpha-2 macroglobulin-2 (A2M-2), was significantly 
associated with Alzheimer's. Different teams of investigators 
are continuing to analyze the NIMH Genetics Initiative sample, 
and recent evidence has been found by three different groups to 
support linkage between genetic markers on chromosome 10 and 
Alzheimer's disease. Researchers are actively working to find 
the specific gene involved. These findings, if replicated, will 
offer important clues into the disease process and will help 
discern the role of additional genetic and environmental 
factors involved in creating vulnerability to the disease.


    Nearly 5 million of the 32 million Americans age 65 and 
older suffer from depression. Significantly, many late-life 
depressions are amenable to treatment. Recent NIMH-supported 
studies provide important information relevant to depression 
treatment in the elderly. One study compared treatment response 
among elderly depressed patients who had their first depressive 
episode early in life and those whose first episode occurred at 
age 60 or older. Although age at onset did not affect overall 
efficacy of treatment, patients who had experienced their first 
depressive episode early in life took 5-6 weeks longer to reach 
remission. This slower treatment response, combined with the 
increasing rates of suicide among the elderly, particularly 
among males, indicates that elderly depressed patients with 
early-onset illness need particularly careful management.
    Another study found that a combination of pharmacotherapy 
and psychotherapy is extremely effective in preventing 
recurrence of depression among the elderly. Older adults who 
received interpersonal therapy and an antidepressant medication 
during a three-year period were much less likely to experience 
recurrence than those who received medication only or therapy 
only. Positive long-term outcome, however, was less durable in 
individuals above age 70 than in those below this age.
    NIMH-supported research has suggested that, among depressed 
older adults, slower and less complete response to 
antidepressant treatment tends to be associated with 
cerebrovascular pathology, ventricular enlargement, and 
impairment of frontostriatal brain pathways. Patients with such 
brain pathology often also show particular clinical features, 
including psychomotor retardation, lack of insight, and 
impairment of higher-order executive functions. One recent 
study extended this picture by examining the prognostic value 
of executive dysfunction in older adults after their depressive 
symptoms had remitted with treatment. The presence of 
abnormalities of initiating behaviors and perseverating, but 
not memory impairment or other clinical features, predicted 
fluctuations in residual depressive symptoms and greater 
relapse and recurrence of depressive disorder. These clinical 
features thus can help identify patients who need particularly 
vigilant monitoring and follow-up. This body of research is 
leading to further studies on the role of specific prefrontal 
brain pathways in predisposing toward or perpetuating 
depressive symptoms and syndromes in elderly patients.


    Older Americans are disproportionately likely to commit 
suicide. Comprising 13 percent of the population, they account 
for nearly 20 percent of all suicide deaths. The rate of 
suicide is particularly striking among white males aged 85 and 
older: in 1997, the most recent year for which statistics are 
available, the rate in this group was 65 per 100,000 - about 
six times the national U.S. rate of 10.6 per 100,000. 
Researchers interviewed families and associates of elderly 
individuals who committed suicide to determine the state of 
mind of such individuals just prior to their suicide. The 
investigators concluded that major depression was the most 
common predictor of suicide in this study population. At least 
70 percent of those who committed suicide had visited primary 
care providers within a month of the suicide. The findings 
point to the urgency of enhancing both the detection and 
adequate treatment of depression in primary care settings as a 
means of reducing the risk of suicide among the elderly. NIMH 
is currently funding a multi-site study in the elderly to test 
the effectiveness of an intervention aimed at improving the 
recognition of suicidal ideation and depression by primary care 

Sleep Disorders

    Insomnia and other sleep difficulties tend to be highly 
prevalent, chronic ailments among older adults that are most 
commonly managed clinically by prescribing hypnotic 
medications. However, long-term use of such medications can 
often complicate the sleep difficulties. NIMH-supported 
research has demonstrated that psychotherapy can also be used 
successfully to treat chronic primary insomnia in middle-aged 
to elderly individuals. Cognitive-behavioral therapy focused on 
sleep issues proved equal to the sleep medication temazepam in 
alleviating insomnia in older adults, and led to more enduring 
improvements in sleep at 12- and 24-month follow-ups. Combining 
the psychotherapy with medications did not yield advantages 
over the outcomes achieved with either treatment individually. 
Such results indicate that psychological interventions are 
useful techniques in treating sleep problems in late life and 
that, as in other disorders, older patients with chronic 
insomnia respond to psychotherapy comparably to younger adults.

                         National Eye Institute

Age-Related Macular Degeneration

    Age-related macular degeneration is the leading cause of 
blindness in patients over the age of 65. As the population in 
this country ages, this disease will have an even greater 
impact. The condition affects the retina and leads to varying 
degrees of vision loss depending on the form and severity of 
the disease. In initial phases, the disease causes reductions 
in the ability to read fine print and see in dim light. In the 
later stages of the disease, abnormal blood vessel growth takes 
place under the retina and causes severe vision loss resulting 
in an inability to drive, read, recognize faces, and perform 
other visual tasks of day to day living. While the disease has 
been recognized for many years, our understanding of the causes 
and reasons for progression of this disease are still limited. 
Work in humans with this conditions has indicated that certain 
proteins involved in growth of blood vessels are elevated in 
these patients and that one growth factor, vascular endothelial 
growth factor (VEGF), is consistently elevated in patients with 
abnormal blood vessels associated with age-related macular 
degeneration. For the first time, scientists at the National 
Eye Institute (NEI), using a system to manipulate the 
expression of VEGF have been able to cause development of 
abnormal blood vessels in rodent eyes that are identical in 
location and appearance to those seen in humans afflicted with 
the disease. This finding is important, because, to date, no 
animal model has been developed that mimics the disease in 
humans. Modeling this condition in animals will provide an 
invaluable research tool to study the causes and to test 
treatments for this condition. Because the model takes 
advantage of a stimulus known to occur in the human condition, 
a more precise understanding of the trigger factors for the 
growth of the blood vessels will be gained. Subsequently, these 
trigger factors can then be manipulated through various 
therapeutic mechanisms that should be directly applicable to 
patient care. By understanding and using this new model, 
scientists hope to develop better tools to treat patients with 
age-related macular degeneration.

Age-Related Cataract

    Visual impairment and blindness from cataract is an 
important public health problem throughout the world. Age-
related cataract accounts for about 16 million cases of 
blindness worldwide, about half of all cases of blindness. Most 
people with severe impairment from cataract are in the 
developing countries of Asia and Africa where barriers to 
cataract surgery are greatest. In the population-based 
Baltimore Eye Study and the Salisbury Eye Evaluation Project, 
cataracts were the leading cause of visual impairment (best 
corrected visual acuity in the better eye of worse than 20/40 
but better than 20/200) among older adults. In both studies, 
rates of blindness and visual impairment from cataract were 
higher in blacks than in whites. While surgical treatment for 
cataract is effective, the cost of the large number of 
procedures done each year is high. In the United States, 
cataract surgery is the most frequently performed surgical 
procedure in the Medicare program, with about 1.35 million 
cataract operations done each year at a cost of approximately 
3.4 billion dollars. The identification of modifiable risk 
factors or interventions that affect the development of 
cataract could have a large economic impact and reduce rates of 
blindness and visual impairment throughout the world. The Age-
Related Eye Disease Study (AREDS), sponsored by the NEI, is an 
ongoing multi-center study of the natural history of cataract 
and age-related macular degeneration. Data were collected at 
entry on a wide range of possible risk factors for cortical and 
nuclear cataracts, two of the most common types of cataract. 
Results from the study reinforce a growing consensus that 
smoking increases the risk of development of nuclear cataract 
and that higher levels of sunlight exposure increase the risk 
of cortical cataract. The identification of these potentially 
modifiable risk factors for cataract reinforces public health 
recommendations to avoid smoking and decrease exposure to 


    Glaucoma is a group of eye disorders that share a distinct 
type of optic nerve damage that can lead to blindness. 
Approximately three million Americans have glaucoma, and as 
many as 120,000 are blind from this disease. Most of these 
cases can be attributed to primary open angle glaucoma, an age-
related form of the disease. Elevated intraocular pressure is 
frequently, associated with glaucoma, but definitive evidence 
supporting a casual effect has not been demonstrated 
experimentally. Scientists now have evidence that increases in 
intraocular pressure have a profound effect on ganglion cell 
survival. Optic nerve fibers from retinal ganglion cells 
connect to neurons in a part of the brain called the lateral 
geniculate nucleus (LGN). Neurons from the LGN relay 
information to the visual cortex for processing. Using a 
primate model of glaucoma, scientists showed that relatively 
moderate elevations of intraocular pressure cause loss of LGN 
neurons over an extended period of time. These data demonstrate 
that chronic elevation of intraocular pressure has a 
neurodegenerative effect on neurons critical for the 
integration and transmission of visual information.

Low Vision Education Program

    On October 19, 1999, the NEI announced the formal launch of 
its Low Vision Education Program. Low vision is broadly defined 
as a visual impairment, not corrected by standard glasses, 
contact lenses, medicine, or surgery, that interferes with the 
ability to perform everyday activities. Most people develop low 
vision because of eye diseases, such as cataracts; glaucoma; 
diabetic retinopathy; or age-related macular degeneration, the 
leading cause of severe visual impairment and blindness in 
Americans 60 years of age and older. Low vision primarily 
affects the growing population of people over age 65 and other 
higher risk populations, including Hispanics and African 
Americans who are likely to develop low vision at an earlier 
age. While lost vision usually cannot be restored, many people 
can learn to make the most of the vision that remains. The Low 
Vision Education Program will include a multimedia public 
service campaign and a traveling exhibit that will be displayed 
in shopping malls around the country. The program will provide 
communities nationwide with materials and technical support to 
increase awareness of local low vision services and resources.

                  Office of Research on Women's Health

    During 1999 and 2000, the Office of Research on Women's 
Heath (ORWH) supported a number of research activities with the 
NIA and other NIH ICs that specifically address the health of 
older Americans, including:

Study of Women's Health Across Nation II: (SWAN II)

    The goal of this research is to determine menopause-
specific physiological changes and their predictors and the 
impact of menopause on subsequent disease. SWAN consists of 
both cross sectional and longitudinal studies on the natural 
history of menopause and a characterization of endocrinology/
physiology of premenopause. Five ethnic groups are included - 
Caucasian, African American, Hispanic, Chinese, and Japanese.

Black Rural and Urban Caregivers Mental Health Functioning

    The purpose of this study is to assess the mental health 
and social functioning of rural and urban African-American 
women who provide unpaid care to an elder (65 years and older) 
by using a cross-sectional research design and random sample of 

Continuous Low-Dose Hormone Replacement Therapy (HRT) Combined with 
        Alendronate (ALN) in Postmenopausal Women

    The primary outcome measures from this research are spine 
bone mineral density and total hip bone mineral density as a 
result of receiving low-dose HRT, ALN, and both low-dose HRT 
and ALN. Total body bone mineral content and forearm bone 
mineral content will also be measured.

Comprehensive Treatment for Older Breast Cancer Patients

    The hypothesis of this study is that a comprehensive 
geriatric intervention integrated with oncological treatment 
may preserve the independence and quality of life of older 
breast cancer patients.

Exercise and Quality of Life in Older Women with Breast Cancer

    The primary aims of the study are to determine if: 1) A 
moderate exercise program, as compared to enhanced usual care, 
significantly improves the physical function and quality of 
life in older women with breast cancer; and 2) A psycho-
educational program, as compared to usual care, significantly 
improves physical functioning and quality of life in older 
women with breast cancer.

Gender Differences in Pain Responses of the Elderly

    This research will develop future strategies for pain 
treatment in elderly patients by increasing our understanding 
of the role of gender and hormone replacement on pain 

Menopausal Depression: Chronobiologic Basis

    This research is designed to provide information on 
possible mechanisms mediating the effects of reproductive 
hormones on mood and behavior and deriving relevant clinical 
treatment guidelines for menopausal women from this research. 
This proposal represents an extension of the investigators' 
previous work that led to the development of new hypotheses and 
treatment strategies.

NAS Panel on Risk and Prevalence of Elder Abuse and Neglect

    This panel evaluates the potential for pilot studies needed 
to develop instruments that can detect abusive behavior. The 
panel will also discuss issues related to confidentiality and 
data sharing, and make recommendations regarding the scope of a 
national research effort on elder abuse and neglect which will 
include institutionalized victims of abuse and neglect and 
issues related to data collection on victims suffering from 

Estrogen and Cholinergic System Interactions in Aging

    The studies contribute important information on the 
mechanistic link between estrogen, cognition, and Alzheimer's 
disease in older women, and promote further interest in 
designing better therapeutic strategies.

Postmenopausal Estrogen Influences on Olfaction

    This study tests the hypothesis that hormone replacement 
therapy (HRT) is associated with higher olfactory and cognitive 
functioning in postmenopausal women. If HRT were found to 
benefit olfaction and cognition in postmenopausal women, 
improvements in both nutritional and functional status could 

Vascular Gene Expression in Aging Women

    The central hypothesis of the study is that estrogen 
inhibits the initiation and progression of atherogenesis in 
part through direct estrogen receptor-dependent effects on 
vascular gene expression. This study provides insights into the 
progression of the disease as well as potential therapies to 
prevent this age-related disease.

Progestogens vs Phytoestrogens: An Adjunct to ERT

    Postmenopausal estrogen replacement therapy (ERT) reduces 
morbidity and mortality from coronary heart disease (CHD). 
There is a continuing concern, however, that the concurrent use 
of a progestogen to protect the endometrium may reduce the 
cardiovascular benefits of ERT. This research explores whether 
soy phytoestrogens may be an effective alternative approach to 
progestogen therapy.

Hormone Replacement and Cerebral Glucose Metabolism

    There is evidence that estrogen replacement therapy (ERT) 
in postmenopausal women may preserve and improve cognition in 
non-demented women. This study explores whether ERT may produce 
an increase in global cerebral metabolic rate of glucose 
utilization (CMRglc) in humans or whether there are specific 
regional CMRglc increases that may modulate enhanced cognitive 

Selective Estrogen Receptor Modulator (SERMs) Workshop

    The overarching objective of the workshop was to identify 
pivotal questions and formulate future projects in SERM 
research that cross disease boundaries and potentially 
incorporate multiple disease endpoints up front.

Older Adults, Health Information and the World Wide Web Conference

    The conference provided information on how to develop 
senior-friendly web sites and offered hands-on opportunities 
for exploring various sites. A variety of new collaborative 
activities were established among the participants.

Phytoestrogens and Healthy Aging: Gaps in Knowledge

    This workshop examined the relationship between phyto 
estrogens and cardiovascular health, cancer, bone disease, and 
menopausal symptoms. The participants suggested areas of 
research to be included on the agenda for future investigation.

Graylyn Conference on Women's Health

    The purpose of the conference was to review and integrate 
the body of knowledge concerning the effects of estrogen on 
both arterial and venous thrombosis and its effects on vascular 

    National Institute of Diabetes and Digestive and Kidney Diseases

    The National Institute of Diabetes and Digestive and Kidney 
Diseases (NIDDK) supports basic and clinical research in 
several major diseases that disproportionately affect older 
Americans. These include type 2 diabetes, end-stage renal 
disease, osteoporosis, and prostate cancer.


    The risk of type 2 diabetes, the most common form of the 
disease, increases dramatically in middle age. For the elderly 
with diabetes, life poses major problems. Of the nearly 16 
million Americans who have type 2 diabetes, over 6 million are 
aged 65 or older. Among Americans over age 65, over 18 percent 
have type 2 diabetes, with the highest prevalence occurring in 
minority populations (African Americans, Hispanic Americans, 
and Native Americans).
    Primary Prevention: The most important risk factors for 
type 2 diabetes are obesity, insulin resistance, physical 
inactivity, impaired glucose tolerance, and a history of 
gestational diabetes or a family history of diabetes. The 
Diabetes Prevention Program (DPP), a clinical trial under way 
in 26 medical centers nationwide, seeks to determine whether 
type 2 diabetes can be prevented with diet and exercise, or 
medication. The study is designed to determine whether lowering 
blood glucose levels in people with impaired glucose tolerance 
can prevent or delay development of type 2 diabetes. Nearly 21 
million Americans are affected by impaired glucose tolerance, a 
precursor to diabetes. These individuals have high blood 
glucose levels, but not high enough to be diagnosed as having 
diabetes. The DPP has met its recruitment goals ahead of 
schedule. Over 3,000 patients have been recruited with nearly 
20 percent of them over 60 years of age.
    Obesity: Another important clinical trial is designed to 
study if interventions to produce sustained weight loss in 
obese individuals with type 2 diabetes will improve health. 
This trial is expected to recruit a patient population which 
reflects the prevalence rates for diabetes in the United 
States, and plans to include individuals over age 70. The NIDDK 
is spearheading this trial with support from the National 
Heart, Lung and Blood Institute, the National Institute of 
Nursing Research, the National Center for Minority Health and 
Health Disparities, the NIH Office of Research on Women's 
Health, and the Centers for Disease Control and Prevention.
    Complications: Diabetes is a major risk factor for 
cardiovascular disease which accounts for 80 percent of 
mortality in people with type 2 diabetes. The NIDDK is co-
sponsoring two major clinical trials with the National Heart, 
Lung and Blood Institute to address issues of optimal 
management of glucose, blood pressure and lipids in people with 
type 2 diabetes. The NIDDK also supported a multicenter 
clinical trial in patients with type 2 diabetes, the United 
Kingdom Prospective Diabetes Study, which demonstrated the 
importance of good blood sugar control in slowing the eye, 
nerve, and kidney damage caused by diabetes. These findings 
further reinforce the results of the nationwide Diabetes 
Control and Complications Trial, which showed similar benefits 
in type 1 diabetes.
    Genetics: Type 2 diabetes is thought to arise from genetic 
factors, combined with environmental factors, such as obesity. 
More than one genetic alteration or mutation is probably 
necessary for the development of type 2 diabetes, which is 
therefore considered a ``complex'' genetic disease. Researchers 
have now found a gene on chromosome 2 calpain 10 which 
predisposes to type 2 diabetes in a population of Mexican 
Americans and individuals studied in Finland where there is a 
high rate of diabetes. In addition, several other groups of 
investigators have identified genes important in the 
development of rare forms of diabetes findings that may shed 
light on type 2 diabetes. The NIDDK has established and 
fostered an ongoing international consortium on the genetics of 
type 2 diabetes, and will continue to capitalize on these 
remarkable advances in genetics, which could provide the means 
to stem or even reverse the increasing incidence of this 
devastating disease.
    Beta Cell Biology: Type 2 diabetes is a consequence of both 
insulin resistance and impairment of the insulin-producing beta 
cells of the pancreas, such that sufficient insulin cannot be 
produced to compensate for the resistance to its action. Among 
the new NIDDK research initiatives important to type 2 diabetes 
in older Americans are the establishment of a Beta Cell Biology 
Consortium, that can be expected to yield new knowledge about 
the molecular events involved in glucose sensing and insulin 
secretion, and a Functional Genomics of the Endocrine Pancreas 
Consortium, that will identify all genes expressed in the beta 
cell at various stages of development.
    Diabetes Mellitus Interagency Coordinating Committee: In 
cooperation with the National Institute on Aging, and the 
Diabetes Mellitus Interagency Coordinating Committee (DMICC), 
the NIDDK is holding a meeting on ``Diabetes and Aging: From 
Basic Biology to Clinical Care.'' The purpose of this meeting 
is to bring together researchers in the genetic, environmental, 
phenotypic, and pathogenic causes of type 2 diabetes during the 
aging process. Also included are researchers looking at 
diabetes health care among the elderly, including disparities 
in diabetes treatment among minority groups during the aging 
process. Federal Agencies which are members of the DMICC will 
participate in this scientific conference and then meet the 
following day to share information on current initiatives and 
report on their efforts in the treatment and clinical 
management of older Americans with type 2 diabetes.


    Osteoporosis is characterized by low bone mass and bone 
deterioration, leading to fragile bones and an increased risk 
for fractures of the hip, spine and wrist. According to the 
National Osteoporosis Foundation, more than 28 million 
Americans, 80 percent of them women, have osteoporosis or are 
at increased risk of developing the disease. Osteoporosis has 
been reported in people of all ethnic backgrounds. In addition, 
of the population over age 50, one in two women and one in 
eight men will experience an osteoporosis-related fracture in 
his or her lifetime.
    The NIDDK has a strong program on bone and mineral 
research, focused on the hormones that are major regulators of 
bone mass and on nutritional aspects of osteoporosis, 
particularly calcium and vitamin D intake and metabolism . This 
program encompasses both basic and clinical research. In 
December 1999, the NIDDK, together with other institutes with 
an interest in osteoporosis, issued a research solicitation on 
receptors and signaling in bone health and disease.
    Alterations in hormone levels, such as loss of normal 
estrogen production in post-menopausal women, is a major 
contributor to bone loss with aging. Limited clinical trials 
have determined that hormone replacement can partially mitigate 
or reverse the osteopenia associated with menopause. The use of 
estrogen/progesterone hormone replacement therapy has gained 
wide acceptance in peri- and post-menopausal women, through not 
without undesired side effects. The development and use of 
Selective Estrogen Receptor Modulators (SERMs) has the 
potential to lessen the side effects, while giving some degree 
of protection against post-menopausal bone loss. Still other 
hormonal therapeutic agents, such as parathyroid hormone, have 
recently shown great promise as new approaches to treatment of 
osteoporosis. These clinical studies are a direct outgrowth of 
a longstanding NIDDK-supported basic research program on 
hormonal regulation of bone. Additional studies are needed to 
evaluate the role of these newer therapies in combination with 
established therapies for osteoporosis.
    The NIDDK co-sponsored an NIH Consensus Development 
Conference on Osteoporosis Prevention, Diagnosis and Therapy on 
March 27-29, 2000. The panel's recommendations for future 
research included identifying and intervening in disorders that 
can interfere with peak bone mass in children of ethnic 
diversity; improving diagnosis and treatment of secondary 
causes of osteoporosis; collecting the data necessary to 
establish guidelines for testing for osteoporosis; developing 
quality-of-life measurement tools; conducting randomized trials 
of combination therapies; and developing a paradigm for the 
management of fractures.

End-Stage Renal Disease

    Irreversible kidney failure known as end-stage renal 
disease or ESRD is a serious health problem in older Americans, 
who require either lifelong dialysis or kidney transplantation 
to survive. While ESRD affects persons of all ages, the peak 
incidence is in the sixth decade of life. Over the last decade 
there has been a worrisome growth in the incidence of ESRD, and 
incidence rates have grown more rapidly for individuals over 
age 75. In most instances, ESRD develops as the consequence of 
progressive damage to the kidney that occurs over a decade or 
more. A number of underlying diseases can cause progressive 
renal failure, most importantly diabetes mellitus, which in 
1997 accounted for 42 percent of incident cases of ESRD, and 
hypertension, which was responsible for 26 percent of incident 
    The NIDDK supports several initiatives to combat ESRD 
through the generation of fundamental insights into kidney 
abnormalities and their progression to kidney failure, and 
through research aimed at improving therapies, as well as 
developing prevention strategies. Some examples of major 
initiatives include:
    Hemodialysis Vascular Access Clinical Trials Consortium: 
Vascular access has been called the ``Achilles heel'' of 
hemodialysis. A very sizable portion of costs of care of 
dialysis patients are attributable to problems with vascular 
access. This newly created clinical consortium will conduct a 
series of multicenter, randomized studies of strategies to 
reduce the failure and complication rate of arteriovenous 
grafts and fistulas in hemodialysis patients over a five-year 
    Prospective Cohort Study of Chronic Renal Insufficiency: In 
FY2000 the NIDDK is initiating a new longitudinal cohort study 
to understand the epidemiology of chronic renal disease. The 
goals of the study are two-fold: To determine the risk factors 
for accelerated decline in renal function, and to determine the 
incidence and identify risk factors for cardiovascular disease. 
Because of the relative and increasing importance of diabetes 
as a cause of ESRD, approximately one-half of the study 
participants in the cohort study will be diabetic.
    The United States Renal Data System (USRDS): Since its 
creation in May 1988, USRDS has pursued the collection, 
analysis, and distribution of information on the incidence, 
prevalence, treatment, morbidity, and mortality of ESRD in the 
United States. The USRDS monitors outcomes for dialysis and 
transplant patients. USRDS data are publicly available on the 
NIDDK World Wide Web site (
    Long-Range Plan: In 1999, the NIDDK, in collaboration with 
the Council of American Kidney Societies, released a long-range 
plan for research to improve the treatment and prevention of 
kidney disease and kidney failure. The strategic plan reflects 
the consensus of more than 100 researchers, members of kidney 
societies, and of patients regarding research needs, 
opportunities for advances, and barriers to progress.
    Healthy People 2010: Healthy People 2010 contains the 
first-ever chapter on Chronic Kidney Disease, a major 
contributor to ESRD. It includes scientific background, 
specific objectives, and current and future challenges to 
improving the Nation's kidney health.

Prostate Disease

    The NIDDK supports an active portfolio of basic and 
clinical investigations on benign prostatic hyperplasia and 
prostate cancer, both of which disproportionately affect older 

                      Benign Prostatic Hyperplasia

    Benign prostatic hyperplasia (BPH) is an enlargement of the 
prostate gland that can interfere with urinary function in 
older men. It causes blockage by squeezing the urethra, which 
can make it difficult to urinate. Men with BPH frequently have 
other bladder symptoms including an increase in frequency of 
bladder emptying both during the day and at night. Most men 
over the age of 60 have some BPH, but not all have problems 
with blockage.
    Medical Therapy of Prostate Symptoms (MTOPS): This 
multicenter clinical trial is assessing the effect of two 
different pharmacological agents on the prevention of 
progression of symptomatic BPH, and correlating those clinical 
effects with molecular and genetic actions on prostate biopsy 
tissue from participants in the study.
    Minimally Invasive Surgical Therapies Treatment Consortium 
for Benign Prostatic Hyperplasia: This new initiative, in 
collaboration with the National Cancer Institute and the 
National Institute of Environmental Health Sciences, is 
establishing a group of collaborative Prostate Evaluation and 
Treatment Centers and a Biostatistical Coordinating Center to 
develop and conduct randomized, controlled clinical trials of 
the long-term efficacy and safety of the major ``minimally-
invasive'' approaches for the treatment of symptomatic benign 
prostatic hyperplasia.

                            Prostate Cancer

    In the United States, prostate cancer has become the most 
frequently diagnosed cancer, and the second leading cause of 
cancer mortality in men after lung cancer. Its incidence rate 
has continued to increase rapidly during the past two decades 
especially in men over the age of 50 years.
    Molecular Epidemiology of Prostate Carcinogenesis: This new 
initiative is encouraging molecular epidemiologic studies for 
advancing understanding of prostate cancer development and 
progression. The purpose is to stimulate development and 
application of biological markers of prostate cancer risk and 
tumor aggressiveness and for utilization in chemoprevention 
studies. Of special interest are studies of markers to 
elucidate multiethnic differences in prostate cancer 
    Role of Hormones and Growth Factors in Prostate Cancer: 
This initiative is encouraging studies to explore the 
underlying mechanism(s) of action of hormones and growth 
factors in the regulation of prostate development, growth, and 
tumor development.
    Biology, Development, and Progression of Malignant Prostate 
Disease: This initiative, in collaboration with the National 
Cancer Institute, the National Institute on Aging, and the 
National Institute of Environmental Health Sciences, is 
encouraging a range of fundamental biological issues considered 
critical for progress in defeating prostate cancer. The purpose 
is to support studies focusing on the biology that underlies 
the development and progression of malignant prostatic disease.

 National Institute of Arthritis and Musculoskeletal and Skin Diseases

    Researchers supported by the National Institute of 
Arthritis and Musculoskeletal and Skin Diseases (NIAMS) use 
powerful research tools to acquire and apply new knowledge to 
studies of some of the most challenging diseases affecting 
older Americans today. Many of these diseases have troubled 
patients and their health care providers for decades, but each 
year significant discoveries have brought researchers closer to 
fully understanding, diagnosing, treating, and ultimately 
preventing these common, disabling, costly and chronic 
diseases, which greatly compromise quality of life. These 
disorders include the many different forms of arthritis and 
numerous diseases of joints, muscles, bones, and skin.

Rheumatoid Arthritis

    Rheumatic diseases such as rheumatoid arthritis and 
osteoarthritis affect people of all races and ages, and are the 
leading cause of disability among adults age 65 and older in 
the United States. It is estimated that by the year 2020, 
nearly 60 million Americans will be affected by arthritis and 
other rheumatic conditions. These diseases may cause pain, 
stiffness, and swelling in joints and other supporting 
structures of the body such as muscles, tendons, ligaments, and 
bones. The NIAMS funds a broad array of research studies across 
the spectrum from basic to clinical to translational, in an 
effort to better understand what causes these conditions and 
how best to treat and prevent them. Such investments include 
support for studies of target organ damage in rheumatoid 
arthritis (RA), an inflammatory disease of the lining of the 
joint, and of new imaging technologies in animal models of RA. 
Other scientists funded by the NIAMS have launched a 
multicenter clinical trial to test the oral administration of a 
small peptide for RA treatment.
    The Institute is also building the research infrastructure 
needed to stimulate additional innovative studies of arthritis 
and other rheumatic conditions. Such efforts include support 
for a consortium that is searching for genes that predispose 
individuals to RA, with the overall scientific goal of 
developing better diagnostic and treatment methods; funding of 
a new research registry on RA in the African American 
population; and support for specialized centers of research in 
both RA and osteoarthritis, which is a degenerative joint 
disease. In the NIAMS intramural research program, we continue 
to support studies designed to understand the genetic and 
cellular bases of arthritis, as well as novel therapeutic 
trials involving targeted biologic agents. Finally, the NIAMS 
is committed to disseminating science-based health information 
on arthritis and related conditions. For that purpose, the 
Institute published a bilingual brochure, in Spanish and 
English, entitled ``Do I Have Arthritis?'' and developed a 
primer for patients on new medications for RA and OA.


    The NIAMS is pursuing a multipronged approach to the 
challenge that osteoarthritis (OA), a degenerative joint 
disease that is the most common form of arthritis, poses as the 
U.S. population ages. This approach includes efforts to create 
a public-private partnership to identify biomarkers and 
surrogate endpoints that can facilitate clinical trials and 
enhance drug development for OA; the initiation of a major 
research contract, in collaboration with the National Center 
for Complementary and Alternative Medicine, to study the 
efficacy of the dietary supplements glucosamine and chondroitin 
sulfate for the treatment of knee OA; and the recent 
publication of a handout on health on OA for affected patients, 
family members, health care providers, and health educators. 
Scientists supported by the Institute have made a number of 
important contributions in the field of OA in recent years, 
including investigations to develop specific chemical compounds 
that prevent the expression of enzymes that cause cartilage 
degradation, and studies to determine the genetic 
predisposition of daughters whose mothers have knee OA in the 
hopes of identifying susceptible individuals as early as 
    These projects complement other efforts supported by the 
Institute that range from basic studies to examine 
biomechanical signaling mechanisms in cartilage, to tissue 
engineering work that includes the use of animal models to 
develop joint scaffolds and test surgical approaches for 
engineered joints, to novel imaging studies designed to better 
identify joint disorders and assess their progression. We are 
also supporting several pilot projects to test the feasibility 
of new methodologies to understand the causes of, and develop 
novel treatments for, OA. Furthermore, we recently funded a 
number of new grants to identify and evaluate chondroprotective 
agents that prevent cartilage destruction, or facilitate its 
repair. In addition, the NIAMS is building on the insights 
gained at a scientific conference on OA held in the summer of 
1999 by issuing a new solicitation for research on the onset, 
progression, and disability associated with OA, in conjunction 
with other interested Institutes.


    Osteoporosis, a disease characterized by low bone mass and 
structural deterioration of bone tissue, is the leading cause 
of bone fractures in postmenopausal women and older people in 
general. The NIAMS leads the Federal research effort on 
osteoporosis and related bone diseases, and supports research 
ranging from very basic studies to clinical and translational 
projects, as well as early intervention and prevention efforts. 
Significant advances in the prevention and treatment of 
osteoporosis are available today as the direct result of 
research focused on determining the causes and consequences of 
bone loss at cellular and tissue levels, assessing risk 
factors, developing strategies to maintain and even enhance 
bone density, and exploring the roles of such factors as 
hormones, calcium, vitamin D, drugs, and exercise on bone mass. 
For example, scientists at a NIAMS-funded specialized center 
for research on osteoporosis recently reported that giving 
lower doses of estrogen and progesterone during hormone 
replacement therapy (HRT), in combination with calcium and 
vitamin D, spares older women significant osteoporotic bone 
mass loss while limiting HRT's more negative side effects.
    In 1999, the Institute funded two new core centers for 
research on musculoskeletal disorders. The first is 
concentrating on studies of skeletal integrity, which 
encompasses biological, chemical, and mechanical influences on 
bone. The second core center focuses on basic bone biology and 
bone diseases. The work at these core centers will boost the 
critical mass of talented scientists working on problems of 
bone growth and disease. In addition, in 2000, the NIAMS issued 
a request for applications for additional specialized centers 
for research in osteoporosis. Such centers are supported by the 
NIAMS to further the translation of basic research findings to 
clinical applications that will help affected patients. 
Furthermore, in the spring of 2000, the Institute sponsored a 
major consensus development conference on osteoporosis at which 
national and international experts presented the latest 
research findings on this disorder, and developed 
recommendations to enhance future diagnosis, prevention, and 
treatment approaches. Finally, the NIAMS and several other NIH 
components support the Osteoporosis and Related Bone 
DiseasesNational Resource Center to promote the dissemination 
of science-based health information to patients, health care 
providers, and the general public.

       National Center for Complementary and Alternative Medicine

    NCCAM is dedicated to exploring complementary and 
alternative healing practices in the context of rigorous 
science; educating and training complementary and alternative 
medicine (CAM) researchers; and disseminating authoritative 
information to the public and professionals. CAM use spans the 
spectrum of conditions and diseases confronting the American 
public as a whole, however, it is especially associated with 
chronic conditions. Consequently, a large component of the 
NCCAM research portfolio, addresses dementia, arthritis, 
cancer, cardiovascular disease, and pain conditions affecting 
the quality of life and longevity of our nation's elderly. Key 
examples from our portfolio are described below.

CAM Use by the Elderly

    Contemporary studies of CAM practices estimate that 42 
percent of all adults in the United States use some form of 
CAM. New findings from an NCCAM-supported survey of senior 
citizens confirm that the extent of their CAM use closely 
mirrors that of the population at large. Results from this 
study of Medicare beneficiaries found that more than 40 percent 
reported using CAM. Of those using CAM, some 80 percent 
maintained that they experienced substantial benefit from it. 
However, the majority did not disclose their use of CAM 
therapies to their physicians. These findings underscore the 
need for conventional physicians to inquire about CAM use by 
their elderly patients.


    For centuries, extracts from the leaves of the Ginkgo 
biloba tree have been used as Chinese herbal medicine to treat 
a variety of medical conditions. In Europe and Asia, 
standardized extracts from ginkgo leaves are routinely taken to 
treat a wide range of neurocognitive symptoms, including those 
of Alzheimer's disease. Little is known, however, about the 
safe dosage levels of Ginkgo biloba extract, let alone its 
actual effectiveness in preventing Alzheimer's disease. NCCAM, 
in collaboration with the National Institute on Aging (NIA), 
the National Heart, Lung and Blood Institute (NHLBI), and the 
National Institute of Neurological Disorders and Stroke 
(NINDS), may help resolve these questions through a six-year, 
multi-center effort to study the efficacy of Ginkgo biloba 
extract in preventing dementia, a cognitive decline in memory 
and other intellectual functions, in older individuals. This 
study, the largest of its kind ever conducted on Ginko biloba, 
includes four clinical centers and an enrollment of almost 
3,000 people. Participants who take Ginkgo biloba are being 
compared to a second group of individuals who are taking a 


    Osteoarthritis (OA), or degenerative joint disease, is a 
common type of arthritis caused by the deterioration of 
cartilage, the connective tissue that cushions the ends of 
bones and permits their surfaces to slide smoothly across one 
another within the joint. Arthritic diseases are major public 
health problems affecting the quality of life for a large 
segment of the older American population. In 1995, it was 
reported that 32 million Americans were afflicted with this 
disease. Estimated medical costs for people with arthritis 
total $15 billion annually. Accordingly, the first U.S. multi-
center study to investigate the dietary supplements glucosamine 
and chondroitin sulfate for knee OA has been funded by the 
NCCAM in collaboration with the National Institute of Arthritis 
and Musculoskeletal and Skin Diseases (NIAMS). Glucosamine and 
chondroitin sulfate are two natural substances, found in and 
around the cells of cartilage, and commonly used today as 
nutritional supplements. The study is expected to verify their 
clinical safety and effectiveness alone or in combination in 
reducing joint pain and improving mobility. The study involves 
nearly 1,600 OA patients at 13 study centers across the 

Cardiovascular Disease

    Cardiovascular disease, (CVD) accounts for more than 40 
percent of all U.S. deaths and is the leading cause of death in 
African-Americans. NCCAM supports a Speciality Research Center 
for CAM, Minority Aging, and CVD at the Maharishi University of 
Management in Iowa. In collaboration with traditionally black 
universities and medical schools, the Center is testing the 
efficacy of Vedic medicine, an ancient Hindi system of healing, 
for reducing mortality and morbidity associated with CVD in 
high risk, older African-Americans.
    NCCAM has also established a CAM Research Center for 
Cardiovascular Diseases to focus on the investigation of CAM 
modalities to treat and prevent CVD. The Center is employing a 
double-blind, placebo-controlled, randomized trial of a 
standardized extract of the plant Crataegus (Hawthorn) in 
patients who, despite optimal conventional medical therapy, 
continue to experience symptomatic heart failure. The goal is 
to obtain a comprehensive understanding of the potential role 
of Hawthorn in the treatment of heart failure. This study is 
also testing the effectiveness of Reiki treatment for sub-acute 
stroke inpatients. The randomized trial employs three arms: 
Reiki plus standard care, a placebo plus standard care and 
standard care alone. Additionally, the center stresses CAM 
education and promotion of validated CAM treatments for 
cardiovascular well-being.


    More than 175,000 women will have been diagnosed with 
breast cancer in the year 2000; nearly 30 percent will 
ultimately die of the disease. Studies show that support group 
participation improves breast cancer survival rates. NCCAM and 
the National Institute of Nursing Research (NINR) are 
supporting the investigation of strategies of self-
transcendence among support group members to improve well-being 
and immune function and to increase understanding of the 
relationship between survival rates and support group 
    In 2000 NCCAM funded two Specialty Research Centers for 
Cancer dedicated to studying the safety and effectiveness of 
several popular CAM therapies. One of these centers is 
examining the anti-oxidant effects of herbs in cancer cells and 
the safety and efficacy of PC-SPES, a popular mixture of 
Chinese herbal medications, in men with prostate cancer.
    Finally, in conjunction with the National Cancer Institute, 
(NCI) NCCAM is supporting a Phase III clinical trial of shark 
cartilage in over 700 lung cancer patients in the United States 
and Canada.


    In collaboration with the NIH Office of Dietary Supplements 
(ODS), NCCAM funds four Centers for Dietary Supplement Research 
with an emphasis on botanicals. The Centers serve to identify 
and characterize botanicals, assess bioavailability and 
activity, explore mechanisms of action, conduct preclinical and 
clinical evaluations, establish training and career 
development, and help select the products to be tested in 
randomized controlled clinical trials. In one of these centers, 
amultidisciplinary team of investigators studies the clinical 
safety and efficacy of botanicals for menopause. Additional 
studies will address identification of active compounds, 
characterizationof metabolism, and pharmocokinetics of active 
species contained in these botanicals.

Prostate Enlargement

    Benign prostatic hyperplasia (BPH), or enlargement of the 
prostate, is the most common benign tumor found in men. 
Anecdotal reports suggested that the botanical product saw 
palmetto is effective in decreasing the swelling associated 
with BPH. To determine the validity of these observations, 
NCCAM, in collaboration with the National Institute of Diabetes 
and Digestive and Kidney Diseases (NIDDK), is supporting a 
large, rigorously designed, placebo-controlled, prospective 
study to evaluate the effect of saw palmetto extract on 
symptoms and quality of life in men with moderate-to-severe 
prostate swelling.

Parkinson's Disease

    The NCCAM's multi-site, double blind study compares the 
effects of the nutritional supplement, melatonin, given at two 
different doses, and placebo on nocturnal sleep. The study 
allows for assessment of any adverse events associated with 
melatonin related to its safety and tolerableness. This 
research may lead to the development of safer, more physiologic 
therapies for treating sleep disturbances in patients with 
Parkinson's Disease.

    National Institute on Deafness and Other Communication Disorders

Genetic Association and Age-Related Causes for Hearing Loss

    Scientists are determining if different mutations in the 
same genes that cause profound hereditary hearing impairment 
also cause age-related hearing loss (presbycusis), a common 
problem for older Americans. It has been presumed for some time 
that presbycusis may be inherited and that genetic factors may 
influence the rate and severity of hearing loss. An NIDCD-
supported study involving a large population of related and 
non-related individuals has demonstrated that a clear genetic 
component exists for age-related hearing loss. The 
investigators were able to demonstrate a genetic component by 
measuring several different hearing thresholds at specific 
frequencies that are most commonly affected in presbycusis. In 
fact, estimates for the amount of a genetic component to age-
related hearing loss were greater than, or comparable to, those 
seen for blood pressure or cholesterol levels. With the ability 
to predict who is at increased risk, better strategies to 
minimize or delay hearing loss within the aging population can 
be developed.
    In another project, NIDCD-supported scientists are 
conducting basic and clinical research on the structural and 
molecular changes in the aging auditory system. Information 
from these studies should form the rationale for designing 
pharmacological and gene-based therapies for treating 
presbycusis and preventing or reducing its prevalence.

Hearing Aid Clinical Trial Yields Important Results

    The prevalence for hearing impairment significantly 
increases with age, and hearing aids are the most common means 
of assistance for persons with hearing loss. The NIDCD and the 
Department of Veterans Affairs conducted a multi-center trial, 
which included elderly volunteers, to compare the effectiveness 
of three commonly used hearing aid circuits. Data from the 
trial 0showed minimal performance differences among the three 
hearing aid circuits. Of greater importance, the trial 
demonstrated that each circuit improved speech recognition 
under both quiet and noisy listening conditions, improved the 
quality of speech for soft and conversational speech levels, 
and reduced the frequency of problems encountered with using 
hearing aids in verbal communication. NIDCD remains committed 
to support research leading to smaller and better hearing aids, 
capitalizing on bioengineering advances in microelectronics.

Vestibular Disorders in the Elderly

    Disorders of balance and the vestibular system affect a 
large proportion of the population, particularly the elderly. 
Disorders of balance and spatial orientation are common 
conditions. Based on an NIDCD analysis of the 1994-1995 
Disability Supplement of the National Health Interview Survey, 
an estimated 6.2 million Americans reported chronic problems of 
dizziness and/or balance. These problems were self-reported in 
approximately nine percent of individuals ages 65 years and 
older. Furthermore, balance-related falls account for a large 
proportion of fractures, including hip fractures, and 
accidental deaths in the elderly. Loss of body stabilizing 
information across the senses will result in problems with 
balance and gait. Scientists supported by the NIDCD are 
studying the mechanisms that control posture and equilibrium in 
stance and gait to better understand disorders of the 
vestibular system and the other body stabilizing systems. The 
scientists are determining how individuals with loss of 
vestibular function substitute sensory information from touch 
and muscle/joint sensations to maintain balance. This research 
will reveal information on how the somatosensory and the 
vestibular systems contribute to movement and stance, with aims 
in developing better rehabilitative strategies for individuals 
with balance disorders.

Molecular Mechanisms Governing Our Sense of Taste

    In humans, the loss of taste sensation can contribute to 
the loss of appetite and poor nutrition, a particularly common 
problem for older Americans. Although scientific advances have 
resulted in a better understanding of the basic mechanism of 
taste, there is still much to be learned about the cellular and 
molecular mechanisms critical for taste perception. The 
molecular pathway resulting in perception of taste is initiated 
when a sweet, bitter, salty, or sour substance binds to 
specific taste receptors found on the outer surface of taste 
cells on the tongue. In a collaboration between investigators 
supported by the National Institute of Dental and Craniofacial 
Research and NIDCD, scientists have discovered a large family 
of genes that encode taste receptors that bind bitter 
substances. The family consists of about eighty genes that code 
for receptor proteins in certain taste cells on the tongue. 
This vast array of receptors explain why structurally diverse 
molecules produce the same perception of bitter taste. These 
ground-breaking studies are crucial towards understanding the 
mechanisms underlying the sense of taste.


    Language deficits in the elderly are most frequently 
associated with aphasia as a result of stroke or head injury or 
with the onset of central nervous system diseases, such as 
Alzheimer's or Parkinson's disease. A language deficit may 
affect employment and social status and can result in isolation 
from family and friends. Aphasia results when the portions of 
the brain that are responsible for language are damaged. This 
disorder usually occurs suddenly and impairs bothexpression and 
understanding of language, as well as reading and writing.
    For many years, it was thought that brain activity 
associated with human language function was restricted to the 
left side of the brain. Studies of individuals with aphasia and 
other types of disorders of language function have revealed 
that other regions in the brain also participate in language 
function. Using functional magnetic resonance imaging (fMRI), 
NIDCD-supported scientists have documented reorganization of 
brain activity after treatment for acquired reading disorders 
following stroke. The neuroimaging performed during a reading 
task before and after treatment indicated a shift in brain 
activation from one area to another, showing that it is 
possible to alter brain activity patterns with therapy for 
acquired language disorders.

           National Heart, Lung, and Blood Institute (NHLBI)

    Many research areas supported by the National Heart, Lung, 
and Blood Institute (NHLBI) re closely related to the health of 
older people. The following paragraphs describe some recent 
NHLBI-supported research results of special relevance to older 

Older (and Cheaper) Blood Pressure Drug Holds Its Own

    Although newer, more expensive, antihypertensive drugs do a 
good job of lowering blood pressure and are being prescribed 
widely by physicians, their ability to reduce cardiovascular 
events such as heart attacks has not been demonstrated. A large 
clinical trial that is comparing a diuretic with three types of 
newer drugs, including an alpha-adrenergic blocker, recently 
showed that the diuretic was superior to the alpha-adrenergic 
blocker in terms of its ability to reduce the overall incidence 
of cardiovascular disease events, and particularly the 
incidence of congestive heart failure, in patients over 55 
years of age. This finding provides valuable information for 
physicians seeking to prescribe the best and most cost-
effective drugs for their patients, particularly as the 
incidence of congestive heart failure increases as the 
population ages.
    Antibiotic Inhibits Key Enzyme Responsible for Abdominal 
Aortic Aneurysm.--Scientists recently identified MMP-9 as the 
key enzyme responsible for the development of abdominal aortic 
aneurysm (AAA), a bulging or ballooning of a weak area in the 
main artery, the aorta, as it runs from the heart down through 
the abdomen. More important, the investigators determined that 
the antibiotic doxycycline inhibits MMP-9 production. Aneurysms 
tend to grow and can eventually rupture, causing profuse 
internal bleeding that usually results in death. AAA is 
projected to affect more and more people, since up to 9 percent 
of those over 65 have AAA and since the U.S. population 
continues to age. No drug treatment is currently available to 
prevent small aneurysms from developing into larger, life-
threatening ones. The identification of MMP-9 as the key enzyme 
in AAA development and the recognition that doxycycline 
inhibits it should lead to new strategies for managing AAA. 
Additionally, results suggest that doxycycline has potential 
for preventing aneurysm growth in patients, thereby reducing 
the need for risky and expensive surgery.

Researchers Identify a Potential Therapeutic Compound for Reducing 
        Stroke Damage

    Modern treatment of many strokes includes use of a natural 
compound, tissue-type plasminogen activator (tPA), that helps 
to reestablish blood flow by dissolving clots in the blood 
vessels of the brain. However, tPA can cause serious 
complications if it leaks from the blood vessels into the brain 
cells. Additionally, studies in animal models indicate that the 
brain produces its own tPA in response to traumas such as 
stroke although, paradoxically, the expression of tPA has been 
positively associated with increased brain damage in such 
models. Scientists recently concluded that brain cells can 
reduce damage from tPA by producing an inhibitor called 
neuroserpin. Experiments in rats revealed that injecting 
neuroserpin immediately after a stroke reduces brain cell 
injury and death, indicating that neuroserpin has potential as 
a therapeutic agent to reduce the risks of hemorrhage and brain 
damage associated with tPA treatment.

Combination Therapy to Reduce Risk of Coronary Artery Disease in Women

    Research suggests a new approach for treating healthy 
postmenopausal women who are at increased risk of developing 
coronary artery disease by virtue of elevated cholesterol 
levels. A recent study found that the addition of estrogen 
replacement therapy to treatment with a cholesterol-lowering 
drug has an extra protective effect against heart disease for 
such women. Results showed that combining the two therapies was 
more effective than either treatment alone at lowering the 
level of harmful low-density lipoprotein cholesterol and 
raising the level of the beneficial high-density lipoprotein 
cholesterol. In addition, among women who also received 
estrogen the investigators observed an improved capacity of the 
blood vessel wall to break down blood clots and to resist 
inflammation, two processes important for impeding the 
progression of atherosclerosis. By reducing the risk of 
developing atherosclerosis, this combination therapy could 
reduce the risk of heart attacks and strokes, thereby resulting 
in improved quality of life and monetary savings from fewer 
hospitalizations and less need for surgery.

New Advice for Inhaled Corticosteroids to Help COPD Patients

    A recent study suggests that inhaled corticosteroids have a 
modest benefit in terms of lessened airway reactivity and 
respiratory symptoms in patients with chronic obstructive 
pulmonary disease (COPD), but have no effect on the rate of 
decline of lung function in people with mild to moderate COPD. 
COPD is a result of accelerated decline in lung function and is 
thought to be caused by inflammatory changes in the lung that 
can be initiated by cigarette smoke. Although corticosteroids 
have been widely prescribed for COPD because of their anti-
inflammatory properties, their benefit has been questioned. 
Researchers suggest that inhaled corticosteroids should be used 
only for reducing symptoms rather than as agents to modify the 
long-term course of the disease.

Blood Clot Risk Increases with Old Age

    The potential for developing blood clots, which can lead to 
heart attacks and strokes, increases throughout adulthood, but 
until now little has been known about the mechanisms 
responsible for this normal aging phenomenon. Researchers 
recently identified two elements that are responsible for age-
regulation of the human gene for blood coagulation factor IX. 
Using a mouse model, they determined that one element (called 
AE5'), is responsible for age-stable expression of the gene and 
the second element (designated AE3') controls the age-related 
elevation of expression. These findings provide a new avenue 
for understanding age-related physical disorders and 
determining potential target sites for new therapeutics for 
thrombotic disorders.

Insights into Human Cell Aging

    Researchers have used the ras gene, normally associated 
with many cancers, to study the process of aging in human 
cells. By adding an active form of the gene to human cells 
being grown in laboratory culture, investigators were able to 
induce rapid cellular aging. This occurred because the gene 
dramatically increased the intracellular levels of highly 
reactive forms of oxygen known as free radicals, which can 
function as oxidants and are known to be capable of damaging 
various cellular components. The investigators also determined 
that the chief sources of free radical production were 
mitochondria, which are small structures found scattered 
throughout the cell. Furthermore, these scientists have 
preliminarily identified a class of chemical compounds that 
appear to significantly inhibit the level of mitochondrial 
free-radical production without being toxic to the cells, 
suggesting that an approach using inhibitors of free radicals 
may have potential as one possible strategy for slowing the 
aging process.

               The National Institute of Nursing Research

    The National Institute of Nursing Research (NINR) supports 
studies that address health issues of the older population, 
including prevention of illness and disability; health 
promotion strategies; management of the symptoms of chronic 
diseases, including pain; interventions for family caregivers 
to help them maintain their own health as well as that of their 
ill relatives; and end-of-life issues to ensure that dying 
patients receive compassionate and life-affirming health care 
that promotes comfort and dignity.
    The National Institute of Nursing Research (NINR) supports 
studies that address health issues of older people, including 
preserving cognition and ability to function; prevention of 
illness and disability; health promotion strategies; management 
of symptoms of chronic diseases, including pain; interventions 
for family caregivers to help them maintain their own health as 
well as that of their relatives; and end-of-life issues to 
ensure that dying patients receive compassionate and life-
affirming health care that promotes comfort and dignity.
    Below are examples of findings during 1999-2000.
           Nursing research has developed a successful 
        arthritis self-management program in Spanish. To test 
        the effectiveness of the program, the investigator 
        analyzed the results of a 6-week course led by lay 
        community members involving 219 participants and 112 
        controls originating from Mexico and Central and South 
        America. The mean age was 62 and a half, and about 85 
        percent were women. Four months after the program, 
        there were notable improvements among those who took 
        the course in range of motion exercise, degree of 
        disability, relief of pain, and self efficacy. A year 
        after the course, participants showed significant 
        improvements in these areas and in self-reported health 
        status and depression. Not only was this hard-to-reach 
        Spanish language population recruited and retained for 
        the course and its evaluation, but they provided 
        important research information and showed continued 
        improvement in their health.
           Research has been conducted in a population 
        of women aged 55 through 75 before coronary artery 
        bypass surgery and one year after. Although they 
        experienced weight loss following surgery, 58 percent 
        of the women continued to be obese, and their dietary 
        intake of fat and cholesterol remained above 
        recommended levels. Blood pressures significantly 
        increased, and 54 percent of patients continued to 
        exhibit hypertension one year after surgery. One-third 
        exceeded recommended levels for triglycerides, 78 
        percent for total cholesterol, and 92 percent for low-
        density lipoproteins. These findings indicate a high 
        risk for future coronary heart disease for these women 
        and a need for healthcare professionals to design 
        prevention strategies for the women's lives after 
           A study of genetic influences for obesity 
        and weight loss has identified variants in PPAR-gamma-2 
        and LPL genes that can serve as potential indicators of 
        obesity and successful weight loss among older, 
        postmenopausal women. These women were placed on a 
        regimen of moderate, regular exercise and a heart-
        healthy diet. Those with the LPL Pvull variant of a 
        gene pair had higher total cholesterol, low-density 
        lipoprotein cholesterol and fasting glucose than women 
        with the normal LPL Pvull gene, thus placing them at 
        increased risk for atherosclerosis. Further, although 
        women with the PPAR gamma-2 variant of a gene pair were 
        highly successful in losing weight, their ability to 
        maintain weight loss was far less successful than women 
        with two normal copies of the gene. They had a nearly 
        two-fold rate of weight regain at 18 months after the 
        intervention was completed. They also had a larger body 
        mass index and a greater increase in insulin 
        sensitivity, which may contribute to their more rapid 
        weight gain. This finding adds important information 
        for development of weight management strategies.
           It is important that caregiver health, as 
        well as that of the patient, be assessed by health care 
        professionals. Research has shown that caregivers who 
        themselves have physical problems are at greater risk 
        for psychological distress. An intervention that better 
        prepares them for their tasks can minimize this 
        distress in the long term and improve the well being of 
        both caregiver and patient. Research comparing a home 
        care intervention using oncology nurse clinical 
        specialists with standard home care found that patients 
        showed 32 percent less distress. Sixteen percent of 
        patients improved function for up to six weeks longer 
        than patients receiving standard care. After the 
        patients died, spouses who were followed for 13 months 
        showed 28 percent less psychological distress. The 
        oncology nursing intervention included providing 
        caregivers with skills training in assessing and 
        monitoring problems, managing symptoms, and taking care 
        of themselves.
           In the absence of specific advance 
        directives, health care providers must rely on 
        decisions made by the patient's family or friends when 
        the patient can no longer communicate adequately. At 
        issue is whether the choices these surrogates make are 
        in tune with what the patient would wish. Researchers 
        looked at how closely these decisions are reflective of 
        the patient's decision by posing three hypothetical 
        clinical scenarios (permanent coma, small chance of 
        survival, severe dementia) to dying patients and their 
        surrogate decisionmakers. Researchers found that 66 
        percent of the time, the surrogates predicted 
        accurately the patients' wishes - under the coma 
        scenario, they made accurate predictions with 84 
        percent accuracy. Among those whose decisions differed 
        from the patient, there was no trend either for or 
        against treatment.

                 National Center for Research Resources

    The National Center for Research Resources (NCRR) creates, 
develops, and provides a comprehensive range of human, animal, 
technological, and other resources to enable biomedical 
research advances in aging research. NCRR serves as a 
``catalyst for discovery'' for NIH-supported investigators by 
supporting resources in four areas: Biomedical Technology, 
Clinical Research, Comparative Medicine, and Research 

Growth Patterns in the Developing Brain Using Continuum Mechanical 
        Tensor Maps

    The dynamic nature of growth and degenerative disease 
processes requires the design of experimental protocols to 
detect, track, and quantify structural changes in the brain. 
Researchers at UCLA have created complete four dimensional 
(x,y,z, and time) maps of growth patterns in the developing 
human brain. A new tensor mapping strategy allows much greater 
spatial detail and sensitivity than was previously obtainable. 
A major finding of the research was that different parts of the 
brain grow at markedly different rates during the development 
of a normal child. The researchers also found that the same 
areas of the brain that grow fastest in children degenerates 
fastest during the early stages of Alzheimer's disease. The 
sensitivity of the new experimental protocol may offer 
advantages in tracking the effects of various treatments for 
Alzheimer's disease. This approach can also be extended to 
evaluating the effect that treatments have on other age-related 
diseases affecting the brain such as dementia.

Detection of Neuritic Plaques in Alzheimer's Disease by MR Microscope

    Researchers at Duke University Medical Research Center have 
used Magnetic Resonance Microscopy as a means to identify 
neuritic plaques, the neuropathological hallmark of Alzheimer's 
Disease, in autopsy tissue specimens. Experimental parameters 
were identified to supply sufficient contrast in the magnetic 
resonance microscopy signal to visualize the plaques in vitro 
and correlate them with histological samples. Future and 
ongoing efforts are focused on applying this technology in 
vivo, for example in transgenic rodents overexpressing amyloid 
protein. The ability to detect and follow the early progression 
of amyloid-positive brain lesions will greatly aid and simplify 
the many possibilities to intervene pharmacologically in 
Alzheimer's disease. Ultimately, results gained from such 
studies would benefit humans afflicted with Alzheimer's disease 
and related neurodegenerative disorders associated with aging.

Proton Emission Tomography (PET) Scans in Aged Monkeys

    Aged rhesus monkeys were used in studies at the California 
Regional Primate Research Center to assess safety and survival 
of intracranial grafts. Fibroblastic cells containing a gene 
for the expression of nerve cell growth factor were implanted 
into the cerebrum and were monitored by PET imaging. The 
initial studies suggest that such an approach could be 
successfully used as a potential treatment for Alzheimer's 
disease. This delivery of nerve cell growth factor might 
prevent the death of crucial neurons and ameliorate the effects 
of aging on the central nervous system.

Cognitive studies of aging monkeys

    All of the Regional Primate Research Centers have 
significant populations of aging nonhuman primates, principally 
rhesus macaques, which are being studied to determine the 
behavioral, physiologic and pathologic events which occur 
during aging in a controlled and closely monitored setting. The 
NCRR cooperates with a program of the NIA to study the effects 
of dietary restriction on the aging process which shows that, 
as in rodent studies, caloric restriction is effective in 
retarding the aging process. Investigators at the Oregon, 
Tulane, Wisconsin, Emory and California Regional Primate 
Centers are conducting cognitive research on aging monkeys. 
Studies at the Yerkes Center at Emory are examining the neural 
substrates of cognitive decline in aging rhesus to identify the 
specific cell populations which are important in this decline. 
At the same center, the effects of age and stress are being 
examined in the female rhesus monkey population.

Less Estrogen May Be Just As Effective in Preventing Post-menopausal 

    Osteoporosis, a dangerous thinning of the bones, affects 
millions of Americans, 80 percent of whom are women. Millions 
also suffer from low bone mass, an early warning sign of the 
disease, which can lead to painful, debilitating breaks. 
Osteoporosis is associated with a decrease in estrogen after 
menopause. Replacing estrogen with supplements can slow the 
erosion of bone, as can a number of drugs. Researchers at the 
University of Connecticut General Clinical Research Center 
compared three daily doses of the estrogen estradiol--0.25 mg, 
0.5 mg, 1 mg, the typical treatment dose,--and placebo in women 
age 65 and over. To gauge how well the treatments worked, the 
scientists looked for markers related to bone turnover at 
regular intervals over the three-month study. All doses of 
estrogen helped control bone destruction, but the 0.25 mg dose 
yielded essentially the same response as the 1.0 mg dose. 
However, the women taking the 0.25 mg dose of estrogen reported 
less breast tenderness, and only one woman in the 0.25 mg group 
had bleeding or spotting, compared with eleven in the 0.5 and 1 
mg groups. And, while women taking 1 mg had a marked increase 
in the thickness of the womb tissue, those in the 0.25 mg and 
placebo groups did not. It appears that a lower dose of 
estrogen may prevent osteoporosis as well as the usual, higher 
dose, but with fewer side effects and potentially less risk of 
uterine and breast tumors.

Risk for Alzheimer's Disease in Ethnic Minorities

    The 4 allele of the apolipoprotein E gene (APOE) 
is the chief known genetic risk factor for Alzheimer's disease 
(AD), the most common cause of dementia late in life. At the 
Columbia University General Clinical Research Center in New 
York, an ongoing series of studies is examining the interaction 
of genetic factors and ethnicity on AD risk. A major previous 
finding was that the relative risk of AD associated with one or 
more copies of the 4 allele was significantly 
increased in whites, but not in African Americans or Hispanics. 
A more recent study of familial aggregation of AD confirms that 
genetic factors, but not necessarily the same ones, contribute 
to AD in ethnically diverse communities. The total magnitude of 
the genetic risk component of AD seems to be the same in 
whites, African Americans, and Hispanics. However, in light of 
the weaker contribution of the 4 allele to AD risk in 
African Americans and Hispanics compared with whites, other (as 
yet unknown) genetic risks factors must be present in these 

Relationship of Parkinson's Disease and Rebound Burst Firing in Rat 
        Subthalamic Neurons

    The subthalamic nucleus (STN) of the basal ganglia is 
important in both normal movement and movement disorders. 
Lesioning or deep-brain stimulation of the STN can alleviate 
resting tremor in Parkinson's disease. Electrophysiologic data 
and therapeutic effect of inactivating the STN strongly 
indicate that this structure is involved in the origin of 
parkinsonian tremor in Parkinson's disease patients. 
Reciprocally connected glutamatergic subthalamic and GABAergic 
globus pallidus neurons have recently been proposed to act as a 
generator of low-frequency oscillatory activity in Parkinson's 
disease. The investigators results suggest that synchronous 
activity of pallidal neuron inputs could underlie rhythmic 
bursting activity of subthalamic neurons which results in 
tremor in Parkinson's disease.

Aging and Central Interleukin-1 Beta Control of Glucose Homeostasis

    Impaired glucose metabolism has long been associated with 
aging. Investigators funded through the Institutional 
Development Award Program (IDeA) have found that injection of 
interleukin-1beta (IL-1b) into the brain causes inhibition of 
insulin secretion and that this inhibition occurs in the 
presence of elevated plasma glucose levels. The investigators 
propose that increased levels of IL-1b within the brain of old 
rats compared to younger rats are responsible for altered 
regulation of insulin secretion. The control of insulin 
secretion by brain levels of IL-1b could be a contributing 
factor in age-related insulin resistance and non-insulin 
dependent diabetes mellitus.

        National Institute of Child Health and Human Development

    The National Institute of Child Health and Human 
Development (NICHD) supports a broad research portfolio that 
has far-reaching implications for human development throughout 
the entire lifespan. Listed below are some examples of the 
Institute's recent initiatives that may be most directly 
related to issues of human aging.

Potential Avenue for Treating Aging or Damaged Brains

    Information gained from neurobiological research is 
challenging old theories about the functioning of the central 
nervous system--specifically, whether old or damaged nerve 
cells can eventually be regenerated or repaired. Once thought 
to be fixed at birth, the number of nerve cells in an 
individual's brain may in fact change to help maintain 
stability later in life, and may be responsive to signals 
outside the cell. NICHD-supported researchers have discovered 
that, instead of decreasing, the number of brain cells is 
actively maintained throughout life. They also found that a 
specific protein, basic fibroblast growth factor, not only 
regulates, but stimulates nerve cell growth. Ultimately, 
treatment with growth factors may help slow the onset of 
neuronal damage, help repair injured brain cells, and stimulate 
replacement of nonfunctional or dead brain cells, offering hope 
to patients with Alzheimer's disease and acute injuries due to 
stroke and trauma.

Older Women's Health

    The transition to menopause encompasses a wide ranging set 
of changes for women. For at least half of their adult lives, 
most women will be affected by decreased levels of the hormone 
estrogen that accompany menopause. Recently, NICHD-supported 
researchers provided important new information about cognitive 
function in postmenopausal women and the possible benefit of 
hormone replacement therapy. They used functional magnetic 
resonance imaging to study the effects of estrogen replacement 
on women's brain activation patterns, finding that estrogen 
actually changed those patterns. These findings indicate that 
the memory systems of mature women are not fixed or immutable 
as previously believed and are responsive to external stimuli.
    In another clinical study funded by NICHD, researchers 
found that nearly two-thirds of women who experienced premature 
ovarian failure (POF) had increased risk for hip fracture due 
to bone loss. Of all bone injuries, hip fractures pose the 
greatest threat, leading to death in some cases and significant 
disability in others. Because estrogen replacement therapy 
alone has been ineffective at stemming bone loss for some of 
these women, researchers are now investigating whether adding 
small amounts of testosterone to the estrogen therapy will 
    Through a Small Business Innovation Research Grant, NICHD 
investigators have developed a new approach to correct urinary 
incontinence. This condition affects nearly twice as many women 
as men; ``stress incontinence,'' in particular, often occurs in 
women due to weakening of the muscles after childbirth or 
menopause. Using recombinant DNA technology, scientists 
developed special polymers that strengthen damaged muscles 
after injection. This discovery holds promise for restoring 
independence and improving quality of life for millions of 

Heart Disease

    One of NICHD's areas of major emphasis involves the 
scientific search for ways to predict adult disease, which in 
turn can often lead to premature aging or death. In one effort, 
scientists examined children's blood levels of the amino acid 
homocysteine to determine if it was associated with their 
parents' history of coronary heart disease. They found that 
significant differences in these levels were associated with 
differences in parents' history of coronary heart disease and 
high blood pressure. Thus, homocysteine levels in childhood 
have become another possible marker for coronary heart disease 
later in life.


    Obesity is one of the most widely known risk factors for a 
range of adult diseases. In one study, NICHD researchers found 
that certain ``homeobox'' genes control the origin of fat 
cells. Hoemobox genes are the ``master genes'' that determine 
the pattern in which embryos develop and direct the formation 
of specialized body genes. The researchers identified 10 
different genes that direct early cells to transform themselves 
into fat cells. Further studies may help determine how these 
processes can be altered or blocked.
    On a related front, the prevalence of obesity is increasing 
so rapidly in children of minority populations that an epidemic 
of Type 2 diabetes is appearing in Hispanic and Native American 
adolescents, far earlier than usual. Obesity, Type 2 diabetes, 
and fat metabolism disorders have their origins in the 
interaction of an individual's genes and the intrauterine and 
post-birth environments. In a trans-NIH effort, NICHD will 
support grants to identify variations in coding sequences and 
regulatory regions of genes that may contribute to obesity and 
related chronic diseases.

                      National Library of Medicine

Initiatives To Help Seniors Access Health Information

    The National Library of Medicine joined the National Heart, 
Lung, and Blood Institute, the Office of Research on Women's 
Health, and the Department of Health and Human Service's Health 
Care financing Administration to release findings of a jointly 
sponsored project to ``train trainers'' of senior citizens from 
around the country in how to access health information on the 
Internet. Results of the project indicate that training had a 
positive impact on seniors' confidence in using computers and 
the Internet, in conducting consumer health information 
searches online, and in sharing health care information with 
doctors, families and friends. The report also found that 
seniors can learn to use the Internet and don't want to be left 
behind on the information superhighway. Two-thirds of those who 
search for health information on the Internet talked about it 
with their doctors, and more than half indicated they were more 
satisfied with their treatment as a result of their search. The 
findings suggest that the ``rain the trainer'' approach may be 
used successfully to enable older adults to access credible 
medical information on the Internet. The report, ``Internet 
Train-the-Trainer Program for Older Adults,'' may be requested 
from the Library's Office of Communications and Public Liaison.
    To make the ``Train the Trainer'' program more widely 
available, the National Library of Medicine is supporting the 
development of an online training curriculum which will be 
tested by trainers in senior centers in selected states 
nationwide. This project is administered by the SPRY (Setting 
Priorities for Retirement Years) Foundation in Washington, D.C. 
SPRY is a nonprofit national organization devoted to research 
and education efforts on senior citizens health and retirement 
    Development Of A Health Website for Older Americans.--The 
National Library of Medicine recognizes that more and more 
older people are using the Internet as a source of health 
information. A survey conducted by Microsoft and the American 
Society on Aging found that 24 percent of seniors age 60 or 
older use computers, and that number is growing daily. Many 
older Americans who log on for health information turn to the 
websites of the National Institutes of Health, where they know 
they can receive free, reliable, comprehensive, and timely 
information. To better serve this population, NLM and the 
National Institute on Aging (NIA) will continue their 
development of a website designed for older Americans during 
2001. A jointly sponsored NLM/NIA pilot to determine the 
usability of this new website is underway in several senior 
centers in Maryland and the District of Columbia. Upon the 
pilot's completion, the website will incorporate recommended 
improvements and add topics of primary interest to senior 
citizens. This new website will serve as an entry point to 
MEDLINEplus for seniors as well as a distance learning site 
specifically geared to older populations and their caregivers. 
Web-based courses will not only contain information seniors 
want and need, they will be designed based on NIA-funded 
research about cognitive function, computer use and 
technological interface among senior populations.

         National Institute of Allergy and Infectious Diseases

    The National Institute of Allergy and Infectious Diseases 
(NIAID) supports and conducts basic and clinical research on 
several diseases and conditions that affect the health of older 
Americans. Several research initiatives are yielding advances 
in the understanding and treatment of these disorders.


    Shingles (zoster) is caused by the same virus, varicella-
zoster (VZV) that causes chickenpox (varicella). Primary 
infection with VZV manifests as chickenpox; after a latent 
period, reactivation of the virus leads to shingles. Current 
research is aimed at preventing shingles and shingles-
associated pain in otherwise healthy older Americans.
    Every year, 600,000 to one million Americans are diagnosed 
with shingles. A person has a one-in-five chance of developing 
shingles in his or her lifetime. More than half of shingles 
cases occur in persons 60 years or older, and the incidence and 
severity of shingles and its complications increase with 
increasing age. During the next 30 years, as the number of 
American seniors continues to increase, the need for a shingles 
vaccine will grow.
    The Shingles Prevention Study (SPS) is a national trial of 
an experimental vaccine for the prevention of shingles and its 
complications in people 60 years or older. The SPS is being 
conducted by the Department of Veterans Affairs in scientific 
collaboration with NIAID and Merck & Co., the vaccine's 
developer. The SPS will enroll 37,200 volunteers across the 
United States. The vaccine being studied is a more potent form 
of the same vaccine routinely given to children to prevent 

Pneumococcal Disease

    Streptococcus pneumoniae, also called pneumococcus, is a 
bacterium that infects the upper respiratory tract and can 
spread to the blood, lungs, middle ear, or nervous system. In 
the United States, S. pneumoniae causes 40,000 deaths, 7 
million middle ear infections (otitis media), 500,000 cases of 
pneumonia, 50,000 blood stream infections (bacteremia), and 
3,000 cases of meningitis annually. Pneumococcal disease kills 
more Americans each year than all other vaccine-preventable 
diseases combined. Adults 65 years old and older are among the 
people disproportionately affected by pneumococcal disease. 
Pneumococcal disease can be difficult to treat because it has 
become more resistant to drug treatment. This makes prevention 
of the disease through vaccination even more important. NIAID 
has conducted and supported research on pneumococcal vaccine 
development for more than 30 years.
    Two Phase I/II trials will be conducted in a high risk 
population to determine what impact a multivalent pneumococcal 
conjugate vaccine has on safety and immunogenicity when 
administered to elderly individuals. Multiple injections of a 
9-valent and an 11-valent pneumococcal conjugate vaccine in 
addition to a propriety adjuvant will be given to study 
participants using several different vaccine schedules. Due to 
the large number of vaccinations, vaccine safety will be 
closely monitored. One trial has begun, and the second trial is 
scheduled to begin within the next couple of months.

Immune Response in the Elderly

    Several of the most common afflictions of the elderly 
involve the immune system, directly or indirectly. 
Historically, the aging of the immune system has not received 
research attention equal to that of other aspects of 
immunology. The effects of aging on the immune system have not 
been widely appreciated by immunologists until fairly recently. 
Several ongoing NIAID research projects should add to the body 
of knowledge about the effects of aging on the immune system.
    A Program Project titled ``Molecular Aspects of Human 
Lymphopoiesis'' is uniting four investigators in studies of the 
development of the immune system. Two of the projects focus on 
the effects of aging on B cell development. The combined 
efforts of these investigators should yield new insights into 
the molecular events in human lymphocyte development and 
abnormalities which lead to immunodeficiencies, autoimmunity, 
and malignancies in the elderly.
    A project titled ``Costimulatory Interactions During the 
Aging Process'' will examine CD4 T cells, which play a pivotal 
role in immunity, primarily by directing responses of other 
lymphoid cells. It is generally accepted that CD4 T cell 
function in aged individuals is diminished, although the 
reasons and mechanisms responsible for this are not clear. This 
study explores several potential explanations for the decrease 
in CD4 T cell function as people age. This research also may 
provide novel findings with regard to T cell-antigen presenting 
cell interactions during the aging process and may highlight 
ways in which hyperesponsiveness can be corrected.

        National Institute of Neurological Disorders and Stroke

    The National Institute of Neurological Disorders and Stroke 
(NINDS) supports research on disorders of the nervous system, 
which includes the brain, spinal cord, and nerves of the body. 
Many nervous system diseases present special problems or are 
markedly prevalent among older people. These include not only 
the classical neurodegenerative diseases of aging, such as 
Parkinson's and Alzheimer's, but also chronic pain, epilepsy, 
trauma, and many other disorders. For this reason, much of the 
research that NINDS supports is relevant to problems of aging.
    In order to more effectively carry out is mission, NINDS 
has embarked on a strategic planning process, engaging the 
efforts of more than 100 of the nation's experts in clinical 
and basic neuroscience. This process produced a five-year 
strategic plan for the Institute, Neuroscience at the New 
Millennium. One immediate outcome of the planning process was 
the reorganization of the Institute's extramural programs into 
seven cross-cutting areas of research emphasis that follow our 
current understanding of the nervous system and disease. One of 
these, Neurodegeneration, reflects the increasing recognition 
that common mechanisms contribute to the many neurodegenerative 
disorders that are caused by the progressive death of neurons, 
such as Alzheimer's and Parkinson's diseases. Another focus 
area, Clinical Trials, will help improve both the number and 
quality of clinical trials that are supported by the Institute. 
Neurodegenerative diseases are an obvious target of many of 
these trials, as are other disorders, such as stroke, that have 
a disproportionate impact on older individuals. Other planning 
activities are underway that complement this initial effort. 
These activities, and selected research highlights of 
particular significance to the field of aging research, are 
described below.

Parkinson's Disease

    To complement its strategic planning activities, which 
emphasize cross-cutting themes, NINDS has also begun planning 
efforts focused on specific disorders. The first of these, 
targeting Parkinson's disease, was initiated in January 2000 
with a major planning conference that included NIH staff, 
researchers, clinicians, and advocacy group representatives. 
Based on the recommendations from this meeting, NINDS, along 
with several other institutes, developed a five-year NIH 
Parkinson's Disease Research Agenda, which was released in 
March 2000. This agenda outlines a number of strategies that 
the NIH will utilize in enhancing research progress in this 
    To help carry out the Parkinson's Agenda, NINDS has 
developed a Parkinson's Disease Implementation Committee that 
includes Institute staff, extramural researchers, and members 
of the advocacy community. This Committee monitors progress and 
suggests new directions for implementation in response to new 
findings. NINDS has taken several actions to make progress on 
the plan as rapidly as possible. In March 2000, the Institute 
convened representatives of the 11 currently funded Morris K. 
Udall Parkinson's Disease Research Centers of Excellence to 
discuss research being conducted at each center and to 
coordinate ongoing and future collaborations. NINDS has awarded 
supplements to Udall centers for critical projects highlighted 
in the agenda such as expediting drug discovery, identifying 
Parkinson's genes, and investigating Parkinson's disease in 
minority populations. Other NINDS actions include a Request for 
Applications (RFA) on parkin, a protein implicated in the 
early-onset forms of Parkinson's, an RFA on the role of 
mitochondria in neurodegeneration, and the funding of several 
projects in response to an RFA on deep brain stimulation. Deep 
brain stimulation is a novel therapy that holds promise for 
providing symptomatic treatment for some Parkinson's patients. 
A follow-up RFA will focus on other aspects of this form of 
therapy. Other program activities in the planning stages 
include an RFA for a large-scale clinical trial on 
neuroprotective agents to slow the progress of Parkinson's. 
Lastly, Parkinson's disease was highlighted in two recent 
meetings sponsored by the Institute, the first a workshop on 
Gene Therapy, and the second a meeting of the Therapeutic 
Opportunities in Parkinson's Disease Working Group, both held 
in late 2000. Both will guide the Institute in further efforts 
in these areas.
    Over the past several years, NINDS-supported researchers 
have made several significant findings, including:
           Demonstration of the potential of stem cell 
        transplantation in animal models of Parkinson's 
        disease, and the development of a technique to 
        stimulate cultured embryonic stem cells in mice to 
        develop into large numbers of dopamine neurons that may 
        someday be useful in cell replacement therapies in 
        Parkinson's patients.
           Generation of a new rodent model of 
        Parkinson's disease using exposure to the pesticide 
        rotenone. The cellular changes that take place in this 
        model of Parkinson's bear such a close similarity to 
        the changes that take place in the human brain as a 
        result of Parkinson's, that this model should prove 
        exceedingly useful in studying both the cellular basis 
        of the disease and in evaluating treatments at the 
        preclinical stage.
           Demonstration that the delivery of specific 
        growth factors in a primate model of Parkinson's 
        disease can be successfully achieved using gene 
        therapy, and that this technique can slow the disease 
        progression in these animals. This was a critical final 
        step before this approach can be initiated in human 
           Characterization of the genes that cause 
        Parkinson's in different forms of the disease. These 
        studies suggest that important similarities exist 
        between genetic changes in early-onset and late-onset 
        forms of Parkinson's. Other research has expanded our 
        knowledge about how multiple genetic events, each 
        impacting a different protein family, may be involved 
        in the degeneration of affected neurons.

Alzheimer's Disease

    In efforts coordinated with other institutes at NIH, NINDS 
provides support for a broad range of studies in the area of 
Alzheimer's disease. To foster the transition from preclinical 
findings to human testing as efficiently as possible, the 
Institute, along with the NIMH and NIA, issued two joint 
Program Announcements (PAs) encouraging the submission of 
Alzheimer's Disease Pilot Clinical Trial Planning Grants and 
Clinical Trial grant applications in early 1999. In addition, 
an RFA was released in December 2000, in the area of vaccine 
and immune therapies for Alzheimer's disease. The ultimate 
effect of these program initiatives will not be known for some 
time, but the goal of these activities is to accelerate the 
development of therapies for Alzheimer's disease towards 
clinical testing. NINDS continues to coordinate these, and 
other, research activities in Alzheimer's disease with all 
other institutes working in this field, including NIA and its 
Alzheimer's Disease Center Program.
    Recent research highlights in NINDS-supported Alzheimer's 
disease research include:
           Characterization of the mechanisms by which 
        changes in amyloid beta protein, a cellular hallmark of 
        Alzheimer's disease, lead to neuronal cell damage. A 
        recent study suggests that the conversion of this 
        protein to a fibrillar form may lead to abnormal, and 
        ultimately toxic, interactions with the cell membrane 
        of affected neurons.
           Discovery of a novel mutation in the amyloid 
        precursor protein gene, which may play a role in the 
        development of early-onset Alzheimer's.
           Validation of the theory that the 
        presenilins play an important role in the cleavage and 
        ultimate buildup of amyloid beta protein, confirming 
        that these proteins are an appropriate therapeutic 
        target in Alzheimer's research.
           Demonstration that improved magnetic 
        resonance imaging techniques may be useful in 
        identifying early cognitive changes in individuals at 
        risk for Alzheimer's disease.


    Stroke research is a high priority of NINDS because of the 
enormous public health burden and the opportunities science 
presents for progress against stroke. As with Parkinson's and 
Alzheimer's, increasing age is also a risk factor for stroke. 
It has been reported that the chance of having a stroke more 
than doubles for each decade of life after age 55. NINDS is 
engaged in a broad range of activities, from targeted programs 
of public education and prevention, to the design of large-
scale clinical trials of therapeutic agents, and fundamental 
research on how stroke damages brain cells. To enhance these 
efforts, the Institute is now developing a five-year plan for 
stroke research, which will identify topics in need of 
additional study and strategies to improve stroke prevention 
and develop new therapies. The initial organizational phase is 
underway with a planning workshop anticipated by late 2001. 
NINDS will collaborate with other NIH institutes and voluntary 
health organizations in this effort, as it has in many stroke 
related activities in the past.
    In the past two years NINDS-supported researchers have made 
several significant research findings in the area of stroke 
research, including:
           The development of a vaccine that, in animal 
        models of stroke and epilepsy, is capable of reducing 
        damage to the brain caused by these disorders. The 
        vaccine causes the body to produce antibodies to a 
        specific neurotransmitter receptor that has been 
        implicated previously in neuronal cell death.
           The identification of a novel method of 
        introducing genes into the nervous system, across the 
        blood-brain barrier (BBB). The BBB has traditionally 
        acted as an obstacle in the delivery of therapeutic 
        agents to the central nervous system.
           The discovery that individuals experiencing 
        transient ischemic attacks (TIAs) have a much greater 
        risk of experiencing a full-blown stroke shortly after 
        the attack. Intervention with agents such as blood 
        thinners or surgery after a TIA may be useful in 
        preventing subsequent strokes, if patients can be 
        identified and treated rapidly.
    Over the past few years, NINDS has also been involved in a 
number of broad-based stroke education activities, including:
           Creation of a multi-faceted communication 
        effort to raise awareness of the signs of stroke, the 
        need for urgent action, and the possibility of a 
        positive outcome with timely hospital treatment.
           Collaboration with the Brain Attack 
        Coalition (BAC), a group of professional, voluntary, 
        and government groups dedicated to reducing the 
        occurrence, disabilities, and death associated with 
        stroke. Recent accomplishments of this collaboration 
        include the distribution of a stroke symptom list that 
        is now used by all participating BAC organizations, 
        publication of the first clearly defined set of 
        recommendations for hospitals to update their stroke 
        treatment strategies, and creation of a web-based 
        resource for healthcare professionals to provide the 
        latest tools for diagnosis and treatment of stroke.
           Development of a series of public education 
        materials including: airport dioramas jointly sponsored 
        with the National Stroke Association, billboard 
        displays, consumer education brochures, exhibits, and 
        new television and radio public service announcements, 
        all designed to increase awareness of stroke.
           Involvement in a number of community-based 
        stroke awareness activities, both locally and in other 
        regions of the country.

        The National Institute of Environmental Health Sciences

    The National Institute of Environmental Health Sciences 
(NIEHS) explores the environmental factors that contribute to 
human disease, especially the interaction between environment, 
susceptibility, and time over the age span. Understanding of 
these interactions is a key step in promoting seniors' health, 
which manifests the influences of a lifetime of environmental 
exposures. Research on the effects of the environment on aging 
and diseases of aging has been increasing for the past few 
years at the NIEHS. Various NIEHS research activities in the 
area of aging are highlighted below.

Parkinson's Disease

    During 1999-2000 the NIEHS released two requests for 
applications (RFAs) associated to an age-related ailment, 
Parkinson's disease. Parkinson's disease is a neurologic 
disorder marked by a progressive loss of motor function 
resulting from the degeneration of neurons in the area of the 
brain that controls voluntary movement. The average age of the 
onset of this disease is 57. The prevalence of Parkinson's 
disease (PD) is estimated to be approximately 500,000 in the 
general population, with about 50,000 new cases appearing each 
year. Recent evidence has shown that genetics plays less of a 
role and environmental factors play a potentially greater role 
than previously thought in the progression of late-onset PD. 
The purpose of one RFA was to stimulate the career development 
of physician-scientists engaged in research on the factors that 
cause PD. The other RFA was to encourage research aimed at 
revealing the role of the environment in the occurrence of 
Parkinson's disease. The results of these investigations will 
contribute to clarifying the part environmental factors play in 
the development of this disease.


    The NIEHS also has a number of intramural researchers who 
are studying aspects of the aging process and certain diseases 
associated with them. An NIEHS investigator is addressing the 
problem of cancer in the elderly. By studying aging at the 
molecular level this scientist hopes to uncover factors that 
influence the development of cancer that create major health 
problems for the aged. More importantly this research may offer 
new insights on how to treat or prevent cancer. Another 
researcher is expanding a technique that will help to better 
study chemical exposures and brain development. This research 
will examine how these chemicals disrupt neurological functions 
and help determine how these exposures affect cognitive 
function later in life. Other intramural researchers are 
studying various components of the aging process to better 
understand how the environment may cause certain diseases or 
cause them to progress faster thereby producing destructive 
health effects later in life. All of these studies should help 
to better understand the aging process and develop better 
intervention and prevention strategies.
    Additionally, NIEHS grantees are working to determine how 
various environmental exposures affect the development of 
assorted diseases in the later stages of life. For example, in 
three separate studies researchers are examining the effects of 
lead, methylmercury, and aluminum exposure and the development 
of chronic diseases such as hypertension and decreased 
cognitive functioning. Determining the consequences of these 
exposures, especially related to cognitive function through the 
aging process, will help understand how to provide therapies 
and intervention strategies to reduce harmful health impacts.


                     Bureau of Primary Health Care

    The Bureau of Primary Health Care (BPHC) helps assure that 
primary health care services are provided to persons living in 
medically underserved areas and to persons with special health 
care needs. It also assists States and communities in arranging 
for the placement of health professionals to provide health 
care in health professional shortage areas. The BPHC provides 
services to older Americans through BPHC-supported Health 
Centers, Migrant Health Centers, Health Care for the Homeless 
Program sites, Public Housing Primary Care Program sites, the 
National Health Service Corps, and the Division of Federal 
Occupational Health.
    In April 2000, the Health Resources and Services 
Administration approved BPHC's establishment of the ``Healthy 
Aging Initiative.'' BPHC named Marion E. Primas, Ph.D., M.S., 
Director of this initiative and she is located in the Division 
of Programs for Special Populations. A number of activities 
have been launched including internal and external 
infrastructure building around the following areas of focus:
          (1) Reimbursement (dual Medicare and Medicaid health 
          (2) Outreach (improved methods to bring older persons 
        into care)
          (3) Quality (appropriate health care specific to 
        client needs)
          (4) Modeling of effective approaches for adaptation 
        in other communities
    Partnerships are being developed with Primary Care 
Association Members and Primary Care Offices throughout the 
Nation. We are collaborating with other Department of Health 
and Human Services programs, (e.g., the Administration on 
Aging, the National Institutes of Health's National Institute 
on Aging and the National Cancer Institute) and the Department 
of Education's Office of Special Education and Rehabilitation 
Services. Collaborating organizations also include the American 
Association of Retired Persons, the Helen Keller National 
Center, the American Foundation for the Blind, the National 
Center and Caucus on Black Aging, Inc., the National Asian 
Pacific Center on Aging, and the National Council of Hispanic 

                      Consolidated Health Centers

    On October 11, 1996, the President signed the Health 
Centers Consolidation Act of 1996. This Act consolidates the 
Community Health Centers, Migrant Health Centers, Health Care 
for the Homeless Programs, and Public Housing Primary Care 
Programs under a single statutory umbrella that revised section 
330 of the Public Health Service (PHS) Act. Health Center 
programs are designed to promote the development and operation 
of community based primary health care service systems in 
medically underserved areas for medically underserved 
populations. Legislation governing this program can be found in 
section 330 the PHS Act, as amended (42 U.S.C. 254b). The 
Health Centers Consolidation Act of 1996, under section 
330(a)(1) of the PHS Act, defined the term ``health center'' as 
an entity that serves medically underserved population 
comprised of migratory and seasonal agricultural workers, the 
homeless, and residents of public housing.
    The Consolidated Health Centers Programs entered into 
fiscal year 2000 with 826 grantees and a total of approximately 
$1.0187 billion covering over 3,000 sites, located in medically 
underserved areas throughout the United States and its 
territories. The Consolidated Health Centers Programs entered 
into fiscal year 2001 with an estimated 850 grantees and 
$1.1687 billion covering approximately 3,600 sites.
    Health centers provide access to case-managed, family-
oriented, culturally sensitive preventive and primary health 
care services for people living in rural and urban medically 
underserved areas. The medical services include: preventive 
health and dental services, acute and chronic care services, 
and appropriate hospitalization and specialty referrals. Health 
centers also provide essential ancillary services such as 
laboratory tests, X-ray, environmental health and pharmacy 
services. In addition, many centers provide such enabling 
health and community services as transportation, health 
education, nutrition, counseling, and translation. Case 
management--the coordination of the center's services 
appropriate to the needs of the patient (social, medical, or 
economic)--is emphasized.
    Health centers target medically underserved, disadvantaged 
populations. These populations include: minorities, women of 
child-bearing age, infants, persons with HIV infection, 
substance abusers and/or homeless individuals and their 
families. In fiscal years 1999-2000, the Health Center Program 
served more than 9,500,000 patients annually. Of this total, 7 
percent were age 65 or older.
    The BPHC has implemented clinical performance measures 
related to the primary and preventive care of elderly users. 
The measures include: (1) a functional assessment of activities 
of daily living; (2) an inventory of prescription and 
nonprescription drug use; and, (3) pneumococcal and influenza 
immunization administration.

EXHIBIT A.--Breakdown by program and age cluster of the number of elderly persons who received health care services from BPHC-supported programs for the
                                                                    years 1999-2000.
               Program                                      Age 65+Years                                               Total Users
Community & Migrant Health Center...                                          Females: 395,517                                        Medical: 7,809,390
                                                                                Males: 240,229                                         Dental: 1,235,992
                                                                                Total: 635,746                                          Total: 9,045,382
Homeless Program....................                                            Females: 4,826
                                                                                  Males: 6,534
                                                                                 Total: 11,360                                                   473,057
Public Housing......................                                            Females: 1,137
Primary Care Program................                                                Males: 921
                                                                                  Total: 2,058                                                    42,969
      Total.........................                                                   649,164                                                 9,561,408

   EXHIBIT B.--Breakdown by program and age cluster of the number of elderly persons who received health care
                                   services from BPHC for the year 1999-2000.
                    Program                       AGE 65-74    AGE 75-84     AGE 85+      Elderly    Total Users
1999/2000 CLUSTER..............................      372,749      198,912       70,948      642,609    9,017,325

                   The National Health Services Corps

    The National Health Service Corps (NHSC) places primary 
care physicians, nurse practitioners, physician assistants, 
certified nurse midwives, dental and mental health 
professionals in health professional shortage areas. There are 
now 4,400 clinicians serving communities and populations of 
greatest need (53 percent rural and 47 percent urban). Older 
Americans with special health care needs benefit from the 
proximity of dedicated primary care clinicians that provide 
high quality health care. The NHSC works closely with Bureau-
supported health centers, other primary care delivery systems, 
and the Indian Health Service to provide assistance in 
recruiting and retaining health personnel for the poorest, the 
least healthy, and the most isolated of our fellow Americans, 
including the aging population.

                Division of Federal Occupational Health

    The Division of Federal Occupational Health provides a 
variety of services related to health promotion and disease 
prevention in the elderly to managers and employees of over 
3,000 Federal agencies. Retirement planning, care of aging 
parents, and prevention of osteoporosis are some examples of 
generic issues that are regularly addressed in educational 
seminars and employee assistance programs.

                      Bureau of Health Professions

    The Bureau of Health Professions (BHPr) provides national 
leadership, sets policies, and administers programs to assure a 
health professions workforce that meets the health care needs 
of all Americans. The Bureau's five strategic functions 
    1. Enabling access to health care through improved health 
professions distribution.
    2. Enabling culturally competent health care through 
improved racial and ethnic diversity and cultural competence in 
the health professions workforce.
    3. Ensuring adequate information, analysis and planning to 
strategically enable national health professions workforce 
    4. Enabling ongoing improvement in the quality of health 
professions education through demonstration, education 
research, innovation and dissemination; and of health 
professions practice through innovations in financing and 
    5. Providing public information and technical assistance 
relating to health professions.
    Additionally, the Bureau has three areas of emphasis: 
geriatrics, genetics, and diversity. These areas are promoted 
throughout the Bureau's training programs. The geriatric 
emphasis will help ensure that health care workers are trained 
and become knowledgeable about the aging process, diseases and 
common conditions of the elderly, and older people's special 
problems and needs.
    The strategies defined by these functions and areas of 
emphasis are implemented through a variety of collaborative 
public and private efforts and programs supported and operated 
by the Bureau. Programs include: education and training grant 
programs for institutions such as health professions schools 
and health professions education and training centers; loan and 
scholarship programs for individuals, particularly those from 
disadvantaged backgrounds; the Vaccine Injury Compensation 
Program; the National Practitioner Data Bank; the Healthcare 
Integrity and Protection Data Bank; the Ricky Ray Program; and 
the Children's Hospitals Graduate Medical Education Program. In 
addition, BHPr administers several education-service network 
multidisciplinary and inter-disciplinary programs such as the 
Area Health Education Centers (AHECs), the Geriatric Education 
Centers (GECs), and Rural Interdisciplinary Training Programs.
    The multi- and inter-disciplinary programs:
          Train health professional to deliver cost-
        effective, high-quality health care in medically 
        underserved areas;
          Stimulate curricula improvements so that 
        health education reflects the needs of vulnerable 
        populations and changes in health care financing; and
          Improve racial and cultural diversity in the 
        health professions, which results in greater access to 
        health care by minority and lower-income Americans.
    The Bureau also supports the Council on Graduate Medical 
Education, which reports to the Secretary and the Congress on 
matters related to graduate medical education, including the 
supply and distribution of physicians, shortages, or excesses 
in medical and surgical specialties and subspecialties, foreign 
medical graduates, financing medical educational programs, and 
changes in types of programs. It also supports the National 
Advisory Council on Nurse Education and Practice which provides 
advice and recommendations to the Secretary concerning policy 
matters relating to nurse workforce, education, and practice 
    The National Vaccine Injury Compensation Program, 
administered by BHPr, became effective October 1, 1988. It was 
created by the National Childhood Vaccine Injury Compensation 
Act of 1986, as a no-fault system through which families of 
individuals who suffer injury or death as a result of adverse 
reactions to certain childhood vaccines can be compensated 
without having to prove negligence on the part of those who 
made or administered the vaccines.
    BHPr maintains a federally sponsored health practitioner 
data bank on all disciplinary action and malpractice claims. 
The National Practitioner Data Bank (NPDB) was created by The 
Health Care Quality Improvement Act of 1986, Title IV of P.L. 
99-660, as amended November 1986. The Act authorized the 
Secretary of Health and Human Services to establish a data bank 
to ensure that unethical or incompetent medical and dental 
practitioners do not compromise health care quality. The NPDB 
is a central repository of information about: malpractice 
payments made on behalf of physicians, dentists, and other 
licensed health care practitioners; licensure disciplinary 
actions taken by State medical boards and State boards of 
dentistry against physicians and dentists; and adverse 
professional review actions taken against physicians, dentists, 
and certain other licensed health care practitioners by 
hospitals and other health care entities, including health 
maintenance organizations, group practices, and professional 
societies. The NPDB began operation on September 1, 1990.
    The Secretary of the U.S. Department of Health and Human 
Services, acting through the Office of Inspector General was 
directed by the Health Insurance Portability and Accountability 
Act of 1996 to create the Healthcare Integrity and Protection 
Data Bank (HIPDB). The HIPDB is a national health care fraud 
and abuse data collection program for the reporting and 
disclosure of certain final adverse actions taken against 
health care providers, suppliers and practitioners. Health 
plans and Federal and State programs and officials (including 
licensing agencies, certification agencies, criminal 
prosecutors, government attorneys participating in civil cases, 
and agencies taking program exclusion actions) are required to 
report to the data bank all final adverse actions (such as 
revocations, suspensions, exclusions, criminal convictions and 
civil judgments) against health care providers, suppliers and 
practitioners. Federal and State agencies and health plans are 
permitted to query the data bank. It began full operation on 
March 2000.
    The Ricky Ray Hempohilia Relief Act of 1998 established in 
the Treasury of the U.S. a trust fund to be known as the 
``Ricky Ray Hemophilia Relief Fund'', to provide compassionate 
payments for individuals with blood-clotting disorder, such as 
hemophilia, who contracted HIV from contaminated antihemophilic 
factor between July 1, 1982 and December 31, 1987. A former 
legal spouse, who was a legal spouse and contracted HIV through 
transmission from their spouse, and an individual who acquired 
infection through perinatal transmission from either of the 
individuals listed above are also eligible for compassionate 
payments under the program. The Act specifies that the Fund 
shall terminate upon the expiration of the 5-year period 
beginning on the date of enactment of the Act.
    The Children's Hospitals Graduate Medical Education Program 
provides a more adequate level of support for health 
professions training in U.S. children's teaching hospitals that 
have a separate Medicare provider number (``free-standing'' 
children's hospitals). These hospitals receive very small 
amounts of from Medicare for graduate medical education (GME) 
and other health professions training, while children's 
hospitals that share Medicare provider numbers with other 
teaching hospitals receive more typical amounts of GME from 
Medicare. As managed care organizations become increasingly 
unwilling to pay for GME, free-standing children's teaching 
hospitals are at a competitive disadvantage, in the absence of 
a similar level of support from Medicare that other hospitals 
receive, and are coming under increasing pressure to reduce 
their level of residency training. Children's hospitals train 
over 25 percent of all U.S. general pediatric residents, the 
majority of pediatric subspecialty residents, and about 4 
percent of all medical residents. The goal of this program is 
to make the level of Federal GME support more consistent with 
other teaching hospitals, including children's hospitals which 
share Medicare provider numbers with other teaching hospitals.

                   Division of Medicine and Dentistry

    The Division of Medicine and Dentistry (DMD) continues to 
support, through its grant and cooperative agreement programs, 
significant educational and training initiatives in geriatrics.
    For FYs 1999 and 2000, predoctoral grantees indicated that 
they were actively involved in the development, implementation, 
and evaluation of their geriatrics curriculum and training. 
There are eleven predoctoral grantees that received funds 
totaling $285,340 for geriatric activities.
    Residency program grants were awarded with a focus on 
geriatrics, emphasizing the interdisciplinary approach, home 
visits, and nursing home visits. There were nine residency 
primary care grantees that received funds totaling $221,463 for 
geriatric activities.
    Faculty development programs instituted training 
activities, enhanced primary care research training, and 
developed strategies for career development in geriatrics. 
These programs also placed an emphasis on the instruction of, 
``Teaching Geriatrics.'' There were twelve faculty development 
grantees that received funds totaling $725,000 for geriatric 
    The majority of academic administrative units developed a 
research infrastructure in support of primary care research 
with an emphasis on the elderly, palliative care, and geriatric 
education. There are five academic administrative unit grantees 
that received funds, for FY2000, totaling $239,200 for 
geriatric activities.
    One physician assistant training program grantee continued 
participation in the Rural Elderly Assessment Project and 
received funds totaling $30,000 for geriatric activities.
    Podiatric primary care residency programs supported 
training which emphasized geriatric health. Two podiatric 
grantees that emphasized geriatric training received funds 
totaling $167,920.
    Title VII funded training programs in the general and 
pediatric practice of dentistry provide a favorable Special 
Consideration for applicants that propose to prepare 
practitioners to care for underserved populations and high risk 
groups such as the elderly and patients of long term care 
facilities. In addition, applicants may also propose innovative 
projects that encourage curriculum enrichment or unique 
resident experiences in the area of geriatric dentistry. In 
FY1999, twenty-three dental training programs provided care to 
the elderly in nursing homes, clinical settings, and geriatric 
treatment centers. For FY2000, twenty training programs 
utilizing over a hundred and twenty residents provided much 
needed care and treatment for this population in various 
settings throughout the nation.
    The Society of Teachers of Family Medicine (STFM) was 
awarded a four-year contract to develop a faculty resource 
manual to assist medical school faculty with the inclusion of 
geriatrics into the curriculum for medical students over the 
entire four years of medical school. This project will define 
new competencies for medical students that also include 
palliative and end-of-life care. This grantee received 
approximately $25,000, for FY2000, for geriatric activities.
    The Undergraduate Medical Education for the 21st Century 
(UME-21) and Partnerships for Quality Education (PQE): 
Collaborative Faculty Development Program in Managing Patient 
Care with Harvard Pilgrim Health Care, Boston, Massachusetts, 
was initiated in 1999. This 18 month contract was created to 
develop, implement, and evaluate a set of two faculty 
development workshops for physician faculty of UME-21 and PQE 
programs centering on two content areas of managing patient 
care. The purpose is to develop faculty competencies in the 
basics of curriculum development and teaching methodology 
appropriate for medical students in UME-21 and residents in 
PQE. These competencies will be learned within the context of 
two content areas selected from among those common to UME-21 
and PQE; namely, evidence-based and population-based medical 
care; healthy systems finance, economics and delivery; ethics; 
patient-provider communication skills; leadership; quality 
measurement including cost-effectiveness and patient 
satisfaction; systems-based care; medical informatics; and 
wellness and prevention. The focus population for UME-21 and 
PQE range from pediatric to geriatric. The final phase of this 
faculty development program involves dissemination of results 
and instructional materials.

                          Division of Nursing

    In FY1999, the Division of Nursing awarded grants through 
four programs: (four grants) Advanced Nurse Education, (two 
grants) Nurse Practitioner/Nurse Midwifery, (three grants) 
Nursing Special Projects and (four grants) Professional Nurse 
Traineeships. The Professional Nurse Traineeship Program 
provides funds to schools that allocate these funds to 
individual full-time master's and doctoral students preparing 
to be nurse practitioners, nurse-midwives, nurse educators, 
public health nurses, or other clinical nurse specialists. 
Geriatric Nurse Practitioners and Geriatric Clinical Nurse 
Specialists are among those benefitting from the Traineeship 
    In FY2000, the Division of Nursing legislation changed, 
resulting in the renaming of the four FY1999 grant programs. 
The Advanced Nurse Education Program and the Nurse 
Practitioner/Nurse Midwifery Program were combined and are now 
entitled Advanced Education Nursing. The Professional Nurse 
Traineeship Program was changed to Advanced Education Nursing 
Traineeship Program and expanded traineeship eligibility to 
include part-time students. The Nursing Special Projects Grant 
Program was changed to the Basic Nurse Education and Practice 
    In FY1999, the Advanced Nurse Education Program supported 
four projects totaling $894,049. In FY2000, the Advanced 
Education Nursing Program supported three projects totaling 
$547,470. All of these projects supported gerontological 
nursing programs leading to a master's or doctoral degree. 
Graduates of these programs are prepared broadly to meet a wide 
range of health needs relative to the elderly in many settings, 
but are particularly prepared to deal with the older individual 
with multiple health care needs. In addition, the program 
prepares nurses who can teach and offer consultation in this 
important field.
    In FY1999, the Nurse Practitioner and Nurse-Midwifery 
Program, supported six master's or post-master's geriatric 
nurse practitioner (GNP) program grants totaling $598,955. In 
FY2000, three master's or postmaster's GNP program grants 
totaling $492,978 were supported. In addition, seven Adult 
Nurse Practitioner (ANP) programs were supported in FY1999 for 
a total of $712,961, and five Family Nurse Practitioner (FNP) 
programs were supported for a total of $735,498. In FY2000, the 
Advanced Education Nurse Program supported five Geriatric Nurse 
Practitioner grants totaling $805,261, and five Adult Nurse 
Practitioner grants totaling $708,825.
    GNPs, ANPs, and FNPs all provide primary care services to 
older adults. As nurses with advanced academic and clinical 
preparation, they are prepared as primary health care providers 
to manage the health problems of the elderly in a variety of 
settings, such as long-term care facilities, ambulatory 
clinics, and homes. They provide nursing care and clinical 
management of common acute and chronic health problems, 
including health promotion and maintenance, disease prevention, 
health assessment, and long-term management of chronic health 
problems. Emphasis is placed on teaching and counseling the 
elderly to actively participate in their own care and to 
maintain optimal health.
    In FY1999, the Nursing Special Projects Grant Program 
supported five Long-Term Care Fellowships for Paraprofessional 
projects in four institutions totaling $1,057,564. These 
fellowships supported approximately 88 individuals employed by 
nursing facilities, including long-term care facilities or home 
health agencies as paraprofessionals and enrolled in approved 
nursing program. The agencies assist the fellows financially to 
obtain further education in nursing.
    In FY1999, the Nursing Special Project Grant Program 
supported three nursing centers providing services specifically 
for elderly populations received support totaling $371,503. In 
FY1999, an additional thirteen nursing centers providing 
services to elders in housing and other community sites 
received support totaling $2,229,950.
    In FY2000, the Basic Nurse Education and Practice Program 
supported six nursing centers providing services to elders in 
clinics in rural and urban underserved areas, receiving support 
totaling $1,312,287. In addition, one nursing center project 
(University of Maryland) provided services specifically to the 
geriatric population, receiving $231,089. All of these centers 
demonstrate methods of improving access to primary health care 
in medically underserved communities.
    The nursing center project at the University of Maryland, 
Baltimore, Maryland, now in the first year of a three year 
grant period, is designed to provide a community-based 
continuum of senior services. The Senior Care Center offers 
three programs: (1) Comprehensive Geriatric Assessment; (2) 
Geriatric focused primary care and (3) Wellness Programs. In 
addition, faculty and students are conducting a community needs 
assessment that will form the basis for the design of 
structured wellness programs that can be implemented at a new 
senior housing facility in Baltimore. This project also 
provides clinical experiences for graduate and undergraduate 
students which will prepare them to provide the specialized 
care needed by older adults.

        Division of Interdisciplinary, Community-Based Programs

    The Division of Interdisciplinary, Community-Based Programs 
was created in FY2000 in response to the Health Professions 
Partnership Act of 1998 (Part D of Title VII of the Public 
Health Service Act). Programs supported by the Division are 
designed to ``carry out innovative demonstration projects for 
strategic workforce supplementation activities as needed to 
meet national goals for interdisciplinary, community-based 
linkages.'' Supported programs include Area Health Education 
Centers, Health Education and Training Centers, Education and 
Training Related to Geriatrics, and Rural Interdisciplinary 
Training Grants.
    The Division (DICP) supports the training of health 
professionals in geriatric care though three principal 
programs--Geriatric Education Centers; Faculty Training in 
Geriatrics for Physicians, Dentists, and Behavioral and Mental 
Health Professionals; and Geriatric Academic Career Awards. 
Authorized by the Public Health Service Act, as amended, 
Sections 753 (a), (b), and (c) respectively, these three 
programs focus on preparing the health care workforce to serve 
an aging population. The AHEC program supports continuing 
education in geriatrics. The Quentin R. Burdick Rural 
Interdisciplinary Training program promotes rural health care 
practice which may include geriatrics.
    Geriatric Education Centers (GECs).--GEC grants help 
accredited health professions schools collaborate with health 
care facilities to train health professions students, faculty 
and practitioners in the diagnosis, treatment, disease and 
disability prevention, and other health problems of the aged. 
Projects must involve at least four health disciplines one of 
which must be medicine. These Centers are educational resources 
providing multidisciplinary and interdisciplinary geriatric 
training for health professions faculty, students, and 
professionals in medicine, dentistry, pharmacy, nursing, 
occupational and physical therapy, podiatric medicine, 
optometry, social work, and related allied and public or 
community health disciplines. They provide comprehensive 
services to the health professions education community within 
designated geographic areas. Grants may support geriatric 
residencies, traineeships or fellowships; development and 
dissemination of curricula; training and retraining of faculty; 
continuing education of health professionals; and clinical 
training in geriatrics in various care settings. Grantees may 
be single institutions or consortia of institutions.
    At the State and National level, the GECs comprise a 
comprehensive educational system, serving as the primary 
coordinating body for the preparation of faculty, health 
professions students, and health care personnel to better serve 
the Nation's elderly. GECs use ambulatory care centers, 
hospitals, long-term care facilities and senior centers to 
provide appropriate educational experiences to health 
professions students and providers, to prepare them to deliver 
humane and dignified care and to be responsive to older 
individuals whose ability to care for themselves has been 
reduced by physical and/or mental disorders. Over 40,000 health 
care professionals received education and training through the 
GECs in FY1999-2000.
    Of the 43 GECs Geriatric Education Centers that make up the 
membership of the National Association of Geriatric Education 
Centers, 34 received BHPr funding in both FY1999 and FY2000. In 
FY1999, there were 27 consortia and 7 single institution 
awards. In FY2000, there were 26 consortia and 8 single 
institution awards. Awards were made to the following 
institutions in FY1999 and FY2000:

                      Geriatric Education Centers

                                                   FY1999       FY2000
    University of California, Los Angeles,         $258,323     $319,028
     Univ. of California, Davis, Univ. of
     California, San Francisco, UCLA School of
     Medicine, California State University at
    New York University, Columbia University,       312,422      162,000
     Hunter College...........................
    University of Pittsburgh, Pennsylvania          159,982      263,733
     State University, Temple University......
    University of Miami, Barry University,          252,566       23,673
     Florida A&M;, Florida International
    St. Louis University, U. of Missouri,           323,245      160,283
     School of Optometry, Washington U.,
     Occupational Therapy, St. Louis College
     of Pharmacy, Kirksbille College of
     Osteopathic Medicine.....................
    University of Kentucky, East Tennessee          313,236      160,365
     State Univ., U. of Ohio Cincinnati.......
    University of Kansas Medical Center, Aging      161,891      269,991
     Research Institute, University of
     Missouri-Kansas City.....................
    University of Medicine & Dentistry of NJ,       324,807      161,997
     Rutgers University School of Social Work.
    University of Oregon, Portland State            261,847      290,058
    University of Iowa, University of               270,000      324,000
     Osteopathic Medicine and Health Sciences.
    Baylor College of Medicine, University of       322,720      162,000
     Texas, Houston HSC, Univ. Texas, Medical
     Branch, Univ. of North Texas, Univ. of
     Texas-Pan AM, Texas Southern Univ., Univ.
     of Houston, Texas A&M; University.........
    George Washington University, Georgetown        321,653            0
     University, Howard University............
    Case Western Reserve University, Ohio           319,440      161,200
     University college of Osteopathic
     Medicine, Bowling Green State University,
     Northeastern Ohio Universities College of
    Marquette University, Univ. of Wisconsin-       162,000      269,821
     Madison, Univ. of Wisconsin-Milwaukee,
     Milwaukee Area Technical College, Medical
     College of Wisconsin, Geriatrics Inst.of
     Sinai Samaritan Medical Center...........
    Michigan State University, Wayne State          269,592      324,000
     University, Michigan Primary Care
     Association, St. Lawrence Hospital.......
University of New Mexico, New Mexico State          248,832      312,292
 University, New Mexico Highlands University,
 National Indian Council on Aging, Indian
 Health Service, Sisters of Charity Health
 Care System..................................
    University of Pennsylvania, Geisinger           235,490      321,191
     Medical Center, Lehigh Valley Hospital,
     Philadelphia College of Pharmacy.........
    University of Rhode Island, Rhode Island        161,997      269,989
     College, Brown University, Rhode Island
    Meharry Medical College, Alabama A&M;            269,971      313,616
     University, Tennessee State University...
    University of North Carolina-Chapel Hill,       161,821      204,516
     Program on Aging, Rural Health Group,
     Inc, Area L Area Health Education Center.
    Stanford University, San Jose State             266,219      319,707
     University, On Lok, Senior Health
    University of Oklahoma....................      211,809      319,887
    University of Texas San Antonio HSC,            162,000      270,000
     University of Texas at El Paso...........
    University of Rochester, Ithaca College,        279,070      149,974
     Cornell University, Nazareth College.....
    University of West Virginia, Rural Health       194,043      161,454
     Education Partnership, West Virginia
     State Community and Technical College,
     West Virginia School of Osteopathic
    University of Minnesota, Arrowhead              324,000      162,000
     Regional Development Commission, Central
     Minnesota Council on Aging, Rochester
     Community and Technical College, Mankato
     State University.........................
    Harvard Medical School, Maine Geriatric/        310,220      160,495
     Gerontology Education....................
Single Institution:
    University of Hawaii......................      215,760      107,934
    University of Puerto Rico.................            0      108,000
    University of Washington..................      161,206      215,997
    University of South Florida...............      216,000      108,000
    University of Nevada......................      158,809      214,013
    University of Arkansas....................      106,258      157,063
    University of Virginia Commonwealth.......      215,040      107,785
    University of Florida.....................       40,711       99,373
    Total GEC Funding.........................   $7,972,980  $7, 485,435

Faculty Training in Geriatrics for Physicians, Dentists, and Behavioral 
                      Mental Health Professionals

    Faculty Training Projects in Geriatric medicine, dentistry 
and behavioral/mental health grants are awarded to public and 
private nonprofit schools of allopathic or osteopathic 
medicine, teaching hospitals, and graduate medical education 
programs. The grants support fellowships and other training 
efforts that assist health professionals who plan to teach 
geriatrics. Funded projects support two-year fellowships and 
one-year retraining programs.
    Projects emphasize primary care and enable health 
professionals who plan to teach geriatrics to care for elderly 
people at different levels of wellness and functioning and from 
a range of socioeconomic and racial and ethnic backgrounds. 
They offer service rotations such as geriatric consultation, 
acute care, dental care, psychiatry, day and home care, 
rehabilitation, extended care, ambulatory care as well as 
community care for older people with mental retardation. No 
programs were funded in FY1999. In FY2000, a total of $1.6 
million was awarded to five newprograms.

     Faculty Training in Geriatrics for Physicians, Dentists, and 
                 Behavioral/mental Health Professionals

University of California Los Angeles.......................     $336,040
Boston University/Boston Medical Center....................      430,010
New Jersey University of Medicine and Dentistry............      261,052
University of North Texas Health Science Center............      251,892
University of Texas Health Sciences Center at San Antonio..      371,006
    Total..................................................  $1, 650,000

                Geriatric Academic Career Awards (gacas)

    The Bureau of Health Professions made awards for the first 
time under the newly established Geriatric Academic Career 
Award (GACA) Program in September 1999. Intended to support the 
development of newly trained geriatric physicians into first 
rate teachers of geriatrics, GACAs provide five years of 
support for academic career development. The awards require and 
allow the recipients to devote the bulk of their academic 
careers to teaching geriatrics to a wide range of health care 
professionals. The career development plans of the first cohort 
of awardees show a strong commitment to the development of best 
practices in the care of older patients. They have chosen a 
wide range of topics to devote their time to developing, 
including direct service projects such as mobile geriatric 
assessment clinics for older people living in rural areas, 
home-based geriatric assessment, and geriatric rehabilitation, 
all aimed at restructuring and facilitating delivery of care to 
the elderly; interdisciplinary care for the chronically ill and 
the development of chronic disease state ``glide paths;'' 
effective clinical teaching of palliative care for the elderly; 
geropharmacy and nutrition; acute care of the elderly; 
culturally competent care of the elderly; infection control 
interventions in long-term care; development of resource 
materials on organ system normative aging; hospice care; 
special issues in the delivery of rural health care by family 
practitioners; and the design and implementation of community-
based programs which allow the frail elderly remain in their 
homes. The program contributes not only to the training of 
physicians but to many other health professionals who have 
responsibility for the care of the elderly. As specified in the 
statutory language, awards were made directly to individuals 
who were required to obtain the commitment of their employing 
institution for a period of five years.

                    Geriatric Academic Career Awards

                                                   FY1999       FY2000
Total Awarded.................................     $818,400     $795,645

                    Rural Interdisciplinary Training

    The Quentin R. Burdick Rural Health Interdisciplinary 
Program promotes rural health care practice by providing 
support for the interdisciplinary training of health 
professions students. The program requires two or more 
applicant organizations to apply together in order to foster 
collaborative efforts to promote and retain health 
professionals in rural areas. Specific programs demonstrate 
innovation in interdisciplinary training and curriculum 
development, and forge linkages among academic health training 
institutions and rural health care agencies and practice 
facilities, State health departments, and health professionals 
who practice in rural areas. Though not limited to training in 
geriatrics, some projects focus prominently on geriatric care. 
In FY1999, one project focused primarily on geriatric care, and 
in FY2000, two projects focused on geriatrics.

                                         FY 1999            FY 2000
Total.............................           $147,165           $373,377

     Area Health Education Centers (ahec) ce Programs in Geriatrics

    The Area Health Education Centers (AHEC) is an active 
provider of continuing education (CE) for primary health care 
providers with nearly every Federally funded AHEC program 
within 40 States providing a wide array of topics. CE Programs 
in Geriatrics is one of the most frequently requested and 
offered topics. During FY99, a summary of the AHEC CE offerings 
in geriatrics were as follows: a total of 478 programs was 
offered, 118 were offered via distance education methodologies, 
12,445 CE participants attended these geriatric programs, and 
1157 were distance participants in the CE programs.

                  Geriatric Education Futures Project

    In 1994-1995, the Bureau of Health Professions sponsored a 
major assessment of the state of workforce development in 
geriatrics. The effort resulted in the production of A National 
Agenda for Geriatric Education with specific recommendations 
for action in eleven broad areas. In Fiscal Year 2000, the 
Bureau is beginning a follow-up to the National Agenda. Through 
various efforts, the Bureau will track where health professions 
training is in relation to the earlier recommendations and 
where workforce development activities need to go in light of 
progress-to-date and recent changes in health care delivery 


    A National Agenda for Geriatric Education: Forum Report, 
Volume 2. Rockville, MD: Interdisciplinary, Geriatrics and 
Allied Health Branch, Division of Associated, Dental and Public 
Health Professions, Bureau of Health Professions, Health 
Resources and Services Administration, Public Health Service, 
U.S. Department of Health & Human Services. 1996
    A National Agenda for Geriatric Education: White Papers, 
Volume 1. Rockville, MD: Interdisciplinary, Geriatrics and 
Allied Health Branch, Division of Associated, Dental and Public 
Health Professions, Bureau of Health Professions, Health 
Resources and Services Administration, Public Health Service, 
U.S. Department of Health & Human Services. 1995
    Geriatric Education Centers: A Resource Directory, 
Rockville, MD: Interdisciplinary, Geriatrics and Allied Health 
Branch, Division of Associated, Dental and Public Health 
Professions, Bureau of Health Professions, Health Resources and 
Services Administration, Public Health Service, U.S. Department 
of Health & Human Services. 1998

                     Office of Rural Health Policy

    The Office of Rural Health Policy (ORHP) was established in 
1987 at the urging of the Senate Special Committee on Aging in 
order to address severe shortages of health services in rural 
areas, where one quarter of the Nation's elderly live. Aging-
related issues are of particular importance to the Office, 
since rural counties have, on average, a higher percentage of 
individuals over 65 years of age than urban counties; and these 
residents are often poorer, sicker, and more isolated than 
their urban counterparts.
    To strengthen support for health services in rural areas, 
the office plays a collaborative role throughout the Department 
and with the States and the private sector. For example, it 
informs interest groups, such as the National Council on Aging 
and the American Association of Retired Persons about its 
activities and about the needs of the rural elderly. Within the 
Department, the Office advises the Secretary and the Assistant 
Secretary on Aging on the affects that Medicare and Medicaid 
programs have on rural health care, on the shortage of health 
care providers, the viability of rural hospitals, and the 
availability of primary care and also emergency medical 
services to elderly and other rural residents.
    The Office supports local and States initiatives to build 
rural health care services through almost $39 million in grants 
to rural communities, themselves, and a $3 million program of 
matching grants to the States to support States offices of 
rural health, which can recruit rural providers and assist 
their rural communities in developing more local health 
    The ORHP also promotes informed policy making by 
administering a $3.0 million program of grants for policy-
relevant studies at established rural research centers 
throughout the country. These centers provide data capability 
on a wide range of rural health concerns, including areas 
relevant to the elderly. For example, one study currently 
underway looks at quality differences between rural and urban 
nursing homes to examine the consequences of a lower skill-mix 
of staff in rural areas. Another is estimating the 
Medicare+Choice threshold payment rate which will attract and 
retain Medicare managed care plans in rural areas. Also under 
study is an examination of the impact on rural elderly of 
different approaches for restructuring Medicare.
    The Office also administers a $25 million grant program to 
States to help them implement the Medicare Rural Hospital 
Flexibility Program. Under this program, rural hospitals that 
convert to a smaller Rural Critical Access Hospital can receive 
cost-based payments from the Medicare. The grants help States 
and rural communities plan and implement the conversion of 
rural hospitals and promote the development of new local 
networks of care.
    In collaboration with other Federal agencies such as the 
Health Care Financing Administration, the Department of 
Agriculture, the Department of Transportation, and the National 
Institute on Aging, ORHP sponsors workshops and seeks public 
advice on a range of rural health needs. These issues may 
included such issues as emergency medical services, managed 
care options for Medicaid and Medicare clients, physician 
recruitment, and rural economic development.
    To provide health care professionals, researchers, 
community officials, and the public with an efficient source of 
information and referral, the office sponsors the Rural 
Information Center Health Service, or RICHS. This service is 
operated in cooperation with the USDA and its National 
Agricultural Library. It is available toll-free at 1-800-633-
7701. Internet information is available at: http://
    The Office also channels public advice on rural issues to 
the Department by staffing the Secretary's National Advisory 
Committee on Rural Health, a citizen's advisory panel chartered 
in 1987 to address health care crises in rural America.



    The Office of Inspector General (OIG) was established by 
the Inspector General Act of 1978. The OIG's mission is to 
identify ways to improve effectiveness and promote economy and 
efficiency in HHS programs and operations, and protect them 
against fraud, waste, and abuse. This is accomplished by 
conducting independent and objective audits, evaluations, and 
investigations which provide timely, useful, and reliable 
information and advice to Department officials, the 
Administration, the Congress, and the public. In carrying out 
its mission, the OIG partners with the Department and its 
operating divisions, the Department of Justice (DOJ), other 
Federal and State agencies, and the Congress to bring about 
systemic improvements in HHS programs and operations, and 
successful prosecutions and recovery of funds from those who 
defraud the Government. The OIG is comprised of the following 
    The Office of Audit Services (OAS) conducts and oversees 
audits of HHS programs, operations, grantees, and contractors; 
identifies systemic weaknesses that give rise to opportunities 
for fraud, and abuse; and makes recommendations to prevent 
their recurrence. The OAS also provides overall leadership and 
direction in carrying out the responsibilities mandated under 
the Chief Financial Officers Act of 1990 and the Government 
Management Reform Act of 1994 relating to financial statement 
    The Office of Evaluation and Inspections (OEI) seeks to 
improve the effectiveness and efficiency of departmental 
programs by conducting program inspections that provide timely, 
useful, and reliable information and advice to decision makers. 
These inspections are program and management evaluations that 
focus on specific issues of concern to theDepartment, the 
Congress, and the public. The results of these inspections 
generate accurate and up-to-date information on how well HHS 
programs are operating and offer specific recommendations to 
improve their overall efficiency and effectiveness.
    The OIG's Office of Investigations (OI) conducts 
investigations of fraud and misconduct to safeguard the 
Department's programs and protect the beneficiaries of those 
programs from individuals and activities that would deprive 
them of rights and benefits. Working with Federal and State law 
enforcement agencies, OIG investigators seek criminal, civil, 
and exclusion actions against those who commit fraud or who 
thwart the effective administration of HHS programs.
    The Office of Counsel to the Inspector General (OCIG) 
coordinates the OIG's role in the resolution of health care 
fraud and abuse cases, including the litigation and imposition 
of administrative sanctions, such as program exclusions, civil 
monetary penalties, and assessments; the global settlement of 
cases arising under the Civil False Claims Act; and the 
development of corporate agreements for providers that have 
settled their False Claims Act liability with the Federal 
Government. It also develops and promotes industry awareness of 
models for corporate integrity and compliance programs and 
monitors ongoing integrity agreements. The OCIG also provides 
all administrative litigation services required by OIG, such as 
patient dumping cases and all administrative exclusion cases. 
In addition, OCIG issues special fraud alerts and advisory 
opinions regarding the application of OIG's sanction statutes 
and is responsible for developing new, and modifying existing, 
safe harbor regulations under the anti-kickback statute. 
Finally, OCIG counsels OIG components on personnel and 
operations issues, subpoenas, audit and investigative issues, 
and other legal authorities.
    The Office of Management and Policy (OMP) provides support 
services to the OIG, including congressional relations; public 
affairs; strategic planning and budgeting; financial and 
information resources management; and preparation of the OIG's 
semiannual and other reports.


    During Fiscal Years 1999 and 2000, the OIG reported more 
than $890 million in fines and restitutions deposited into the 
Medicare Trust Fund. More than 6,320 individuals and entities 
were excluded from doing business with Medicare, Medicaid, and 
other Federal and State health care programs. The OIG's 1999 
and 2000 accomplishments included 815 convictions of 
individuals or entities that engaged in crimes against 
departmental programs.
    The OIG reported savings of $28.2 billion for Fiscal Years 
1999 and 2000. This is comprised of $26.1 billion in 
implemented legislative or regulatory recommendations and 
actions to put funds to better use; $393 million in audit 
disallowances, and $1.6 billion in investigative receivables. 
The savings that result from OIG recommendations that are 
implemented into law or regulation represent the dollars that 
will not be spent.

                              Health Care

    In recent years, Medicare has been a major focus of OIG 
work. Approximately 75 percent of OIG resources in the past two 
years were dedicated to Medicare audits, evaluations, and 
enforcement activities. OIG work continues to show that 
Medicare is not always a prudent purchaser of health care goods 
and services and is inherently vulnerable to making improper 
payments. In discharging its responsibilities, the OIG responds 
both reactively and proactively to counteract these problems 
and is pleased to report that measurable progress is being 
made. For example, through a statistically valid sample of 
FY1999 Medicare fee-for-service payments, OIG estimated that 
the overall dollar value of claims paid in error had decreased 
42 percent since FY1996.
    A key element of HHS/OIG's prevention efforts has been the 
development of compliance program guidance to encourage and 
assist the private health care industry to fight fraud and 
abuse. The guidance, developed in conjunction with the provider 
community, identifies steps that health providers may 
voluntarily take to improve adherence to Medicare and Medicaid 
rules. In 1999 and 2000, the OIG developed and released final 
compliance program guidance for third party medical billing 
companies, hospices, durable medical equipment (including 
prosthetics and orthotics, and suppliers), Medicare+Choice 
organizations offering coordinated care plans, nursing 
facilities, and individual and small group physician practices.
    Some of the significant OIG work involving the elderly, 
during this reporting period, includes the following:
    Quality of Care in Nursing Homes.--The OIG has focused on 
the quality of care in nursing homes in a number of inspection 
reports. Topics include: deficiency trends, survey and 
certification system capacity, public access to deficiency 
information, ombudsman program complaints and overall capacity, 
medical necessity and quality of care of physical and 
occupational therapy in nursing homes, nursing home 
vaccination, effect of the prospective payment system on access 
to skilled nursing facilities, and the effect of financial 
screening and distinct part rules on access to nursing 
    Home Health Care.--Under the interim payment system, in 
effect prior to the start of the prospective payment system on 
October 1, 2000, home health agencies had an incentive to stay 
below the new payment limits by reducing the number of visits 
per patient and limiting the number of potentially high-cost 
patients. Because of this, concerns were raised as to whether 
this system so adversely affected home health agencies that 
they were unable to care for all Medicare patients needing home 
health services. In a number of studies, we found that these 
concerns are not well supported. Hospital discharge planners 
reported that almost all Medicare beneficiaries can be placed 
into home health care. In addition, an OIG follow-up to an 
earlier review revealed that improper Medicare payments for 
home health services had been significantly reduced, down from 
40 to 19 percent.
    Withdrawal of Managed Care Organizations From Medicare.--In 
the last several years, a number of managed care organizations 
(MCO) left the Medicare program or reduced their service areas. 
We recently examined the impact of these withdrawals on 
beneficiaries, including the adequacy of notification, the 
availability of other health care options, and the extent of 
costs to beneficiaries associated with these changes. We found 
that the 1999 MCO withdrawals affected fewer beneficiaries than 
did the 1998 withdrawals (about 300,000 in 1999 versus about 
400,000 in 1998); however, a greater percentage of 
beneficiaries were left without an MCO option in 1999. As a 
related issue, OIG's body of work during this period finds that 
MCOs receive more than an adequate amount of funds to deliver 
the Medicare package of covered services, i.e., those services 
received by 85 percent of Medicare beneficiaries (those in the 
Medicare fee-for-service program).
    Managed Care Marketing Materials.--We examined how well 
informed Medicare beneficiaries were of the choices available 
to them under the managed care option. In one study we found 
that the Health Care Financing Administration (HCFA) did not 
completely meet its goals to expedite the marketing material 
review process; reduce resubmissions of material; ensure 
uniform review across the Nation; and, most importantly, 
provide beneficiaries with accurate and consumer-friendly 
marketing materials to help them make informed health care 
choices. Some of the marketing materials that we examined were 
difficult to understand. We also looked at the influence of 
``extra'' benefits offered by managed care plans on 
beneficiaries' decisions to join Medicare+Choice MCOs.
    Medicare Payments for Mental Health Services.--We examined 
Medicare payments for mental health services across a variety 
of settings. One such setting is community mental health 
centers, where payments for partial hospitalization services 
increased almost five-fold between 1993 and 1997. Although 
partial hospitalization consists of an intensive program of 
outpatient services for acutely ill beneficiaries in order to 
prevent inpatient hospitalization, both OIG and HCFA reviews 
found that Medicare was paying for services to beneficiaries 
with no history of mental illness and for beneficiaries who 
suffered from conditions that would preclude their benefitting 
from the program. Our five-State review found that over 90 
percent ($229 million of $252 million) of such payments in this 
setting were unallowable or highly questionable. In a similar 
review, we examined Medicare charges in 10 States for 
outpatient psychiatric services provided at acute care 
hospitals. Here our statistical sample estimated that 58 
percent ($224 million of $382 million) of such services in 
these States were unallowable or unsupported.




    The Department of Housing and Urban Development is 
committed to providing America's elderly with decent affordable 
housing appropriate to their needs. The Department's goal is to 
provide a variety of approaches so that older Americans may be 
able to afford their housing costs, maintain their 
independence, remain as part of the community, and live their 
lives with dignity and grace.
    The Department is committee to meeting the needs of our 
elderly citizens. This report provides a brief overview of the 
programs and activities undertaken by the Department to assist 
the elderly with their housing needs during FY1999 and 2000.

                          I. Office of Housing

a. section 202--capital advances for supportive housing for the elderly 
    and section 811 supportive housing for persons with disabilities

    The National Affordable Housing Act of 1990 authorized a 
restructured Section 202 program while separating out and 
creating the new Section 811 program for Housing for Persons 
with Disabilities. Funding for both programs is provided by a 
combination of interest-free capital advances and project 
rental assistance. Project rental assistance replaces Section 8 
rent subsidies. The annual project rental assistance contract 
amount is based on the cost of operating the project. The 30 
percent maximum tenant contribution remains unchanged.
    Since the passage of the National Affordable Housing Act of 
1990, there have been 63,023 units approved under the Section 
202 program and 17,494 units approved under the Section 811 
program. Of those amounts 7,142 Section 202 units and 1,801 
Section 811 were approved in Fiscal Year 1999. In FY2000, there 
were 6,518 additional units approved under Section 202 for 
$493,274,200 and 1,483 more units approved under Section 811 
for $109,588,400.

     b. section 221(d)(3) and (4)--mortgage insurance program for 
                          multifamily housing

    Sections 221(d)(3) and (4) authorized the Department to 
provide insurance to finance the construction or substantial 
rehabilitation of market rate rental or cooperative projects. 
The programs are available to non-profit and profit-motivated 
mortgagors as alternatives to the Section 231 program. While 
most projects under the programs have been developed for 
families with children, projects insured under Section 221 may 
be designed for occupancy wholly or partially for the elderly, 
and the mobility impaired of any age. In FY1999, a total of 
31,880 additional units in 198 projects were approved under 
Section 221(d)(3) and (4) for $2.1 billion. In FY2000, 28,707 
units in 155 projects were approved for $1.7 billion.

c. section 232--mortgage insurance for nursing homes, intermediate care 
    facilities, board and care homes, and assisted living facilities

    The Section 232 program authorized the Department to offer 
financing for the construction and rehabilitation (or purchase 
or refinance of existing projects) of nursing homes, 
intermediate care facilities, board and care homes, and 
assisted living facilities by providing mortgage insurance to 
finance these facilities. The vast majority of the residents of 
such facilities are the frail elderly. In FY1999, HUD insured 
155 projects worth $896 million consisting of 76 nursing homes, 
53 assisted living facilities, and 26 board and care homes. In 
FY2000, HUD insured 159 projects at $979 million (100 nursing 
homes, 49 assisted living facilities, and 10 board and care 

                     d. section 8--new construction

    The Section 8 program sponsored the new construction of 
housing for families and for the elderly by attaching subsidies 
to the units being developed. That way the landlord would 
guarantee the ability to make payments and operate the 
developments. The new construction program was active from 1974 
until it was repealed by Congress in 1983. No new units have 
been approved since 1983 but units approved prior to that may 
still receive a subsidy. The maximum term of the housing 
assistance payments vary from 20 to 40 years, depending on how 
the project was financed. There are 1.4 million private, 
project-based Section 8 units, about 50 percent of which serve 
elderly households. About 193,000 of these 658,000 units were 
built under the Section 202 program before the restructuring of 
that program in 1990. That means that about 465,000 units 
developed with Section 8 project-based assistance serve elderly 
households. The Section 8 new construction program is no longer 
used to subsidize new development.

              e. service coordinators in assisted housing

    The National Affordable Housing Act authorized funding for 
service coordinators under the Section 202 program in 1990. 
Eligibility was expanded to cover Sections 8, 221(d)(3), and 
236 projects in 1992. A service coordinator is a social service 
staff person who is part of the project's management team. The 
service coordinator is responsible for ensuring that the 
elderly individuals and persons with disabilities living in the 
project are linked with the supportive services they need from 
agencies in the community to assure that they can remain 
independently in their homes as long as possible and avoid 
premature and unnecessary institutionalization.
    In FY1999, HUD awarded $5,000,000 in service coordinator 
grants to 51 projects, 33 of which were Section 202 projects; 
the remainder were Section 8, 221(d)(3) or 236.
    In FY2000, HUD funded 259 projects for $28,579,665 in new 
grants, 170 of which were 202s, 42 were Section 8, and 47 were 
Section 221(d)(3) or Section 236.
    In FY1999 and 2000, HUD also provided one-year extension 
funds to expiring Service Coordinator contracts. These 
extensions enable the Service Coordinator programs to continue 
operating without breaks. In FY1999, HUD made extensions to 150 
contracts at a cost of $4,069,376. In FY2000, the Department 
extended 329 contracts with $9,168,441 in funding.
    Funding for service coordinators in public housing is 
discussed below.

               f. the congregate housing services program

    The Congregate Housing Services Program (CHSP), initially 
authorized in 1978 and revised in 1990, provides direct grants 
to States, Indian tribes, units of general local government and 
local non-profit housing sponsors to provide case management, 
meals, personal assistance, housekeeping, and other appropriate 
supportive services to frail elderly and non-elderly disabled 
residents of HUD public and assisted housing, and for the 
residents of Section 515/8 projects under the Department of 
Agriculture's Rural Housing and Community Development Service.
    In FY1999, HUD extended 80 existing grantees for an 
additional year at a cost of $9,774,859. In FY2000, HUD 
extended 63 existing grantees for an additional year at a cost 
of $6,156,306. There were no funds appropriated for new grants 
in FY1999 or FY2000.

    g. flexible subsidy and loan management set aside (lmsa) funding

    The Flexible Subsidy Program (FLEX) is comprised of two 
components: (1) the Operating Assistance Program (OAP), which 
is designed to provide temporary funding to replenish project 
reserves, cover operating costs, and pay for limited physical 
improvements. The Operating Assistance (OA) is provided in the 
form of a non-amortizing ``contingent'' loan; of major capital 
improvements when funding such improvements cannot be done with 
project reserves. CILP assistance is provided in the form of an 
amortizing loan. Both programs are designed to restore or 
maintain the physical and financial soundness of eligible 
projects at the lowest possible cost to the Federal government. 
Because of the limited funding, however, Flexible Subsidy funds 
are strictly reserved for the emergency needs of 202 projects. 
Such projects must have been in occupancy for at least 15 years 
and have emergency health and safety needs. In FY1999, 
$13,716,999 was disbursed to over 20 projects. In FY2000, 
Flexible Subsidy funding was awarded to 30 projects, totaling 
    The Loan Management Set Aside (LMSA) Program provides 
Project-based Section 8 funding to HUD-insured and HUD-held 
projects and projects funded under the 202 program which need 
additional financial assistance to preserve the long term 
fiscal health of the project. Funding has not been available 
for this program for several years.

                       h. manufactured home parks

    The Housing and Urban-Rural Recovery Act (HURRA) of 1983 
amended Section 207 of the National Housing Act to permit 
mortgage insurance for manufactured home parks exclusively for 
the elderly. The program has been operational since the March 
1984 publication of a final rule implementing the legislation, 
although HUD insures very few manufactured home parks.

             i. title i property improvement loan insurance

    Title I of the National Housing Act authorizes HUD to 
insure lenders against loss on property improvement loans made 
from their own funds to creditworthy borrowers. The loan 
proceeds are to be used to make alterations and repairs that 
substantially protect or improve the basic livability or 
utility of the property. There are no age or income 
requirements to qualify for a Title I loan. HUD funded 30,689 
loans in FY1999 and 18,387 loans in FY2000.

              j. title i manufactured home loan insurance

    Title I of the National Housing Act authorizes HUD to 
insure lenders against loss on manufactured home loans made 
from their own funds to creditworthy borrowers. The loan 
proceeds may be used to purchase or refinance a manufactured 
home, a developed lot on which to place a manufactured home, or 
a manufactured home and lot in combination. The home must be 
used as the principal residence of the borrower. There are no 
age or income requirements to qualify for a Title I loan. HUD 
funded 350 loans in FY1999 and 313 in FY2000.

          k. home equity conversion mortgage insurance program

    The Department has implemented a program to insure Home 
Equity Conversion Mortgages (HECM), commonly known as ``reverse 
mortgages.'' The program is designed to enable persons aged 62 
years or older to convert the equity in their homes to monthly 
streams of income and/or lines of credit. HUD funded 7,921 
loans in FY1999 and 6,641 loans in FY2000.

     l. section 231--mortgage insurance for housing for the elderly

    Section 231 of the National Housing Act authorized HUD to 
insure lenders against losses on mortgages used for 
construction or rehabilitation of market rate rental 
accommodations for persons aged 62 years or older, married or 
single. Nonprofit as well as profit-motivated sponsors are 
eligible under this program. The program is largely inactive 
and produced no units in FY1999 or FY2000.

                II. Office of Public and Indian Housing

          a. section 8 rental certificates and rental vouchers

    Section 8 of the U.S. Housing Act of 1937 authorizes 
housing assistance payments to aid low-income families in 
renting decent, safe, and sanitary housing that is available in 
the existing housing market.
    About 15 percent of Section 8 certificate and voucher 
recipients are being used by the elderly. As of January 2001, 
this represented 213,000 occupied units.

                b. elderly/disabled service coordinators

    Section 673 of the Housing and Community Development Act of 
1992 authorized the Department to fund service coordinators in 
public housing developments to ensure that the elderly and non-
elderly disabled residents have access to the services they 
need to live independently. From FY 1994 to 1998, the 
Department awarded 227 grants totaling approximately $62.8 
million for public housing authorities to hire service 
coordinators for their elderly and non-elderly disabled 
residents to provide general case management and referral 
services, connect residents with the appropriate services 
providers, and educate residents on service availability. 
Service coordinator grants that were previously awarded are 
being renewed annually to maintain the level of services for 
elderly residents and residents with disabilities. In FY1999 
approximately $13 million in renewal grants were awarded. 
Because funds are still available from FY1999, service 
providers who had not applied for funds were asked to submit 
applications. HUD staff are currently reviewing these 
applications and may award additional funds. In FY2000 
approximately $12 million in grants were awarded.

                     c. tenant opportunity program

    Section 20 of the U.S. Housing Act of 1937, as amended, 
authorized the Tenant Opportunities Program (TOP). The program 
enables resident entities to establish priorities and training 
programs for their specific public housing communities that are 
designed to encourage economic development, stability, and 
independence. The program began in 1988 and to date has awarded 
about 986 grants totaling approximately $80 million. Public 
housing developments with elderly residents are eligible to 
participate and perhaps 7 percent are primarily elderly 
    As part of the implementation of Section 538 of the Public 
Housing Reform Act, the TOP program was consolidated into the 
Resident Opportunities and Self Sufficiency (ROSS) program. 
Section 538 authorizes a program to link services for public 
housing residents to promote self sufficiency and economic 
empowerment. Many of the activities previously eligible under 
TOP are eligible under ROSS.

                 d. public housing development program

    The Public Housing Development Program was authorized by 
Sections 5 and 23 of the U.S. Housing Act of 1937 to provide 
adequate shelter in a decent environment for families that 
cannot afford such housing in the private market.
    In 1999, 4 additional units of public housing for the 
elderly were reserved, 25 started construction, and 261 became 
available for occupancy. In 2000, 36 units were reserved, 36 
started construction, and 775 because available for occupancy. 
As of February 2001, there were approximately 404,860 elderly 
low income persons residing in public housing:

             III. Office Community Planning and Development


    The CDBG Entitlement Communities program is HUD's major 
source of funding to large cities and urban counties for a wide 
range of community development activities. These activities 
primarily help low- and moderate-income persons and households, 
however, they can also be used to help eliminate slums and 
blight or meet other urgent community development needs.
    The Department normally does not ask grantees to report 
CDBG program beneficiaries by age. The Department estimates, 
that grantees spent about 1 percent of their CDBG program funds 
(about $35 million in 1999 and $34 million in 2000) for public 
services that were specifically targeted to senior citizens. In 
addition, HUD staff are aware that senior citizens frequently 
benefit from local housing rehabilitation programs that are 
funded by CDBG. What is not known is how many of those 
benefiting from rehabilitation projects are elderly.


    The CDBG State-administered program (and its predecessor, 
the HUD-administered Small Cities program, which still operates 
in Hawaii) is HUD's principal vehicle for assisting communities 
with populations under 50,000 that are not central cities of 
metropolitan areas. States provide grants to small cities, 
counties and other units of local government, which use the 
CDBG funds to undertake a broad range of activities. (HUD makes 
grants directly to counties in Hawaii.) As is also true with 
the Entitlement Communities program, these activities must 
primarily help low- and moderate income persons and households; 
however, they can also be used to help eliminate slums and 
blight or meet other urgent community development needs.
    The Department has no specific information on the extent of 
benefit from these programs for the elderly, however HUD staff 
are aware that elderly persons and households who live in these 
small cities and counties are benefiting from CDBG-funded 
activities. The extent of benefit to the elderly in the State 
CDBG program may be similar to that in the Entitlement CDBG 
program, since many small communities and rural areas have high 
concentrations of elderly persons.


    The HOME Program continues to serve as a major resource for 
elderly housing assistance, particularly for the rehabilitation 
of deteriorating properties of low-income elderly homeowners, 
allowing them to remain in their own homes and keep those homes 
in standard condition. The figures below represent the number 
of HOME-assisted units that participating jurisdictions 
reported were completed and occupied by elderly residents 
during calendar years 1999 and 2000 and the percentage of units 
in that category that this figure represents.

                                                                              Total Units
          Tenure type             Calendar 1999-2999  Elderly Cumulative       Completed      Percentage Elderly
Homeowner Rehabilitation.......  10,391.............  36,054............  86,974............  42.9%
Rental Units...................  11,589.............  20,193............  125,173...........  16%
New Homebuyers.................  1,624..............  3,911.............  145,234...........  3%
      Total elderly units......  23,604.............  60,158............  357,381...........  17%

    To date, HOME has assisted 60,158 low-income elderly 
households. This constitutes an investment of over 
$1,027,000,000 in HOME funds, which have leveraged another 
$1,406,000,000 in private investment and other non-HOME funds 
(which includes Federal, State and local funds) to provide 
housing for the elderly (estimates based on a weighted average 
of $17,072/per unit HOME subsidy for production, and 
conservative estimate of $1.37 per $1.00 of HOME as leverage).
    For data collection purposes, the HOME Program defines 
elderly as 62 or older. Therefore the above numbers do not 
reflect projects which are designed for seniors between 55 and 


    The Emergency Shelter Grants (ESG) Program provides funds 
to States, metropolitan cities, urban counties, Indian tribes, 
and territories to improve the quality of emergency shelters, 
make available additional shelters, meet the cost of operating 
shelters, provide essential social services to homeless 
individuals, and help prevent homelessness.
    According to a recent Federal study entitled HOMELESSNESS: 
Programs and the People They Serve, about 2 percent of homeless 
persons are 65 years or older. While about 1 percent of the ESG 
funds go to seniors-only facilities for the homeless, this 
population often receives emergency housing and services at 
other shelter facilities that are not reported in the ESG 
program. Shelters normally serve all homeless adults of any 
age, unless they have a particular family or single person 

                     E. SUPPORTIVE HOUSING PROGRAM

    The Supportive Housing Program (SHP) funds may be used to 
provide: (1) transitional housing designed to enable homeless 
persons and families to move to permanent housing within a 24 
month period, which may include up to 6 months of follow-up 
services after residents move to permanent housing; (2) 
permanent housing provided in conjunction with appropriate 
supportive services designed to maximize the ability of persons 
with disabilities to live as independently as possible within 
permanent housing; (3) innovative supportive housing; or (4) 
supportive services for homeless persons not provided in 
conjunction with supportive housing.

            IV. Office of Fair Housing and Equal Opportunity

                        A. THE FAIR HOUSING ACT

    The Fair Housing Act prohibits discrimination in housing 
based on race, color, religion, sex, national origin, handicap, 
or familial status. The Act exempts from its provisions against 
discrimination based on familial status ``housing for older 
persons.'' The statutory exemption of ``housing for older 
persons'' comprises three categories of housing: (1) housing 
provided under any State or Federal program that the Secretary 
of HUD determines is specifically designated and operated to 
assist elderly persons; (2) housing intended for and solely 
occupied by residents 62 years of age and older; and (3) 
housing intended and operated for occupancy by at least one 
person 55 years of age or older per unit, provided various 
other criteria are met.


    The Housing for Older Persons Act (HOPA) of 1995 amends the 
``55 and older'' housing exemption to the Fair Housing Act's 
prohibition against discrimination based on familial status. 
HOPA eliminates the requirement that housing ``55 and older'' 
have significant facilities and services and establishes a good 
faith reliance defense from monetary damages for individual 
real estate professionals on a legitimate belief that the 
housing was entitled to an exemption. In order to qualify for 
the ``55 and older housing'' exemption a housing community or 
facility must: (1) have at least 80 percent of its occupied 
units occupied by at least one person 55 years of age or older; 
(2) publish and adhere to policies and procedures which 
demonstrate an intent by the owner or manager to provide 
housing for persons 55 and older; and (3) comply with the rules 
issued by the Secretary for verification of occupancy through 
reliable surveys and affidavits.
    The Department published the HOPA final rule on April 2, 
1999 with an effective date of May 3, 1999.

                       C. AGE DISCRIMINATION ACT

    The Age of Discrimination Act of 1975 prohibits programs or 
activities receiving Federal financial assistance from directly 
or through contractual, licensing, or other arrangements, using 
age distinctions or taking any other actions which have the 
effect, on the basis of age, of: excluding individuals from, 
denying them the benefits of, or subjecting them to 
discrimination under a program or activity receiving Federal 
financial assistance; or denying or limiting individuals their 
opportunity to participate in any program or activity receiving 
Federal financial assistance. The Department's regulations 
implementing the Age Discrimination Act became effective on 
April 10, 1987, and are codified at 24 CFR Part 146.
    During FY1999, the Department received 16 complaints 
alleging age discrimination, all of which were referred to the 
Federal Mediation and Conciliation Services (FMCS). One of 
these complaints were successfully mediated and agreements was 
reached. Of the remaining cases, 3 were unsuccessfully 
mediated, 1 is pending mediation, and in 11 cases mediation was 
canceled due to the failure to attend the mediation meeting. 
These 15 cases may be administratively closed out at a later 

                         D. DESIGNATED HOUSING

    The 1992 Housing and Community Development Act authorized 
HUD to approve Public Housing Authority plans to designate 
mixed population housing units (serving elderly and persons 
with disabilities) for elderly families only, disabled families 
only, or elderly and disabled families, if the plans met 
certain statutory requirements outlined in Section 7 of the 
United States Housing Act. The Housing Opportunities Program 
Extension Act of 1996 simplified and streamlined those 
requirements, but continued to require HUD to review and 
approve or disapprove designated housing plans.
    For FY2000, 26 housing authorities received approval to 
designate 4,450 units for elderly families.

              V. Office of Policy Development and Research

                       A. AMERICAN HOUSING SURVEY

    The American Housing Survey for the United States, Current 
Housing Report Series Number H150 for the year 1999 contains 
special tabulations on the housing situations of elderly 
households in the United States. Chapter 7 of the regular 
report provides detailed demographic and economic 
characteristics of elderly households, detailed physical and 
quality characteristics of their housing units and 
neighborhoods and the previous housing of recent movers, and 
their opinions about their house and neighborhood. The data are 
displayed for the four census regions, and for central cities, 
suburbs, and non-metropolitan areas, and by urban and rural 
classification. The non-elderly chapters (total occupied, 
owner, renter, Black, Hispanic, central cities, suburbs, and 
outside MSAs) also contain data on the elderly. In addition, 
Current Housing Report Series Number H170 contains data on the 
elderly for the 47 largest metropolitan areas that are 
individually surveyed over four-to six-year cycles.
    An elderly household is defined as one where the 
householder, who may live alone or head a larger household, is 
aged 65 years or more. Special information in these 
publications is provided on households in physically inadequate 
housing or with excessive cost burden, and on households in 


    The New Congregate Housing Services program was authorized 
under the National Affordable Housing Act of 1990 and amended 
by the Housing and Community Development Act of 1992.
    The Congregate Housing Services Program (CHSP) provides a 
combination of housing and support services to frail elderly 
and non-elderly disabled persons living in federally subsidized 
apartment developments. CHSP services include service 
coordination and non medical supportive services, such as 
housekeeping, congregate meals, personal care, and 
    The main purpose of CHSP is to promote and encourage 
maximum resident independence within a home environment, and to 
improve housing management's ability to assess eligible 
residents' service needs and provide or ensure the delivery of 
needed services to them. HUD pays up to 40 percent of the costs 
of CHSP; the grantees pay 50 percent or more, and the remaining 
10 percent is paid by fees from participating residents. CHSP 
services are subsidized through grants to public housing 
authorities, Section 202 and other developments that serve 
frail elderly and disabled residents (project based model).
    Data for the evaluation was collected over a two-year 
period. The final report, which was Congressionally mandated, 
was transmitted to Congress in September 2000.


    The number of residents served in different developments 
ranges from fewer than 10 to more than 100, with a median in 
1996 of 24 participants. Services are targeted to residents who 
have functional limitations that meet eligibility requirements, 
and are income-eligible for subsidized housing. CHSP 
participants are typically elderly (average age 81 years) white 
women who live alone. In their age and race/gender composition, 
the group served by CHSP is similar to other frail elderly 
populations receiving supportive services. Although they live 
alone, they are not socially isolated: 84 percent have at least 
one family member living nearby, and more than half (58 
percent) see family at least once a week. Also, most have 
contact with friends (63 percent see friends at least once a 
    Most participants (75 percent) report 3 more activities of 
daily living (ADL) limitations and half have 6 or more ADLs. 
Areas in which more than half of CHSP participants report ADL 
limitations include: doing housework (81 percent); shopping (72 
percent); getting in or out of a tub or shower (59 percent); 
preparing meals (56 percent); and getting in or out of a bed or 
chair (54 percent). Comparison shows that CHSP participants are 
more impaired than the overall population of U.S. elderly.
    Half of CHSP participants studied were still in the program 
24 months after the baseline survey; about 14 percent had died; 
and about 9 percent had left the program because they were no 
longer eligible; were dissatisfied, or obtained services from 
another source. Among residents who remained in CHSP over the 
24 month study period, about half (48 percent) showed the same 
ADL level over the period and 29 percent experienced decline.
    Annual per-participant costs of CHSP services and 
associated housing were estimated and compared with costs for 
assisted living and nursing homes. These show that the costs 
per participant for housing plus CHSP services ($8,900 to 
$11,000 per year) are substantially lower than the costs for 
assisted living ($15,000 to $20,000) or a nursing home 
($41,000). This supports the view that CHSP provides a cost 
effective means of providing housing and supportive services 
for the frail elderly.
    Several conclusions from the evaluation are specially 
relevant: (1) CHSP has been successful in delivering supportive 
services to frail, low-income elderly residents of subsidized 
housing; (2) HUD funds have been important for grantees in 
leveraging funds from other sources; (3) the CHSP data show 
that housing and supportive services can be delivered in 
subsidized housing at costs below those for assisted living and 
nursing home care; and (4) the kinds and levels of service can 
be changed as individual residents needs change over time.

                            PROGRAM--HOPE IV

    The final report on the evaluation of the HOPE for Elderly 
Independence Program was released in February 1999.
    HOPE IV combines HUD Section 8 rental assistance with case 
management and supportive services to low-income elderly 
persons (62 and older) with limitations in three or more 
personal care and home management activities, such as bathing, 
dressing, and housekeeping. The purpose of HOPE IV, 
administered by local Public Housing Agencies (PHAs), is to 
expand access to Section 8 rental assistance by frail elderly 
tenant populations and help participants avoid nursing home 
placement or other restrictive settings when home and 
community-based options are appropriate. In addition to rental 
assistance, as vouchers for private-market housing, HUD pays 40 
percent of the supportive services costs, the grantees pay 50 
percent, and participants, except for those with very low 
incomes, pay 10 percent.
    The vast majority of HOPE IV participants are widowed, 
white females, consistent with the profile of frail elderly 
Americans overall. In addition, approximately half of the 
participants are age 75 and over, have less than a high-school 
education, and receive incomes under $8,000 per year. Over half 
of the participants, however, are between 62 and 74 years old, 
but with few exceptions and in spite of their relatively young 
age, these persons have similar levels of frailty as their 
counterparts above age 75.
    Most HOPE IV participants have several factors that are 
highly correlated with frailty and risk of institutionalization 
in national studies--low-income, low level of education, 
minority status, and living alone. HOPE IV participants are 
much frailer than non-instutionalized elderly persons in the 
general population, and they are considerably less frail than 
elderly persons in community-based programs (nursing home 
eligible) or persons receiving nursing home care. During the 
two-year period between the baseline and follow-up survey, the 
percentage of participants and comparison group (control group) 
members reporting an ADL limitation increased for all 
activities of daily living. However, the comparison group 
reported fewer increases than the participants.
    Many HOPE IV participants are not isolated, participate in 
activities outside the home, and enjoy their social contact. 
However, the patterns of both in-person and telephone contact 
showed that most participants have either a great deal of 
contact or little contact at all, with surprisingly few cases 
in between.
    Participants in the HOPE IV program received a 
significantly higher level of supportive services than the 
comparison (or control) group, and this disparity in access to 
care remained over time. For example, at follow-up (2 years 
after baseline), nearly one-third (32 percent) of the 
comparison group reported receiving no services at all despite 
high levels of frailty, versus seven percent of the 
participants. In addition, receipt of services has a 
significant correlation with range of positive outcomes, across 
multiple domains of functioning. For example, service 
recipients scored significantly higher in four major mental 
health dimensions, social functioning, vitality, and other 
measure of social well-being. However, there wee no 
statistically significant differences between the participants 
and the comparison group members in the rates of nursing home 
placement, mortality, or remaining in Section 8. This finding 
is consistent with the results of prior studies that show the 
impacts of similar programs address quality of life and care, 
rather than changing such overt outcomes as death, 
institutionalization, or otherwise having to leave one's home 
due to frailty.
    Over the two-year period of the study, 40 percent of the 
participants left the HOPE IV program, including Section 8. 
This consisted of 15 percent who died, 9 percent who went into 
a nursing home or other similar setting, 9 percent who moved to 
another location, and 7 percent who left HOPE IV and Section 8 
for other or unspecified reasons. Sixty percent of the 
participants remained in assisted housing, including 7 percent 
who left HOPE IV but retained their Section 8 rental 
assistance. Over the same two-year period, 38 percent of the 
frail elderly comparison group left Section 8, including 13 
percent who died, 8 percent who went into a nursing or related 
care home, 9 percent who moved to another location, and 8 
percent who left for other or unspecified reasons.
    An overwhelming 85 percent of participants at baseline, and 
an even higher 91 percent at follow-up (2 years later), 
reported they were very satisfied with HOPE IV; 11 percent and 
6 percent, respectively, said they were somewhat satisfied. 
Only one respondent indicated active dissatisfication with the 
program at either point in time, while a very few were 
uncertain or did not say.

Comparison of HOPE IV and CHSP

    This report compares the effectiveness of providing 
assistance under the Congregate Housing Services program (CHSP) 
and the HOPE for Elderly Independence Demonstration (HOPE IV) 
program as requested in the 1990 Cranston-Gonzales National 
Affordable Housing Act (Public Law 101-625. HOPE IV and CHSP 
combined HUD housing assistance with case management and 
supportive services for low-income elderly persons (62 and 
older) with limitations in personal care and home management 
activities, such as bathing, dressing, and housekeeping. The 
report was released in June 2000.
    The purpose of HOPE IV and CHSP was to expand existing 
housing assistance programs to an elderly population often 
deprived of access to them due to frailty and to help these 
participants avoid nursing home placement or other restrictive 
settings when home and community-based options were 
appropriate. In addition to the housing assistance, HUD paid 40 
percent of the supportive services costs, the grantees paid 50 
percent, and participants, except for those with very low 
incomes, paid 10 percent of total program costs.




               Departmental Office for Equal Opportunity

    The Departmental Office for Equal Opportunity (OEO) is 
responsible for enforcing a variety of Federal anti-
discrimination laws that guarantee equal employment opportunity 
and nondiscrimination in all aspects of the Department of the 
Interior's (DOI) operations. OEO serves as the focal point for 
ensuring nondiscrimination on the basis of age in all aspects 
of DOI's operations including its employment practices, 
federally conducted education programs, and in all programs and 
activities receiving Federal financial assistance. In calendar 
years 1999 and 2000, OEO promoted and oversaw an array of 
proactive diversity initiatives to ensure nondiscrimination in 
DOI's employment practices, i.e., diversity training for bureau 
and office managers, diversity presentations, and listening 
sessions on diversity workforce issues. Each of these diversity 
initiatives covered age discrimination matters and quality of 
life issues that generally affect older DOI job applicants and 
employees. DOI continues to provide equal employment 
opportunity (EEO) counseling services through collateral duty 
personnel who have been specifically trained to address age 
discrimination issues that may affect DOI job applicants and 
employees. DOI has a ``Zero Tolerance Policy'' in place that is 
aimed at prohibiting discriminatory employment policies and 
practices based on age. DOI's age discrimination policy is 
prominently proclaimed to the public and its employees through 
a variety of approaches.
    In 1999, DOI processed a total of 117 civil rights 
complaints of which two were age discrimination complaints. In 
2000, out of a total of 132 civil rights complaints received by 
DOI, as in 1999 only two complaints alleged discrimination on 
the basis of age. These complaints were filed against State and 
local government agencies who received Federal financial 
assistance from DOI. Generally, the complaints did not relate 
to discriminatory age based policies, rather these complaints 
alleged instances of maltreatment and inaccessible programs 
encountered by older people with disabilities. In calendar year 
1999, experts from the U. S. Department of Health and Human 
Services, the lead Federal agency for providing government wide 
guidance in enforcement of the Age Discrimination Act of 1975, 
provided comprehensive civil rights training to key DOI equal 
opportunity personnel on the requirements of the Act. (The Age 
Discrimination Act of 1975 prohibits discrimination on the 
basis of age in federally assisted programs.) This training was 
provided to all DOI bureaus and offices that administer Federal 
financial assistance programs. During the period, policy 
guidance and procedural information were developed on how to 
conduct age discrimination complaint investigations filed 
against recipients of Federal financial assistance. Technical 
assistance was routinely provided by OEO to bureaus having 
responsibility for addressing age discrimination complaints. 
Comprehensive guidance was issued on DOI's civil rights public 
notification requirements which are intended to inform the 
public of DOI's nondiscrimination policy and the procedures for 
filing age discrimination complaints. Additionally, compliance 
reviews of DOI's federally assisted programs were conducted 
that covered age discrimination issues. These reviews were 
conducted to ascertain, in part, whether or not DOI's 
recipients of Federal financial assistance were in compliance 
with the requirements of the Act. DOI's bureaus and offices 
have established continuous civil rights compliance and 
enforcement programs that provide for conducting civil rights 
compliance reviews, complaints processing, training, and the 
provision of technical assistance in DOI's most service-
delivery oriented Federal assistance programs. All of these 
particular processes cover the requirements of the Act. DOI 
continues to have a complaints processing system in place that 
facilitates prompt investigations of age discrimination 
complaints against DOI recipients of Federal financial 
assistance. DOI's complaint processing procedures incorporate 
routine determinations as to whether a complaint is within 
DOI's jurisdiction and covered by the Act. Complaints received 
by DOI that contain sufficient information which identify the 
recipient, the location of the program or activity, the policy 
or issue in question, and the approximate date the alleged 
discrimination occurred are routinely referred to the Federal 
Mediation and Conciliation Service as required by Departmental 
    During the period, DOI also initiated work life assessments 
to ascertain the needs and wants of its employees with the 
older worker in mind. These assessments were accomplished in 
terms of improving conditions in DOI's workplace for all 
workers. These work life assessments resulted in the re-opening 
of DOI's health center and a refurbished fitness center which 
substantially benefits DOI's aging employees. Older workers can 
now take advantage of family support rooms that have been 
established in DOI facilities. In addition, DOI's aging 
employees, on an as needed basis, can avail themselves of DOI 
sponsored wellness programs including free physical 
examinations, flexi-time work schedules, telecommuting, 
retirement planning programs, and alternative work schedules.

                        Bureau of Indian Affairs

    The Bureau of Indian Affairs (BIA) administers initiatives 
and programs to benefit aging American Indians and Alaskan 
Natives. More specifically, BIA provides and finances adults 
with custodial and protective care services. These services 
have been provided in homes, group homes and nursing care 
facilities for elderly persons who lack financial, physical and 
mental capability to care for themselves. Other aging citizens 
have received protective and counseling services without 
custodial care payments. BIA coordinates intensive nursing care 
services for aging residents through referrals to