Toolkit: Building Resilience in Older Adults: Step 01. Overview and Goals

What Is This Step?

In this step, we review this toolkit's intended audience, its goals and specific aims, and why it is needed. We conclude with a brief user's guide that previews the toolkit's content and provides tips for its use and navigation. We also offer a quick checklist to enable you to determine whether this toolkit is right for your work.

Goals and Specific Aims of the Toolkit

The increasing frequency and intensity of weather-related and other disaster events combined with the growing representation of older adults in the overall population have created a new environment in which public health programs and policies will need to actively promote the resilience of the older population.

This toolkit contains information and activities that can bring together those involved in aging-in-place support and those involved in disaster resilience efforts to improve the resilience of older adults to natural and human-caused disasters. The goal of this toolkit is to improve the resilience of older adults by helping to bring together two groups that are currently implementing separate, yet complementary, work:

1. public health departments and
2. aging-in-place groups—specifically, age-friendly communities (AFCs) and villages.

Public health departments are government agencies that are responsible for creating and maintaining conditions to keep people healthy. AFCs are agency collaborations at the municipal or regional level that seek to facilitate the inclusion of older adults in all aspects of community life and are supported in their planning and implementation by AARP and the World Health Organization. Villages are membership-driven grassroots nonprofit organizations that seek to help older adults age in place successfully. Villages generally cover a neighborhood or a city but, in some cases, can cover multiple adjacent counties in rural areas. More detailed definitions of each and how to locate them are available in Step Two. To accomplish this goal, the toolkit aims to:

• orient each group to their shared interests and functions
• describe and support work that each group is already doing or could be doing to promote older adults' resilience
• provide guidance about how to evaluate and improve each group’s independent and collaborative efforts to promote older adults' resilience.

Need to Build the Resilience of Older Adults

There are two important trends that make building the resilience of older adults important: changes in environmental stresses and changes in the numbers and needs of those aging in place.

As weather is becoming more unpredictable and natural disasters like hurricanes, flooding, tornadoes, and earthquakes grow in intensity and frequency, it is increasingly urgent to build resilient communities that can not only bounce back from adversity but also become better prepared to respond to future events (National Oceanic and Atmospheric Administration, National Centers for Environmental Information, 2017; National Association of Insurance Commissioners, Center for Insurance Policy and Research, 2017). Resilient communities are those that can anticipate and successfully adapt to a range of difficulties (e.g., community violence, natural disasters, economic crises; Acosta, Chandra, and Madrigano, 2017). Building resilient communities requires both neighbor-to-neighbor reliance and strong organizational connections (Figure 1.1).

1. Individuals and families have the knowledge to prepare for and respond to disaster
2. People can rely on each other (neighbor to neighbor)
3. There are enough volunteers to help in a disaster
4. Organizations are ready and prepared to respond and recover
5. There are strong relationships between organizations
6. Resilient communities

The backbone of a resilient community is resilient individuals with the knowledge and ability to prepare for, respond to, and recover from adversity, trauma, tragedy, threats, or significant sources of stress. Links between these individuals and volunteers and organizations form the connective tissue of a resilient community. Strong organizational relationships help to weave these connections together (Chandra, Acosta, et al., 2011). When communities are unable to attend to those residents who may have multiple or special needs, it is more difficult for those communities to be resilient. When communities do not actively leverage the assets of all of their residents to help respond and recover, those communities are less resilient.

In addition to the changing disaster landscape, communities are now faced with growing numbers of older adults, as people live longer in general and as the baby boomer cohort swells the ranks of older adults. While the ability to live longer is a promising advancement, some older adults are now living with multiple chronic conditions, limitations in activities of daily living and instrumental activities of daily living, physical and cognitive disabilities, and sensory impairments. This can make older adults particularly vulnerable to physiological and psychological stresses during natural disasters (Bei et al., 2013; Weisler, Barbee, and Townsend, 2006). Social isolation also prevents many older people from receiving warning signals or asking for help, rendering them invisible to rescue teams (Eisenman et al., 2007). Three-quarters of those who perished in Hurricane Katrina in 2005 were older than 60 (Jonkman et al., 2009). Recent wildfires in California and hurricanes in Florida have put a spotlight on the vulnerability of older adults after a series of preventable deaths (Nedelman, 2017). Most fatalities, injuries, and damage caused by natural disasters, such as floods, tornadoes, hurricanes, and earthquakes, are preventable (Fuse and Yokota, 2012). Preparing older adults for disaster response and recovery can alleviate some proportion of the physical, social, and emotional damage that occurs in these situations.

Older adults can also contribute important assets to disaster response. A 2017 qualitative study, using literature review and 17 focus groups with at-risk individuals, found that older adults contribute their experience, resources, and relationship-building capacity to prepare themselves and to support others during an emergency (Howard, Blakemore, and Bevis, 2017). Specifically, older adults both generate and mobilize social capital at a local level during a disaster. Despite existing and useful disaster preparedness guidelines and resources for older adults, critical gaps remain in addressing the needs and leveraging the strengths of older adults (age 65 and older), a population that is expected to rise to 20 percent of the U.S. population by 2050 (Fernandez et al., 2002). A 2014 national survey of older adults found that two-thirds of the sample had no emergency plan, had never participated in any disaster preparedness educational program, and were not aware of the availability of relevant resources. More than one-third of the respondents did not have a basic supply of food, water, or medical supplies in case an emergency situation were to arise (Al-Rousan, Rubenstein, and Wallace, 2014). Such deficits could result in further decline in health status, especially in the presence of mobility and functional limitations (O’Sullivan, 2009). About 15 percent of the sample used medical devices requiring externally supplied electricity. Power interruptions could pose important adverse health effects for these individuals.

Growing proportions of older adults, coupled with today’s increasing climatic and other disaster risks, point to the fact that public health and other programs need to engage in cross-sector collaboration to better identify and address the needs of older adults (Al-Rousan, Rubenstein, and Wallace, 2014). While public health departments are the government entity primarily responsible for the public’s health and for responses to disasters and other stresses, their activities are not always tailored for older adults and thus may not make accommodations for their needs. Aging-in-place efforts, including AFCs and villages (also known as senior villages), represent a promising strategy for U.S. communities and cities to support older adults’ abilities to live in their own homes safely, independently, and comfortably (Centers for Disease Control and Prevention [CDC], 2009) and could contribute to the efforts of public health departments to build community resilience.

Purpose of Toolkit

This toolkit is intended to bring together public health departments and aging-in-place groups to improve the resilience of older adults in the face of emergencies or disasters. It specifically focuses on the role of AFCs and villages because these two groups represent long-standing efforts that have supported successful aging in place and are being used across the United States and globally.

To inform the development of this toolkit, we interviewed 37 representatives from villages, AFCs, and public health departments to identify needs and barriers, as well as organizational and collaborative activities to promote older adults' resilience. We found that while some villages have incorporated resilience-building activities aimed at improving individuals' knowledge and ability to prepare for, respond to, or recover from a disaster, the variability is great, and it is unknown whether this actually improves the resilience of older adults in the face of a natural or man-made disaster.

While a small number of the AFCs included in our interviews have wholly incorporated the critical element of resilience, the majority have not. Public health departments have a focus on building resilience of individuals with functional limitations—which includes many, but not all, older adults—but have limited collaboration with villages and AFCs.

Improving this collaboration is critical to addressing three key barriers to promoting older adults' resilience:

1. Resource constraints: leveraging existing efforts across groups (e.g., having villages disseminate preparedness pamphlets from the public health department) can help address resource constraints of any one group.
2. Competing priorities: some villages and AFCs felt that they were too busy focusing on ways to improve daily quality of life and did not have time for resilience activities. Bringing preparedness experts from the public health department to talk about how aspects of resilience-building can help improve quality of life on a daily basis (e.g., social connections) can help these groups understand that resilience activities are complementary, not in competition with activities to improve daily quality of life.
3. Awareness: public health departments and preparedness, response, and recovery staff can engage more with older adults (through AFCs and villages that have deep connections) to raise staff's awareness and improve their attention to the needs and strengths of older adults, especially those without functional limitations.

Intended Audiences

The intended audiences for this toolkit are policymakers; emergency preparedness, response, and management staff and their supervisors; health directors, commissioners of health, and other health and human services department leaders at the local, state, and federal levels; and leaders and partners involved with aging-in-place efforts (specifically AFCs and villages).

The target audiences for this toolkit are:

• Policymakers
• Researchers
• Older Adults
• Villages
• Individuals responsible for emergency preparedness and response
• Age-friendly Initiatives
• Public health departments

These groups are not mutually exclusive. Users interested in developing new AFCs or villages should refer to the AARP website and the Village to Village Network website.

Toolkit Development

Because there were no similar existing toolkits, the RAND team conducted interviews with public health department staff, village executive directors, and AFC coordinators across the country to create this toolkit. We also conducted a survey of older adults' resilience comparing older adults living in villages and those not living in villages. Findings are detailed in a journal article manuscript available upon request from the authors. The interviews provided information about the types of resilience-building work that public health departments, villages, and AFCs are currently leading with older adults—as well as the barriers to and facilitators of these efforts—and offered insights about whether and how these groups could partner to build resilience. The survey contained measures to characterize older adults' resilience. A detailed description of the methods and findings from the interviews and survey can be found in a companion report (Shih et al., 2018) and the journal article manuscript (available upon request from the authors), respectively.

We also based a portion of the toolkit (evaluation planner and continuous quality improvement information in Step Four) on the Getting To Outcomes approach because it is the only evidence-based model and intervention proven to increase a prevention practitioner's ability to conduct self-evaluations. Getting To Outcomes is a set of tools, trainings, and technical assistance that builds practitioner capacity to conduct ten implementation best practices. Process evaluation, outcome evaluation, and continuous quality improvement are three of those practices that we highlight in this toolkit because they can help public health departments and aging-in-place groups to evaluate and improve their efforts to promote older adults' resilience.

More details on the methods used to develop the toolkit can be found in the appendix.

User's Guide

Overview of Content

The remainder of this toolkit walks users through a series of figures and tools. These figures and tools help you (the toolkit's intended audiences) identify areas where your organization or group may have shared interests and functions with other similar or different groups, including public health departments, villages, or AFCs (Step Two); what types of activities each of these groups may already be doing to promote older adults' resilience (Step Three); and what additional activities could be done independently or together with other organizations or groups to promote older adults' resilience (Step Three). The toolkit concludes with guidance on how to design an evaluation to capture process, outcome, and partnership measures. These measures will help you determine whether your resilience work is achieving the desired effects. We also offer guidance on how to use evaluation findings to improve your current and future work (Step Four).

Potential Benefits

This toolkit will help you achieve the following benefits:

• Support collaboration between public health departments and the work of aging-in-place groups by clarifying their common ground.
• Promote activities to enhance older adults’ resilience by building on this common ground.
• Collect and apply data to evaluate whether these efforts are effective.

The toolkit is designed to guide users through a series of sequential steps to help you identify ways to collaborate (across public health departments and aging-in-place groups) to achieve shared interests and improve older adults’ resilience. Repeating the process on a regular basis will help you improve this collaborative work.

Tips for Navigating the Toolkit

This document contains several types of tools:

• Worksheets ask you to answer questions.
• Checklists help direct you through the toolkit and provide guidelines to review your own work.
• Tables summarize relevant research.
• Figures provide a snapshot of key information in a visually appealing format.

Start Using the Toolkit

Checklist 1.1 will help you decide whether this toolkit is appropriate for your group. If the toolkit is right for you, it is time to start using it!

Be sure to use the toolkit sequentially. Worksheets, tables, and figures build on previous content, informing tools in later sections of the toolkit. Starting in the middle of the toolkit (e.g., in Step Three) may require referring back to earlier steps. Therefore, we strongly encourage users to go through the toolkit sequentially.

Checklist 1.1. Is This Toolkit Right for Me?

• 1. Do you represent a public health department or an aging-in-place group, such as a village or AFC?

  • Yes—This toolkit is right for you! Skip the remaining questions and proceed to the Summary section for this Step.
  • No—This toolkit is primarily intended for individuals who are working with a public health department, a village, or an AFC. However, it does contain measures and guidance relevant to political leaders, state public health staff, and federal agencies involved with health and human services. If you are still unsure, proceed to Question 2.

• 2. Are you looking for ways to provide or improve access or coordination of community and health services or systems for older adults?

  • Yes—This toolkit is right for you! Suggestions for ways to collaborate to keep older adults safe and healthy through providing or improving access or coordination of community and health services or systems are covered in Step Two. Skip the remaining questions and proceed to the Summary section for this Step.
  • No—Proceed to Question 3.

• 3. Are you looking for ways to work with others in your community to promote older adults' resilience?

  • Yes—This toolkit is right for you! Collaborations and partnered activities to promote older adults' resilience are covered in Step Three. Skip the remaining question and proceed to the Summary section for this step.
  • No—Proceed to Question 4.

• 4. Are you looking to measure older adults' resilience?

  • Yes—This toolkit is right for you! Measures of older adults' resilience are contained in Step Four.
  • No—The types of information provided in this toolkit are probably not applicable to you or your group.

Summary

This step described the purpose and content of this toolkit in order to help you decide whether this toolkit is appropriate for your group. This step also provided a brief summary of how the toolkit was developed. Now that you have read this step and completed Checklist 1.1, you should know whether this toolkit is right for you and your group. If it is, proceed to Step Two, which will help you find common ground between your group and others and identify ways to collaborate to achieve your shared interests of keeping older adults safe and healthy.