well for life: evaluation and policy implications of a health promotion initiative for frail older...

Australasian Journal on Ageing, Vol 26 No 3 September 2007, 135–140

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© 2007 The AuthorsJournal compilation © 2007 ACOTA

DOI: 10.1111/j.1741-6612.2007.00238.x

Blackwell Publishing Asia

Innovation in Aged Care

HEALTH PROMOTION FOR FRAIL OLDER PEOPLE

Well for Life: Evaluation and policy implications of a health promotion initiative for frail older people in aged care settings

Rosemary McKenzie

Centre for Health Policy, Programs and Economics, School of Population Health, The University of Melbourne, Melbourne, Victoria, Australia

Lucio Naccarella

Department of General Practice, The University of Melbourne, Melbourne, Victoria, Australia

Catherine Thompson

Aged Care Branch, Department of Human Services Victoria, Victoria, Australia

This paper discusses the findings and policy implications of an evaluation of ‘Well for Life’, a health promotion initiative that focuses on good nutrition and physical activity for frail older people in Planned Activity Groups and residential aged care facilities.The evaluation methodology employed the RE-AIM framework to identify various dimensions of program quality and public health impact. The evaluation found that Well for Life has achieved positive results in workforce development, health promotion capacity-building and linkages between aged care services and the broader primary care sector. Planned Activity Groups are a promising setting for health promotion for frail older people. Residential care settings are a more challenging environment as there are greater barriers to change in staff practices and greater frailty among residents. Further evaluation is required to inform decision-making about the focus of investment in health promotion for frail older people in the longer term.

Key words:

aged care settings, evaluation, frailty, health promotion, policy.

Background

The Well for Life initiative is an innovative program intro-duced in Victoria in 2004. The program aims to improve nutri-tion and physical activity for frail older people by focussing onlearning and practice change among management and staff ofPlanned Activity Groups (PAGs) and public sector residentialaged care facilities (ACFs). PAGs offer daytime activitiesfor older people at a venue away from home. PAGs focus onmaintaining an individual’s ability to live in the community byproviding planned activities that enhance skills requiredfor daily living and opportunities for support and social inter-action, as well as providing respite and support for carers [1].

The program brings together health promotion approaches, astrong evidence base, continuous improvement principles andsupport for partnerships across aged care and other parts ofthe primary care sector. In its first 2 years of operation, Well forLife has funded 48 projects across the eight regions of theVictorian Department of Human Services (DHS). Agenciesreceived modest funding (less than $A20 000) for 12 monthsto implement evidence-based physical activity and nutritionproposals assessed as suitable by departmental aged care staff.

Introduction

The challenge of ageing populations has resulted in significantresearch and policy development. Much research has aimed atbuilding an evidence base about healthy ageing and the factorsthat maximise quality of life, functional skills and independence[2]. Increasingly, policy has focussed on developing servicesand programs that support healthy ageing and minimise theimpact of chronic disease and disability. The United NationsPrinciples for Older Persons encapsulate the notion of healthyageing underpinned by independence, participation, care, self-fulfilment and dignity [3]. The World Health Organizationpolicy on active ageing builds on these principles and assertsthe right of all older people, in all residential settings, at homeor in the community, to realise their potential for physical,social and mental well-being [4]. Improving the health of olderpeople and encouraging active and positive ageing are prioritiesof governments in Australia at both state and national level. Anumber of strategies and frameworks support the concept ofhealthy ageing [5–9].

In Australia, funding, regulation and planning of residentialaged care are the responsibility of the Australian (federal) govern-ment. However, the federal government is not responsiblefor direct provision of care, which is provided by a mix of not-for-profit and for-profit agencies. In Victoria, the state govern-ment is directly involved in provision of aged residential care,with the state owning and operating through publicly fundedagencies 16% of residential aged care facilities. Many of thesefacilities are in rural Victoria. The state government providescapital funds for building and redevelopment of facilities, someoperational funds and funds for specialised care equipment,workforce recruitment and training and trialling of alternativecare models [10]. The Home and Community Care Program(HACC) is administered and funded jointly by the Australiangovernment and State/Territory governments. HACC providesa wide range of home and community care services encompass-ing nursing and allied health services, personal care, home help,day care, in-home respite, transport, home modifications andmaintenance, carer support, meals, information, training andadvocacy and assessment. PAGs are a HACC-funded service [11].

Correspondence to: Ms Rosemary McKenzie, Centre for Health Policy, Programs and Economics, School of Population Health, The University of Melbourne. Email: [email protected]

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Australasian Journal on Ageing, Vol 26 No 3 September 2007, 135–140© 2007 The Authors

Journal compilation © 2007 ACOTA

Well for Life is consistent with healthy ageing principles andstrategies. As a state-funded program, it targets older peopleliving in public sector residential aged care facilities (i.e. thoseowned by the state) and older people attending PAGs. Infocussing on nutrition and physical activity, the program issupported by a growing evidence base of the multiple benefitsthat can be provided to older people by enhanced nutrition andphysical activity including improved strength, balance andflexibility, decreased risk of falls, improved cardiovascularhealth, increased appetite, reduced anxiety and depression,better quality sleep and improved sense of social connectednesswhen participating in group activities [6,12–15]. Evidencefrom quasi-experimental studies of the positive effects of exer-cise, resistance training and nutritional supplementation forthe very old, supports the inclusion of residential aged care asa target setting for Well for Life [16,17]. The initiative alsomakes use of evidence-based resource manuals to facilitatestaff and carer learning, developed specifically for aged careresidential settings and those caring for frail older people livingat home [18,19]. The program is distinct from a range of otherhealth promotion programs for older people as it targets themost frail subgroup of the older population who are unlikelyto participate in community-based health promotion programsfor healthy and active ageing.

The evaluation

Well for Life has been the focus of external evaluation andmonitoring for 2 years. Evaluation has involved both processand summative evaluation. Forty-eight projects, in metropolitan,regional and rural locations have been monitored during thistime. The aim of the Well for Life evaluation was to provideboth quantitative and qualitative information regarding thesuccess and challenges of the Initiative in a range of communityand residential settings, to inform extension of the program inthe future.

Methodology

Monitoring and evaluation of the program has employed theRE-AIM framework [20]. RE-AIM represents five dimensionsof program quality that collectively interact to constitute aprogram’s public health impact. The dimensions are Reach,Adoption, Effectiveness, Implementation and Maintenanceand each is defined in Table 1 below. RE-AIM was originallydeveloped as a model that could examine the effects of evidence-based health promotion interventions (i.e. derived from research)in a range of dimensions of importance in real-world settings.It was utilised in Well for Life for its practical and theoreticalrelevance to the program, in that the program is derived fromevidence, the funders sought an assessment of the value of theprogram in real settings and the framework has previously

been found by the authors to be an easy to use, readily under-stood approach in evaluation of health promotion programs[21,22].

As the primary data collection method, the evaluation useda detailed project self-assessment tool administered at sixmonthly intervals and completed by the project coordinatorfor each project. The tool has been used in two other statewidehealth promotion evaluations [21,22]. Questions in the self-assessment tool reflected the RE-AIM dimensions and gatheredinformation about participation, implementation, barriersand drivers for success, workforce and organisational healthpromotion capacity development, establishment of new physicalactivity and nutrition-related activities, partnerships andinformation exchange and prospects for sustainability or main-tenance. Maintenance was examined using the SustainabilityChecklist developed by Hawe et al. [23]. Project final reportswere also reviewed for further narrative material on successes,challenges and individual change stories. Effectiveness at thelevel of individual function was not formally examined in thefirst two years due to the difficulty of implementing commonvalid measures of functionality across the range of projects.This has been undertaken in a later phase of Well for Life.Effectiveness at the organisational level was considered inrelation to health promotion capacity. Questions focussed onfour key elements of health promotion capacity-building: part-nerships resource allocation, workforce development andorganisational development [24]. All data were agency reported.No primary data were collected from residents and PAGparticipants by the evaluators.

Evaluation findings

Reach

Approximately 900 staff have participated in professionaldevelopment directly linked to Well for Life, and focussed onphysical activity promotion, such as training for fitness andstrength training leadership, and improving the nutrition of olderpeople, including training to encourage mealtime independ-ence, healthy food choices and identification of nutritionalrisk. Some projects have provided fall prevention training tostaff under the Well for Life auspice. PAG staff participation intraining and professional development has been higher thanamong ACF staff (approximately two-thirds PAG, one-thirdACF). The majority of ACF staff involved in Well for Life havebeen in rural and regional Victoria, where the majority of publicsector residential facilities are located.

Approximately 3000 frail older people are reported by agenciesto have participated in Well for Life activities. Activities have

Table 1: The RE-AIM framework

• Reach – participation and representativeness of the target population for the intervention (an individual level measure).• Effectiveness – the effects or impacts of the program, both positive and negative (both individual and organisational level measure).• Adoption – uptake of the intervention in agencies and settings (an organisational level measure).• Implementation – the extent to which the intervention is implemented as intended in the real world (both individual and organisational level measure).• Maintenance – extent to which a program and/or the benefits it generates is sustained over time (both individual and organisational level measure).

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included walking groups, gentle exercise programs, strengthtraining, tai-chi, community picnics, food tastings, healthyfood shopping and establishment of raised garden beds. Exactfigures for participation have been difficult to obtain as continu-ity of participation is variable because of frailty and ill health,and there is ongoing entry of new participants and residents. Inmetropolitan areas, participation has been predominantly inPAGs, including PAGs for ethnic community members. Whileparticipation by residents in ACFs in country and regionalVictoria has been higher, PAG participants make up the major-ity of Well for Life participants overall. It is estimated thatthree quarters of participants in Well for Life have done so inPAGs, with one quarter being aged care facility residents.

There are approximately 26 200 PAG participants in Victoria[25]. Participation in Well for Life by people attending PAGsis estimated to represent a little less than 10% of total PAGparticipants in Victoria. There are 45 000 residential aged carebeds in Victoria, of which approximately 7000 are publicsector places [10]. On current estimates, participation by agedcare residents in Well for Life is around 10% of the totalnumber of public sector residents in Victoria and less than2% of all aged care residents.

It is also difficult to accurately estimate staff participation inWell for Life workforce development. Funded agencies reportbetween 60 and 100% of PAG staff attending Well for Lifeupskilling and training sessions. However, an estimate of theproportion of PAG staff participating in Well for Life statewidecannot be reliably made because of the unavailability of work-force estimates for PAGs. On the basis of estimates of the sizeof the direct care aged care workforce in residential settings inVictoria [26] of approximately 5600 public sector facilitydirect care staff (many of whom are part time), it is estimatedthat approximately 5% of public sector aged care staff haveparticipated in workforce development through Well for Life.

Effectiveness – Organisational health promotion capacity-building

Agencies rated highly the capacity-building effect of Well forLife, with most agencies identifying workforce development andresource allocation for health promotion as important resultsof the program. Agencies noted that workforce developmentinvolved not only increased knowledge and skills but contributedto changing staff attitudes about the value of health promotionfor frail older people and improving services for clients andresidents. The program also resulted in broader organisationaldevelopment with some agencies reviewing and developingpolicies around healthy lifestyles, physical activity andnutrition, developing procedures and protocols aroundassessment and producing health promotion resources forongoing use.

Adoption – Links and partnerships

A further strength of the program identified by agencies wasthe foundation it provided for staff networks in aged care, newlinks with health professionals and new partnerships with other

agencies in the primary care sector. New PAG staff networkswere formed, PAG and aged care staff developed professionalrelationships with physiotherapists, dietitians and others in alliedhealth, and agencies auspicing PAGs and aged care facilitiesworked with representatives from community health, generalpractice, local government and primary care partnerships.PAG agencies have particularly valued the networks and pro-fessional relationships that have grown out of Well for Life.

Implementation – Success factors

A range of factors were identified that positively influencedprojects at participant, staff and agency levels:

• The presence of participant, resident and staff ‘champi-ons’ who encouraged the participation of others

• Understanding of the potential benefits of Well for Life,both at participant (individual) and at staff (professional)levels

• Commitment of management and staff to the principles ofWell for Life

• The presence of existing professional networks• The presence of existing agency relationships or

partnerships• Availability of funds to purchase equipment and develop

the organisational infrastructure to support Well for Life• Provision of both training and professional development

opportunities for the PAG and aged care workforces thatflowed through to increased capacity and the developmentof new programs and activities for participants andresidents

• Investment in the development of partnerships and net-works across primary health and aged care agencies.

Implementation – Barriers

Other factors were identified that were a barrier to progress orlimited impact of projects at participant, staff and agency levels:

• Resident and participant attitude to physical activity• Reluctance to participate due to cultural factors• Frailty and complexity of resident and participant’s phys-

ical and mental conditions, influencing initial participa-tion and continuity of participation, particularly in high-care residential settings

• Lack of or limited transport affecting participant/residentand staff participation

• Time constraints on staff in residential settings, particu-larly high-care settings

• Task-orientated culture of residential care• Change of role and focus required for staff involvement• Lack of staff continuity• Insufficient training opportunities for all staff• Competing professional development activities in agency• Competing priorities within the agency• Limited amount of initial funding• Lack of ongoing funding

Sustainability

Agencies completed a checklist on sustainability that assessedprospects for maintenance of the program in relation to three



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sets of characteristics: program design and implementationfactors; organisational setting factors known to be associatedwith program longevity and community factors such as level ofdemand or advocacy around an issue [23]. Agencies reportedhigh prospects for sustainability, in regard to organisationalleadership, adoption of Well for Life activities and principlesinto ongoing programs and policies, and a high level of com-munity interest. However, insufficient funds and limited stafftime were identified as possible impediments to sustainabilityonce initial funding ceased, particularly in the residential caresetting.

Discussion

Well for Life is a pioneering initiative that challengesestablished systems, attitudes, and practices with the aim ofimproving the health and well-being of frail older people.In its early stages it has both harnessed and strengthenedthe commitment of those in the aged care sector seeking newapproaches. The enthusiasm of this committed group of staffand managers has been an important driver for the initialsuccess of Well for Life. The program has been successful inmeeting its objectives relating to: improved knowledge andskills among staff; development of organisational healthpromotion capacity and culture; provision of opportunitiesfor frail older people to participate in physical activity andsound nutrition practices and encouragement of partnershipswithin and between agencies, health professionals and careproviders. Strengths of the program are workforce develop-ment, increased health promotion capacity, new networks andpartnerships and the expressed commitment of projects tosustainability.

Nonetheless, despite this promising performance, substantialbarriers are present in the aged care environment that will requiresustained effort – organisationally, culturally and financially– to integrate the principles of Well for Life in the sector. Animportant consideration is whether current organisationaland policy contexts are equally appropriate for Well for Lifein each of the targeted settings – community-based PAGsand residential ACFs. It is also uncertain as to whetherworkforce development and new physical activity andnutrition opportunities have translated into positive outcomesfor participants.

Organisational and policy considerations

Well for Life shows much promise for continued integrationwithin HACC-funded PAGs. Both PAGs and Well for Life havestate-based management and administration. The programhas had high levels of PAG staff participation in workforcedevelopment on health promotion, and new health-promotingactivity programs and practices have been introduced in PAGservices. These developments are consistent with the directionsHACC is taking in other service areas in Victoria, such as thetrialling of Active Service Models in home and personal care[11]. Many PAG participants have joined in new activities thatare enjoyable and good for their health that are wholly in keep-ing with PAG and HACC objectives to strengthen the ability of

participants to live independently at home and in the community.Workforce development for the PAG workforce is a valuablecapacity-building strategy that has been welcomed by agenciesand staff. It has provided new skills and knowledge, increasedstaff satisfaction and built links between PAG workers andwith allied health professionals. The development of new pro-fessional networks and links across primary care consolidatesbenefits for staff and clients and is consistent with the VictorianPrimary Care Partnerships Strategy, a major health-care reforminitiative of the Victorian government. In short, the Well forLife initiative is an excellent fit with the policy and organisa-tional context in which PAGs operate.

Well for Life’s early implementation in residential settings hasencountered more challenges. While there are passionate advo-cates for health promotion in ACFs, and workforce develop-ment opportunities for staff have been generally valued, thereare also organisational culture and systems barriers that makeWell for Life harder to implement. These include the focus ondirect care tasks; staff–patient ratios and the functional andhealth profile of residents, especially in high-care settings. Thesesame barriers also diminish the level of potential benefit toresidents that a small Well for Life investment can generate ina residential setting. As noted, evidence is not yet available as towhether Well for Life delivers functional benefits to participantsand although staff have been upskilled in health-promotingapproaches, agencies also report barriers to implementation ofnew practices. Similar challenges have been identified elsewherein efforts to introduce new approaches to maximise residentfunction and well-being. A pilot program of restorative careapproaches in a nursing home found that staff did not neces-sarily put new knowledge into practice [27] and residentfunctional outcomes were unchanged [28]. A broader debatecontinues in the gerontological literature about the value ofinvestment in interventions designed to delay functionaldecline and prolong life in the very old, or the frail fourth age,given loss in both biological potential for renewal and learningcapacity [29]. While improvements have been shown in thisage group from physical activity interventions, uncertaintyremains about the type and intensity of interventions bestsuited to different functional states and the mechanisms bywhich benefits are realised. In addition, costs and professionalinputs are high for the achievement of gains [30].

In Australia, the residential aged care sector is guided by thequality and accreditation standards of the federal governmentthrough The Aged Care Standards and Accreditation Agency[31]. Well for Life is consistent with at least six of the nationalstandards, including management systems, staffing and organ-isational development (S1); mobility, dexterity and rehabilita-tion (S2.14); leisure interest and activities ((S3.7); educationand staff development (S2.3); nutrition and hydration (s2.10)and continuous improvement (S2.1). However, as a modestlyfunded state-based initiative, Well for Life is not identified as astrategy for achieving accreditation standards and is unlikelyto achieve widespread ACF uptake on these grounds alone,compared with PAGs where Well for Life objectives are


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directly relevant to the objectives of the PAG service. Arguably,such health promotion approaches in residential settingsshould be incorporated as part of all personal care and activityservices funded by the federal government to ensure appro-priate standards of care and resident quality of life, ratherthan being pursued via a single state-based initiative in publicsector facilities.

However, Well for Life provides an opportunity for the state towork with the federal government to develop a model of activehealth-promoting care in ACFs consistent with accreditationstandards, supported by national dissemination of the Well forLife Resource Kit.

Given these policy and organisational considerations, it is vitalto clearly establish if Well for Life is achieving organisationaland individual gains in residential settings. Outcomes forresidents, staff and the organisation should be closelymonitored in aged care facilities to determine if Well for Lifedelivers benefits that justify continuing investment in theresidential setting.

Conclusions

Well for Life is an innovative addition to PAGs and public sec-tor residential care services for frail older people in Victoria.Evaluation of the early years of the program suggests that Wellfor Life can enhance the skills of the aged care workforce andexpand health promotion opportunities for participants. In apolicy context, the program is consistent with HACC policiesand principles and shows particular promise for integrationwith the objectives and role of PAGs. The program’s successin linking PAGs into the broader primary care sector has beenan important achievement that will serve to strengthen healthpromotion for frail older people living in the community,value-adding to the health promotion efforts of other agenciesthat target older people. The impact of Well for Life in agedcare residential settings is less clear-cut. There are many systemicbarriers to implementation of Well for Life in these settings. Itscapacity to contribute to fulfilment of national accreditationstandards appears slight at this stage. There are also questionsas to the appropriate delegation of federal and state governmentresponsibilities in promulgating health promotion in residentialfacilities. The progress of Well for Life in residential facilitiesshould be closely monitored to inform decision-making aboutthe focus of investment of health promotion funds for frailolder people.

Acknowledgements

The Centre for Health Policy, Programs and Economics(formerly Program Evaluation Unit) of The University ofMelbourne has been funded by the Department of HumanServices Victoria to provide evaluation and capacity-buildingservices for the Well for Life initiative. Thanks to WendiKruger, DHS, Maggie Fernie, DHS and Anna Howe for theircomments on this topic.

Key Points

• Well for Life is an innovative health promotionprogram for older people in aged care settings.

• Well for Life has been effective in developingorganisational and workforce capacity for healthpromotion and building partnerships between agedcare providers and the broader primary care sector.

• Well for Life is consistent with HACC policies andshows promise for integration into PlannedActivity Groups.

• The effect of the program in residential settingsrequires close monitoring to guide decision-makingabout future investment in health promotion forfrail older people.

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