Health Indicators: A Proactive and Systematic Approach to Healthy Aging

Fredda Vladeck
Rebecca Segel
Mia Oberlink
Michal D. Gursen
Danylle Rudin

As with the articles in this issue, this introduction reflects the views of the authors and does not necessarily reflect the views of the U.S. Department of Housing and Urban Development.

The challenge of serving a burgeoning elderly population that has an increasing burden of chronic illness cannot be met within the existing paradigm of "one hip fracture at a time"—a limited approach using discontinuous, reactive responses to crises that can be prevented or delayed. As the gap between needs and resources continues to grow, and as the understanding of how to effectively manage chronic conditions improves, a proactive system is needed: a community-oriented, evidence-based approach involving three components—self-care, medical care, and community care and support systems. Merely locating traditional health and social services in communities is not sufficient; any endeavor to effectively integrate these three components at the community level requires good data, strategic partnerships, thoughtful targeting, explicit cross-sector standards, and the capacity to track and measure the effort’s effectiveness.

This article describes a data-driven, community-based, collaborative effort under way in 34 low- and moderate-income communities in New York City. The Health Indicators in NORC (naturally occurring retirement community) Programs initiative, started in 2007, has enabled community-based programs with limited resources to become more systematic in addressing the management of clients with diabetes, heart disease, or an increased risk for falls.