COLLAGE 360 : A Model of Person-Centered Care To Promote Health Among Older Adults

Health care leaders and providers have introduced the assumption the typical elder, even in the presence of complex, chronic disease and prevailing illness, is capable of assuming greater personal responsibility for their health care, with a shift from provider-centered to a person-centered model of care. For older adults who often face challenges managing and maintaining their health status, guidance and support is needed. In this project, COLLAGE 360, a comprehensive assessment system and wellness coaching program that focuses on prevention and wellness was implemented in one continuing care retirement community. Following completion of two assessment tools through directed conversations with a wellness coach, older adults developed an individualized vitality plan that outlined life goals, supporting goals and action plans for goal achievement. Results from this program suggest engagement in the assessment and wellness coaching process via the COLLAGE 360 program translated into sample older adults sensing that they live in a more supportive environment when compared with elders not receiving any wellness coaching. In addition, the older adults had positive responses in the areas of mood and life satisfaction. Strategies to improve health and well being need an extended focus beyond the older adult’s medical conditions and consider psychological, spiritual and social needs with personal preferences being paramount. These issues are foundational to a personcentered, health promotion approach needed among older adults. DOI : 10.14302/issn.2474-7785 .jarh-16-1123 Corresponding Author: Elizabeth Howard, Northeastern University School of Nursing, 360 Huntington Avenue Boston, MA 02115, Email: e.howard@neu.edu.


Introduction
Older adults face an uncertain future, lacking guidance on a course of action to help them maintain their quality of life and independence while at the same time facing the initial onset of complex, chronic diseases and prevailing illnesses. 1Responding to a changing health care environment with increased emphasis on self -care and self-management, attention has shifted to the older adult who may be capable of assuming greater personal responsibility for their health status and health promotion efforts.The Institute of Medicine reported active participation by the elderly will be essential in the future. 2We present a project that assists elders in assuming this role -a program called COLLAGE 360.A detailed description of this program and analysis of select person-centered outcomes are presented.
A comprehensive review of the person including his/her goals and desires is not a standard model of care and soliciting personal preferences and life goals during scheduled health care visits is uncommon. 3The Institute for Healthcare Improvement has indicated, 4 if population health is to improve and costs reduced, efforts to improve the patient's care experience are needed.The Affordable Care Act includes calls for a new focus on prevention and wellness, care coordination, and development of health care self-management skills by the older adults themselves. 5Yet for many, this goal has not been translated into action. 3Health care for elders is not focused on individual needs, but rather, is incentivized for providers to discuss disease management and preventive strategies, overlooking the person. 3,6 align with the Triple Aim of improving the care experience and health of populations while reducing cost, 4 and, achieve the objectives of the Affordable Care Act, health assessments of older adults need to be person specific and address presenting issues as well as personal and individualized goals. 3,7Rather than improve a singular disease state, "people want to live and function as well as possible in spite of the disease and its symptoms." 3For example, chronic pain is condition that affects many older adults but is often under diagnosed.Many co-morbidities develop in the presence of chronic pain including anxiety, sleep disorders, eating disorders, mobility disorders, recurrent falls, and functional decline. 8Health practitioners' failure to diagnose and effectively treat chronic pain may result in decreased functional ability, cognitive performance and physical activity.In addition, depressed mood, social isolation and a reduced quality of life may result.
Personalized assessment and goal identification through a process labeled as 'health coaching' may serve as the nexus to maintaining the health and wellbeing of elders and positively affecting quality of life.
Health coaching provides opportunity to develop an elder's ability to successfully engage in selfmanagement. 9The primary goal of coaching is to focus on what the individual wants to achieve and not on their presenting health issues.Previously, wellness coaching has demonstrated effectiveness for specific problembased health goals such as weight loss, diabetes education, and chronic disease management. 9,10,11,12 ThOLLAGE 360 program is a person-centered model where the elders goals and preferences are paramount.

Materials and Methods
The COLLAGE 360 process (Figure 1) begins with an initial appointment, during which a directed conversation occurs and information is gathered to complete two tools, the interRAI Community Health Assessment (CHA) and the Wellness tool.(WEL)At the conclusion of this initial meeting, the coach reviews the conversation and themes with the resident and then asks them to reflect on life and personal goals prior to their next appointment.An individual's 'Assessment Indicator Report' is generated prior to the next meeting.
This report provides a summary of performance on agerelated scales of cognitive performance, mood, function and physical activity.In addition, the potential for adverse events including re-hospitalization, functional decline, depression, social isolation and uncontrolled pain, if present, will be identified.One to 2 weeks later, at the second appointment, there is review of the resident's reflection of their life and personal goals as and reliable approach to annual standardized resident assessments in the US within senior housing. 13The CHA Measures and Analysis.To examine the effect of COLLAGE 360, particularly the wellness coaching component in this project, another sample of older adults was drawn from 28 other COLLAGE member communities who used the same assessment system but did not offer any organized, formal, wellness coaching process.We examined 3 key outcomes in this first analysis: supportive community environment, mood, and life satisfaction.The effect analysis was based on a oneyear comparison of the CCRC residents at the target site to a closely matched sample from the other 28 CCRC sites.A repeated measures ANOVA was used to test for statistical significance.For the subsequent 1 and 2 year comparisons, we drew data from 4 CCRC's who were members of the COLLAGE consortium, implemented the assessment system using the CHA and WEL tools, but did not implement any formal wellness coaching program among their residents.The data were analyzed using the SPSS 18.0 statistical package.

RESULTS
The average age of the sample was 86.3 years, and 91% of the residents were female.All elders resided in independent living.Approximately 45% reported having intact cognition but with some memory problems and 45% had problems with gait.Given the organization and structure of a continuing care retirement community, we expected all residents would view their community as a supportive environment.One year following implementation of COLLAGE 360, there were notable differences with this outcome when compared with the matched sample.As seen in Figure 2 and 3, the target CCRC sample had a slightly higher percentage of respondents who reported they viewed their community as a supportive environment than the contrast sample at baseline.Notable, this percentage declined in one year for the comparison sample and increased 4.9 percentage points for the target sample."not in the last three days, not in the last 3 days but often feels that way, in 1-2 of the last 3 days, and daily in the last 3 days" and scored 0, 1, 2, and 3 respectively.Thus, with this mood score, a lower score represented a better mood state.For the contrast sample, mood scores worsened at the one year followup but improved markedly for the COLLAGE 360 project sample.With the multiple site comparison, 'good mood' was summarized as the total percentage of people who selected 0, response option "not in the last 3 days" for the question, 'how often have you felt sad, depressed or These results are summarized in Figures 6 and 7.

Conclusion
Within COLLAGE 360, the coaching goal is to provide a comprehensive and holistic approach to improving the lives of older adults.This approach is responsive to changing needs within the current healthcare environment, namely increased selfmanagement and self-care behaviors while permitting the elder to speak for his/her self and set priorities.Such an approach supports the adoption and maintenance of program participation, as decisions reflect a personal sense of meaning and purpose. 16e concept of "life goals" for individuals in the later decades of life is foreign to many, including health well as the CHA and WEL summaries contained within the assessment indicator report.This informative discussion concludes having the resident, with support from the wellness coach, develop his/her life goals, related supporting goals, and defined action steps.The result from this interchange and discussion is summarized into a Vitality Plan, often regarded as a personalized roadmap directing one towards a higher level of wellness and quality of life.Action steps may include enrolling in an evidence-based program to Freely Available Online www.openaccesspub.org| JARH CC-license DOI : 10.14302/issn.2474-7785.jarh-16-1123Vol-1 Issue 1 Pg.no.-23 promote self-management of a chronic disease, volunteering at a local community initiative, participation in a Tai Chi class or actively engaging in the planning and implementation of a social event.Once the Vitality Plan is complete, the wellness coach connects with the resident no less than once every 3 months over the course of the year to monitor the progress towards goal achievement.Full reassessments occur no less than once annually and more frequently if a major life event occurs such as a hospitalization or death of spouse or other family member.A key, distinguishing feature of the COLLAGE 360 is the use of standardized assessment tools (interRAI.org)to assess aging related problems and, equally important, personal preferences.The problem areas assessed using these tools include cognition, communication, mood and behavior, psychosocial wellbeing, physical functioning, continence, disease diagnoses, health conditions, preventive health measures, service use, medications and oral/nutritional status.The WEL solicits individual preferences for exercise-related activities, recreational activities, alternative therapies, social engagement as well as training in physical fitness, fall prevention, and cognitive stimulation.Intervention.COLLAGE 360 was implemented in a continuing care retirement community (CCRC), located in the northeast region of the US and serving a predominantly middle income population of older adults.This program was an in-kind service available to all residents by the organization with the overall goal of improving the residents' quality of life.The CCRC is a member of COLLAGE (www.collageaging.org), a national consortium of CCRCs and elder housing sites initiated and developed by Kendal Outreach, LCC (KOLCC), a subsidiary of the Kendal Corporation, a non-profit organization, and the Institute for Aging Research (IFAR) at Hebrew SeniorLife, a Massachusetts non-profit corporation.All members of the COLLAGE consortium participate in the application of a computerized, valid Figure 1.COLLAGE 360 Process

For the one and
two year post-program comparison, the percentage of residents reporting they felt their community was supportive increased for the COLLAGE 360 CCRC and was higher percentage than the 4 comparative, non-coaching CCRCs.Two years post program implementation, 95% of the residents from the COLLAGE 360 CCRC evaluated their community as a year for the CCRC sample.Selfreported mood was measured with response to the question, "in the last 3 days, how often have you felt sad, depressed, or hopeless.The response options were:

Figures 4 and 5
Figures 4 and 5 display these results.The percentage of residents reporting good mood was not highest for the COLLAGE 360 CCRC but demonstrated fairly consistent results with percentages of 89% and 86% for 1 and 2 years post-program implementation respectively.