214 Wellness Program Guidelines and Requirements

Georgia State Seal

Georgia Division of Aging Services
Home and Community-Based Services Manual

Chapter:

200

Effective Date:

10/27/2021

Section Title:

Wellness Program Guidelines and Requirements

Reviewed or Updated in:

MT 2019-09

Section Number:

214

Previous Update:

MT 2019-09

214.1 Summary Statement

This chapter establishes guidelines and requirements to be followed by Area Agencies on Aging and their contractors when providing State Wellness Program services. The program encompasses the activities authorized by the Older Americans Act of 1965, as amended in 2000 and 2006, through Title III, Part D, Disease Prevention and Health Promotion Services.

214.1A Scope

These requirements apply to services provided in whole or in part by non-Medicaid federal and state funds and any associated matching funds managed by Area Agencies on Aging and their contractors. The use of funds from Title III, Part B, Supportive Services program, and Title III, Parts C1 and C2, Nutrition Services Programs, for related services is also consistent with the purpose of the state’s comprehensive and integrated Wellness Program. Subject to continued availability, State Community Based Services funding is also allocated to the program. The Area Agencies on Aging are responsible for coordinating resources and, where none exist, for creating a way to fill the gaps in services. To prevent duplication of existing community resources, the Area Agencies on Aging will make every effort to fund only those services for which no other resource(s) can be identified.

214.1B Definitions

Evidence-Based Programming

Per the guidelines of the Administration for Community Living (see References – number 1), beginning October 1, 2016, programming for non-Medicaid Disease Prevention and Health Promotion Services shall meet the following criteria:

  1. Undergone experimental or quasi-experimental design; and

  2. Level at which full translation has occurred within a community site; and

  3. Level at which dissemination products have been developed and are available to the public.

A list of evidence-based programs that can be supported by Title III-D funds can be found at www.ncoa.org/resources/ebpchart/.

This list is not exhaustive. Please see Administration for Community Living’s III-D Checklist to verify if programs not included can be supported by III-D funding.
Disease Management

A system of coordinated healthcare interventions and communications for populations with conditions in which patient self-care efforts are significant. Disease management:

  1. Supports the physician or practitioner/patient relationship and plan of care,

  2. Emphasizes prevention of exacerbations and complications utilizing evidence-based practice guidelines and patient empowerment strategies, and

  3. Evaluates clinical, humanistic, and economic outcomes on an ongoing basis with the goal of improving overall health

  4. Disease Management Components include:

    1. Population identification processes

    2. Evidence-based practice guidelines

    3. Collaborative practice models to include physician and support-service providers

    4. Patient self-management education (may include primary prevention, behavior modification programs, and/or compliance)

    5. Process and outcomes measurement, evaluation, and management

    6. Routine reporting/feedback loop (may include communication with patient, physician, caregiver, health plan, and ancillary providers); and

    7. Full-service disease management programs must include all six components. Programs of fewer components are Disease Management Support Services.

Physical Activity

A variety of leisure time, occupational, and self-care activities which, if performed routinely, result in biochemical and physiological adaptations that improve the body’s functional capacity, efficiency, muscular endurance, and range of motion. (A listing of some evidence-based physical activity programs can be found at the link referenced above.)

Health Promotion

The process of enabling people to increase control over and improve their health.

Health Indicator

A characteristic of an individual, population or environment which is subject to being measured, either directly or indirectly, and which can be used to describe one or more aspects of the health of an individual or population in units of quality, quantity, and/or time.

Health Literacy

The cognitive and social skills that determine the motivation and ability of individuals to gain access to, understand, and use information in ways that promote and maintain good health.

Health Outcomes

A change in the health status of an individual, group, or population that can be attributed to a planned intervention or series of interventions.

Health Promotion Evaluation

An assessment of the extent to which health promotion actions achieve a “valued” outcome.

Health Promotion Outcomes

Changes to personal characteristics and skills which can be attributed to health promotion activities.

Levels of Preventive Action

Three levels of measures not only to prevent the occurrence of disease, such as risk factor reduction, but also to arrest its progress and reduce its consequences once established:

  1. Primary Prevention includes interventions designed to keep a disease from ever happening or a trauma from ever occurring. Examples: immunizations; reducing household hazards; reducing risk factors for heart disease; increasing regular, moderate physical activity; and maintaining good nutritional status. Health promotion programs are usually at the primary prevention level.

  2. Secondary Prevention is the use of early detection and early intervention against a disease before it develops fully. Examples: screening programs with referral of persons who appear to be at risk of a particular disease for follow-up and treatment by a health professional [see section 214.2b]; or risk assessments of residential environments.

  3. Tertiary Prevention are interventions that take place after a disease or injury has occurred, intended to prevent deterioration and complication and to rehabilitate and return individuals to as full physical, mental, and social functioning as possible. Usually provided by health professionals.

Self-Care or Self-Management

The activities that individuals, families, and communities undertake with the intention of enhancing health, preventing disease, limiting illness, and restoring health. These activities are derived from knowledge and skills of both professional and lay experience. They are undertaken by consumers on their own behalf, either independently or in collaboration with professionals (see References - number 5).

214.1C Laws and Codes

Each Wellness Program Services site shall operate in compliance with all federal, state, and local laws and codes that govern facility operations, specifically related to fire safety, sanitation, insurance coverage, and wage requirements.

214.2 Disease Prevention and Health Promotion Service Objectives

The objective of Title III-D is to promote better physical, mental, and social health for older adults, persons with disabilities, and caregivers through the provision of the three tiers of evidence-based disease prevention and health promotion programs.

Through using Evidence-Based health and wellness programs, the broad objectives of Wellness Program implementation which affect health and wellness at both the individual and community level are:

  1. To reduce disease and disability

  2. To improve individuals’ health literacy and understanding of diagnosed conditions

  3. To reduce the prevalence of risks to health or to increase behaviors known to reduce such risks

  4. To assist participants in developing behaviors and skills which are conducive to individual and community health

  5. To increase comprehensiveness, accessibility and/or quality of health promotion and preventive services and interventions; and

  6. To promote empowered users of the health care system.

214.2A Service Outcomes

Title III-D programs are implemented to maintain or improve the level of health and wellness of those persons aged 60 years and older, persons with disabilities, and their caregivers through the implementation of evidence-based, community level initiatives.

More specific long-term outcomes for individuals and groups may include, but not be limited to:

  1. Increased physical strength and endurance

  2. Maintaining or increasing independence

  3. Ability to independently perform self-care (activities of daily living)

  4. Ability to independently participate in community and leisure activities (instrumental activities of daily living)

  5. Maintaining or improving nutrition and physical activity behaviors; and

  6. Maintaining or improving overall quality of life/life satisfaction.

214.2B Service Activities

Evidence-based Wellness Program services, provided in both the homes of participants and in community settings, and encompassing both disease prevention and health promotion services must include one or more of the following evidence-based activities:

  1. Health Risk Assessments To identify people at risk and refer them to the appropriate follow-up services. These services may be provided in senior centers, nutrition sites, with health professionals, individuals’ homes, or other community settings. Assessments may include, but are not limited to the following:

    1. Falls risk using the STEADI Toolkit (See MAN 5300, 114 Guidelines for Client Assessment)

    2. Medication management understanding including:

      1. Assessment

      2. Education to prevent incorrect use of medications; and

      3. Prevention of adverse drug events.

    3. Health literacy

    4. Self-efficacy for self-care

    5. Nutrition

    6. Home safety:

      1. Assessments of high-risk home environments

      2. Provision of educational programs and materials on injury prevention; and

      3. Fall prevention education.

    7. Cognition

    8. Depression:

      1. The Patient Health Questionnaire, 9 question version (PHQ-9) – see MAN 5300, 114 Guidelines for Client Assessment

      2. Identifying older adults, persons with disabilities, and caregivers experiencing grief over personal losses; and

      3. Related assistance may include coordination of community mental health services, provision of education activities, and referral to appropriate psychiatric and psychological services.

  2. Health Screenings/services administered by trained and certified professionals including, but not limited to, one or more of the following evaluations:

    1. Blood pressure

    2. Hearing

    3. Vision, to include glaucoma

    4. Dental

    5. Podiatry

    6. Blood tests, including diabetes and cholesterol

    7. Urinalysis

    8. Bone density

    9. Mammography

    10. Prostate

    11. Flu vaccination

    12. Pneumonia vaccination; and

    13. Abdominal aortic aneurysm screening.

  3. Health Counseling may also include specific counseling services. Some types of counseling include, but are not limited to:

    1. Gerontological

    2. Caregiver

    3. Social services

    4. Nutrition [see also MAN 5300 304 Nutrition Service Program Guidelines and Requirements]

    5. Mental health

    6. Depression Screening

    7. Medication compliance; and

    8. Psychological services.

  4. Nutrition Screening [refer to MAN 5300 CH 304.1b and MAN 5300 CH 304.2j] The process of using characteristics known to be associated with nutrition problems to identify individuals who are nutritionally at risk.

  5. Nutrition Counseling [refer to MAN 5300 CH 304.1b and MAN 5300 CH 304.2m] The provision of individualized guidance by a qualified professional on appropriate food and nutrient intakes for those with special nutrition needs, taking into consideration health, cultural, socioeconomic, functional, and psychological factors. Nutrition counseling may include advice to increase, decrease, or eliminate nutrients in the diet, to change the timing, size or composition of meals, to modify food textures, and/or to change the route of administration-from oral to feeding tube to intravenous.

  6. Nutrition Education [see also MAN 5300 CH 304.1b and MAN 5300 CH 304.2l] The provision of information about foods and nutrients, diets, lifestyle factors, community nutrition resources and services to people to improve their nutritional status.

  7. Health Promotion Programming including, but not limited to programs relating to prevention and reduction of the effects of:

    1. Chronic conditions (e.g., osteoporosis, arthritis, diabetes, cardiovascular disease, etc.)

    2. Alcohol and substance abuse

    3. Smoking

    4. Obesity

    5. Stress/anxiety

  8. Physical Fitness Activities including, but not limited to:

    1. Walking programs

    2. Chair exercises

    3. Arthritis exercise programs

    4. Group exercises

    5. Aquatic classes

    6. Resistance programs; and

    7. Other evidence-based low impact aerobics programs

  9. Music, art, and dance movement activities or therapies

  10. Hospital Transitions For more information on a number of evidence-based Hospital Transition programs, visit AoA’s PowerPoint presentation transcript at: acl.gov/sites/default/files/programs/2017-03/AoA_ACA_CT1_transcript_012411.pdf

  11. Benefits Education Program [see Manual 5200 Chapter 5000]

AAAs must include one or more goals for Wellness Programs focused on evidence-based health and wellness program implementation in the Area Plans.

214.2C Target Groups, Eligibility, and Priority for Services

Persons eligible for Wellness Programs are those:

  1. Aged 60 and over, or a spouse (regardless of age) of a person aged 60 or older

  2. Persons with disabilities (18 and older) who are residents of housing facilities occupied primarily by older adults at which congregate nutrition services are provided

  3. Caregivers to persons aged 60 and older or to persons with disabilities.

AAAs shall give priority to areas within their region:

  1. which are medically underserved; and

  2. in which there are many older individuals who have the greatest economic need for such services. (42 U.S.C. 3030n)

Services may be designed to assist healthy older adults, persons with disabilities, and caregivers in maintaining positive health states; to assist persons with chronic conditions to better manage their health; and to promote healthy lifestyles and behaviors among all persons at the community level.

214.2D Conditions for Referral to Other Services

When appropriate, service providers shall work with the AAA (or case management, if available) to refer participants to other service resources that may be able to assist with remaining independent and safe in the home, and/or to assist caregivers with maintaining their own health and well-being.

214.3 Participant Records

The service provider shall maintain files in a form and format approved/accepted by DAS, including information that, at a minimum, identifies participant demographics; documents individuals’ eligibility for the program (based on program requirements); and contains instructions for emergency contacts and care preferences. All providers shall maintain any additional participant information as specified by DAS program policies and procedures and as required by program developers. Refer to MAN 5600 1060 Technology and Data Management and other sections for record keeping policies.

Files of participants served through the DAS contract are confidential and remain the property of the Department of Human Services. All participant files are subject to review and monitoring by the AAA, DAS, and any federal granting agencies.

The provider agency shall make facilities, equipment, and services available to the fullest extent possible in emergencies and disasters, according to the established AAA regional emergency/disaster plan.

The provider agency shall develop a written continuity of operations plan for their agency which will include policies and procedures for operation during any type of emergency and/or disaster. Examples of emergencies include, but are not limited to vehicle breakdowns, inclement weather, or program leader emergencies. Refer also to MAN 5600 3017 Emergency Planning and Management.

214.3B Management and Oversight of the Wellness Program

The AAAs shall identify staff responsible for the overall management of wellness services and compliance with performance standards, requirements, and procedures.

If services are provided by a sub-contracted agency the AAA is responsible for ensuring program adherence and fidelity in implementation as required

214.3C Staff Orientation and Training

The service provider shall assure that orientation and ongoing training for administrative and direct service staff and volunteers shall be adequate for providing safe, appropriate, and efficient evidence-based wellness services to older adults, and compliance with all applicable requirements and procedures. Providers shall document and maintain records of all content and dates of orientation and training for monitoring purposes.

214.3D Record Keeping and Reporting

Providers shall comply with all record keeping and reporting and retention requirements as prescribed by DAS. Documentation requirements specific to wellness services include, but are not limited to:

  1. Daily records documenting persons who receive wellness services (units and persons served)

  2. Documentation of participant feedback, and the method used to obtain feedback on a routine basis.

To document and validate which evidence-based criteria level the selected Wellness Program meets AAAs must:

  1. Retain documentation of the evidence behind their chosen Title IIID health promotion program(s) for AAA records and monitoring purposes.

    • Depending on the program, this could be anything from a copy of an appropriately credentialed practitioner’s certification (e.g., registered dietitian, pharmacist, dentist, CNA, LPN, etc.), to a peer-reviewed journal article, to dissemination products.

  2. For a Title IIID evidence-based health promotion program meeting the minimal criteria such as blood pressure screenings, documentation could include a copy of the CNA, LPN, RN, or other performing practitioner’s license number along with information about the blood pressure screenings that were performed. In the event student volunteers are used, such as dental students, nutritionists or pharmacists, a letter or email from the faculty instructor could be retained as a record of the evidence-base of the health promotion program implemented with Title II-ID funds.

  3. Collect and report pre and post testing as required for specific program implementation (e.g., Chronic Disease Self-Management Education and Matter of Balance requirements found in the appendices).

Refer to MAN 5600 1060 Technology and Data Management and other sections for additional DAS record keeping policies.

214.3E Contributions

Refer to MAN 5600, 3025 Financial Management.

214.3F Provider Quality Assurance and Program Evaluation

Each wellness program provider shall develop and implement an annual plan to evaluate and improve the effectiveness of operations and services to ensure continuous improvement in service delivery.

The evaluation process shall include:

  • A review of the existing program

  • Satisfaction survey results from participants, staff, and volunteers

  • Program modifications made that responded to changing needs or interests of participants, staff, or volunteers

  • Proposed program and administrative improvements

If not directly administered by the AAA, each sub-contracted provider shall prepare and submit to the AAA annually (no later than September 30th) a written report that summarizes the evaluation findings, improvement goals, and implementation plan for implementation.

214.3G Monitoring by Service Provider

Each provider shall adhere to established fidelity guidelines and monitoring policies and procedures as published by DAS or program developers. Refer to MAN 5600 for additional monitoring requirements.

214.4 AAA Responsibility for the Wellness Services Program

The AAA shall develop and implement any necessary additional policies and procedures for the following:

  1. Compliance with the Older Americans Act Title III-D program implementation; and

  2. Verification that all providers comply with licensing and fidelity guidelines for evidence-based programming

References

acl.gov/programs/health-wellness/disease-prevention

Adapted from the World Health Organization, apps.who.int/iris/handle/10665/205887