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The Arkansas Aging Initiative: An Innovative Approach for Addressing the Health of Older Rural Arkansans

Correspondence: Address correspondence to Claudia J. Beverly, PhD, RN, FAAN, 4301 West Markham – 748, Little Rock, AR 72205. E-mail: beverlyclaudiaj{at}uams.edu

	Abstract

TOP Abstract Introduction Arkansas Aging Initiative (AAI)... Evaluations of the AAI Challenges and Lessons Learned Conclusion References

 
The Donald W. Reynolds Institute on Aging at the University of Arkansas for Medical Sciences in Little Rock is addressing one of the most pressing policy issues facing the United States: how to care for the burgeoning number of older adults. In 2001, the Institute created the Arkansas Aging Initiative, which established seven satellite centers on aging across the state using $1.3 to $2 million dollars annually from the state's portion of the Master Tobacco Settlement. These centers on aging assist the state's population of older adults, many of whom reside in rural areas, live in poverty, and suffer from poor health. The centers provide multiple avenues of education for the community, health care providers, families, and caregivers. The Arkansas Aging Initiative, in partnership with local hospitals, also makes geriatric primary and specialty care more accessible through senior health clinics established across rural Arkansas. In 2005, older adults made more than 36,000 visits to these clinics. All sites have attracted at least one physician who holds a Certificate of Added Qualifications in geriatrics and one advanced practice nurse. Other team members include geriatric medical social workers, pharmacists, nutritionists, and neuropsychologists. This initiative also addresses other policy issues, including engaging communities in building partnerships and programs crucial to maximizing their limited resources and identifying opportunities to change reimbursement mechanisms for care provided to the growing number of older adults. We believe this type of program has the potential to create a novel paradigm for nationwide implementation.

Key Words: Geriatrics • Education • Interdisciplinary • Rural aging • Senior health clinics

	Introduction

TOP Abstract Introduction Arkansas Aging Initiative (AAI)... Evaluations of the AAI Challenges and Lessons Learned Conclusion References

	Arkansas Aging Initiative (AAI) Development and Operations

TOP Abstract Introduction Arkansas Aging Initiative (AAI)... Evaluations of the AAI Challenges and Lessons Learned Conclusion References

 
Through a referendum by the citizens of Arkansas in 2000, all of Arkansas's funding from the tobacco settlement was dedicated to improving the health of Arkansans. The Arkansas Center for Health Improvement (2006; hereafter, the Center), an independent nonpartisan organization, was identified to develop the tobacco settlement plan for improving the health of Arkansans and for allocating the funds. The Center's mission is to improve the health of Arkansans through evidence-based research, public issue advocacy, and collaborative program development. Thus, the Center was well positioned to lead development of the tobacco settlement plan and to select the leadership of each of the programs. The Center selected the Donald W. Reynolds Institute on Aging (hereafter, the Institute) to implement the program targeting older Arkansans. Established in 1995, the Institute has built a solid foundation of geriatric education, clinical care, and research programs, and has a broad understanding of the challenges of accommodating the ever-increasing number of older Americans.

The Institute established the AAI between 2001 and 2004 (Figure 1) with its share of the tobacco settlement funds (approximately 3% of Arkansas's total tobacco settlement dollars). The AAI is a statewide network of seven regional centers on aging (COA) formed in partnership with communities to develop the educational and clinical care components of each center. The primary goals of the AAI include (a) preventing future health problems and enhancing the health of older adults by improving access to high-quality, interdisciplinary geriatric health care and by providing education to older adults, family members, caregivers, and the community; (b) providing geriatric education to health care professionals and students; and (c) influencing health policy at state and national levels.

View larger version (70K): [in this window] [in a new window]   Figure 1. Map of regional centers

COA Start Up and Operations
A central leadership team (CLT) of faculty from the Institute directed development of the AAI. The director of the leadership team reports directly to the Arkansas Tobacco Commission and has responsibility for the overall program, including ongoing operations; financial management; and health, education, and policy outcomes.

The first phase of each COA's development involved establishing a steering committee composed of regional partners. These partners included health system chief executive officers, Area Agency on Aging directors, representatives from academia and from the Area Health Education Center, community leaders, and influential physicians from the community. To alleviate fears of competition, committees found it extremely important to include the local health care professional community. Led by the CLT, each steering committee met for about a year to develop the COA's initial goals, objectives, and strategies.

A major task of the steering committees involved filling the COA's two key positions, the director and the education director. For the director position, the committees gave priority to fellowship-trained physicians with a Certificate of Added Qualifications in geriatrics but also considered physicians with a long history of geriatric care and a good reputation in the local community. Currently, each site has at least 1 physician with a certificate in geriatrics (15 physicians total). Of these, 3 had established practices and 12 were new to Arkansas. For the education director, the committees also attempted to recruit from the local community. It was essential that the candidates have master's degrees or higher in a health-related field such as nursing or counseling and be well-known and respected individuals who could jump-start efforts.

Once the committees had hired local leadership, they dissolved, and smaller local/regional leadership teams were created. These smaller groups direct and guide the operations of each COA and include the director, education director, director of the Area Agency on Aging, one or two hospital representatives, and the chair of the community advisory committee. The CLT members serve in an ex officio capacity on each of the seven regional committees.

During the start-up year, each site completed a needs assessment of regional stakeholders using two complementary methodologies to obtain input. First, sites mailed surveys to older adults identified by the various regional and local aging programs or delivered to elders participating in Meals on Wheels programs. Second, trained University of Arkansas (Little Rock) staff conducted focus groups of health care providers and community members in more than 50 locations throughout the state. Results showed that health problems in these regions were consistent with the leading causes of morbidity and mortality at state and national levels and also indicated that respondents' top three health needs related to the affordability of prescription medications, medical care, and health insurance (Beverly, McAtee, Costello, Chernoff, & Casteel, 2005).

Financial Relationships
The AAI has two central components: education and clinical care. The education component is financed by the tobacco settlement dollars, and the clinical component is financed (100% owned and operated) by the local/regional hospital partner. At each COA, 10% of the COA director's time is supported by the educational dollars, and 90% is generally supported by the partnering hospital. Although the two components are financed differently, the integration and partnering of education and clinical care are what comprise a COA.

The financial structure of each COA is similar. University of Arkansas for Medical Sciences distributes tobacco settlement funds to the AAI, which divides the funds evenly between the seven sites and central administration. The AAI receives $1.3 to $2 million annually in tobacco funds, depending on the amount the state actually receives. Central administration and individual COAs use these dollars to support operations such as administrative functions and staff salaries; however, the majority of the funding goes toward educational programming and outreach activities. The Institute does not contribute money directly to the AAI; however, it supports the program in ways such as providing office space for the central leadership team, education and meeting space, and distance-learning capabilities, among other things.

The clinics are provider based and are owned and operated as departments of the partnering hospitals; they do not receive AAI funds. Charging a facility fee makes the clinics financially feasible. This fee is reimbursable under Medicare when the clinic is owned and operated by a hospital (vs an independent practice). The reimbursement mechanism (facility fee) allows for calculation of a time factor for a patient visit, thereby allowing coverage for the various team members who cannot bill Medicare independently.

Unfortunately, most of the participating hospitals have not done a thorough financial analysis of the clinics and, therefore, do not know their exact financial impact. As part of any financial analysis, it will be critical for hospitals to examine not only the cost of operating the clinics and the revenue they receive from professional and facility fees, but the downstream revenue as well. However, the administrative and financial systems in most rural sites are not sophisticated, and they have limited capabilities to track downstream revenue.

Currently, if any deficits do exist, the hospitals absorb the losses. We believe that a more accurate tracking of this downstream revenue will show that the hospitals do break even and probably make money. Clearly, the hospitals believe this as well, as evidenced by the fact that many are looking to expand services by hiring additional geriatricians and/or geriatric nurse practitioners. In fact, because of its success, one hospital has created two additional clinics, further expanding the number of geriatricians and geriatric services available to residents in that region.

AAI Educational Component
As noted previously, a majority of the funding received by each COA (approximately $190,000 minus an administrative fee to the regional Area Health Education Center and minus other operational costs such as leases, travel, supplies, and capital equipment) goes toward providing innovative educational programming in all counties of its region. COAs have used various strategies to implement these educational programs. Figure 2 presents the number of educational encounters by target population, which total more than 101,000. Prior to the existence of the AAI, minimal public education targeted this population; therefore, all encounters noted are new to the communities.

View larger version (16K): [in this window] [in a new window]   Figure 2. Educational encounters by target group

All educational programs sponsored by the Arkansas Geriatric Education Center are evaluated by participants, which include physicians, nurses, pharmacists, social workers, physical and occupational therapists, and others. Additionally, the Arkansas Geriatric Education Center conducts biannual statewide needs assessments alternating with evaluation surveys of all health professionals who participated in its programs during the previous calendar year. Two thirds (67%) of survey respondents have indicated that the knowledge gained from the programs changes the way they care for older adults (Chernoff, 2004).

Education for Students
Beginning in Fall 2006, two junior medical students from each 4-week mandatory geriatric rotation had the option to receive this educational experience at one of the COAs. Leaders anticipate that this will attract two students every 4 weeks of the mandatory geriatric rotation (24 students the first year). Furthermore, the AAI anticipates expanding this to two students in at least one additional COA site annually, and leaders hope to have students in all sites within the next 5 years. Additionally, in their senior elective, two medical students have chosen a senior rotation at one COA, and many family practice residents have received geriatric training in six of the seven sites.

Since 2003, more than 1,048 students in nursing, pharmacy, medicine, social work, and allied health have participated in learning opportunities in all seven COAs. These have been students from local colleges and University of Arkansas branches around the state; some of the students are practicing health professionals participating in the Arkansas Geriatric Education Mentors and Scholars program. Increasingly, colleges are realizing the impact of the exponentially increasing number of older adults and are searching for geriatric learning opportunities for their students. At the same time, they have become more aggressive in requiring geriatric content and practice opportunities as part of their curriculum.

Education for Community Members
Educational efforts are also impacted by and directed toward the health care needs of the community. Each COA focuses much of its efforts on the top three health needs. COAs have addressed the top need, affordability of medications, in at least two ways. First, a University of Arkansas for Medical Sciences faculty member in the College of Pharmacy secured a grant from the Centers for Medicare and Medicaid Services to train trainers from across the state to educate Medicare recipients and their families about the first phase of Medicare Part D. Second, the Office of the Arkansas Insurance Commissioner partnered with each COA and the Area Agencies on Aging to educate older consumers about the next phase of Medicare Part D.

Local community programs also focus on health problems consistent with the leading causes of morbidity and mortality. For example, targeted screenings (e.g., blood pressure, blood sugar and cholesterol levels, prostate, and fecal occult blood) are available at local health fairs; at educational events; and as part of activities at wellness centers, senior centers, and churches. Other activities include implementing evidence-based education guidelines in each COA. Annually, COAs will implement two guidelines statewide that target leading health problems such as arthritis, heart disease, diabetes, or dementia.

Many other activities make for a comprehensive approach, including ongoing tai chi classes, walking groups, healthy cooking classes, discussion sessions with local physicians, stress management groups, dementia and caregiver support groups, and caregiver training. Several education directors have become master trainers, thereby training lay older adults and other health care professionals to lead various groups. This effort has been a primary focus and has led to increased community capacity (Etkin, Prohaska, Harris, Latham, & Jette, 2006; Center for Health Aging, 2004). Educational materials augment educational programs and are written at various literacy levels. Additionally, each COA has also established a resource library housing educational resources in a variety of formats, including audio, visual, Web-based, and hard copy.

AAI Clinical Component
The clinical component consists of a provider-based senior health clinic that employs an interdisciplinary geriatric team of providers. This team incorporates comprehensive geriatric assessments, consultations, prevention-based services, chronic care management, and referrals to programs such as behavior modification (e.g., exercise and smoking cessation). The team usually performs these services as primary care, but often it does them as consultations for more remote rural patients. This geriatric model is well accepted in the geriatric health care community and has yielded high satisfaction rates among older adults and their families (Burns, Nichols, Martindale-Adams, & Graney, 2000; Coleman, Grothaus, Sandhu, & Wagmer, 1999; Schraeder, Shelton, & Sager, 2001).

The clinics vary greatly in size, ranging from a patient panel of just more than 400 in one of the newest and smallest clinics to more than 1,900 in one of the larger clinics. The number of fulltime employees also varies greatly, ranging from 2.5 in the smallest clinic to 15 in the largest. Data from the COAs reflect that 90% to 100% of the clinic patients have Medicare, 2% to 25% are dual eligible (Medicare and Medicaid), and less than 1% have commercial insurance. Further sampling revealed that patients seen in the clinics as referrals from other community physicians ranged from 1% to 25% of their patient volume. Although the clinics serve as the base, the geriatric clinicians work together and provide a continuum of care in hospital, outpatient, home, and nursing home settings. On average, the workload of the geriatric providers is 40% to 50% in the clinic, 15% to 25% in nursing homes, 10% to 25% in hospitals, and less than 1% in older adults' homes. During 2005, providers made more than 36,000 visits to the clinics, and all clinics are increasing their patient numbers.

In summary, these clinics accomplish a great deal by having become a vital component in the holistic approach to care for older adults in these communities. They have also become an exceptional marketing tool to keep the older population in the community to receive their care. Therefore, older adults view local provision of geriatric primary and specialty services as a great service that allows them to stay within their own rural communities to receive appropriate care.

Continued Community Support
Because community support is crucial, each COA's leadership group has developed a community advisory committee. With the assistance of a subcommittee of the Reynolds Institute Advisory Board, leaders of each COA identified community leaders who have a special interest in the care of older adults. The local community advisory committees serve as advocates for the COAs and help address the critical issues of program recognition and financial sustainability for the educational component.

Health Policy
The AAI is currently engaged in several policy-related activities. We reported two previously: consumer education about Medicare Part D and a method to study the financial viability of a rural provider-based interdisciplinary geriatric clinic. The AAI is also currently working with the state's Medicare Quality Improvement Organization to implement Section 649 as outlined in the Medicare Modernization Act of 2003 (Federal Register, 2005). This activity involves assisting in the implementation of electronic health records and practice guidelines in all AAI-partnered clinics. The next step will be to incorporate evidenced-based guidelines available through the Centers for Medicare and Medicaid Services.

	Evaluations of the AAI

TOP Abstract Introduction Arkansas Aging Initiative (AAI)... Evaluations of the AAI Challenges and Lessons Learned Conclusion References

 
A comprehensive AAI evaluation plan ensures that the COAs meet expected outcomes as originally intended in the legislative language and the strategic plan. The AAI evaluation plan includes both internal and external components. Although many consider experimental designs to be the gold standard, experimental or quasi-experimental designs are neither feasible nor necessarily informative in evaluating multifaceted community initiatives (Goodman, 2001). The Authors, believe that evaluation should stem from the information needs of the primary stakeholders (Patton, 1987), which in this case include the state-appointed Arkansas Tobacco Commission, state and federal legislators, and the University of Arkansas for Medical Sciences. Reports to the stakeholders usually revolve around indicators that stem from the original law and the AAI strategic plan and that were developed with the external reviewer hired by the Arkansas Tobacco Commission.

Internal Evaluations
Internally, the AAI has conducted two pilot studies: one to determine consumer satisfaction with their health care from an interdisciplinary team approach and the other on the development of a methodology for studying the financial impact that a senior health clinic has on its rural owner hospital. The consumer satisfaction study compared patient satisfaction with care they had received in the traditional health care delivery system versus care received by the interdisciplinary geriatric team after 1 year of enrollment in two clinics. A 20-question instrument, cast on a 4-point scale, assessed patients' satisfaction with access, accommodation, and acceptability of the previous traditional health care at time of enrollment in the interdisciplinary care clinic and 1 year later (n = 193 at enrollment, and n = 145 after 1 year). Attrition occurred due to death, participant move, or the inability to contact the participant. Results from both sites showed a statistically significant (p <.0001) improvement in satisfaction with the interdisciplinary clinic over the traditional health care system.

Using a descriptive case-study approach, the second internal evaluation study collected data for a 12-month retrospective period on a geriatric provider-based outpatient clinic and the associated downstream revenue. Findings showed a total loss of $326,871, which included a large cost-to-charge ratio (which made the expenses applied to the hospital and outpatient charges large) and a significant gap between Medicare-allowable charges and collections. Initial findings of an investigation into the issue indicated that some bills were missing or had not always been coded and/or billed appropriately. The hospital has successfully completed an audit of charges and coding, and has reorganized some clinical operations. In addition, this study had a major limitation: The hospital's financial and data systems could only track physicians, not geriatric patients (McAtee, 2005); thus, the systems could not trace much of the downstream revenue. For example, if a patient had been admitted by a physician to whom he or she had been referred by the geriatrician, had had tests ordered by the referring physician, or had been admitted during non-business hours, the system could not track him or her as a geriatric referral or patient.

External Evaluations
In addition to the internal evaluation studies, several external entities have extensively evaluated the AAI. Table 1 outlines the methods, findings, and recommendations from the external reviewers. In summary, the external reviewers noted that the clinical and educational components, as well as the AAI's ability to reach out to this neglected target population, were strengths of the program. Needed improvements included increasing funding and acquiring and implementing better data and budget management systems.

	Challenges and Lessons Learned

TOP Abstract Introduction Arkansas Aging Initiative (AAI)... Evaluations of the AAI Challenges and Lessons Learned Conclusion References

Financial Sustainability of the AAI
Tobacco funds fluctuate and depend on the dollars people spend for tobacco products, but projections had the dollars leveling out in 2007 at approximately $1.5 million per year for this initiative. However, tobacco settlement funding is decreasing and is therefore inadequate to maintain the program at its current level; it certainly will not allow for program expansion. Therefore, the AAI as a whole and each regional COA is working hard to identify multiple revenue sources, and advisory committees are forming at each site to assist in the financial development activities of each COA.

Geriatric Workforce
Recruitment of geriatric health care specialists remains an ongoing challenge due to the critical nationwide shortage of geriatric health professionals. The AAI is taking a proactive stance to address this problem and is vigorously working with each site to recruit geriatricians and geriatric nurse practitioners. Several of the sites use a headhunter service to recruit physicians, and the AAI participates in the interview process, especially if the individual will also be the COA director. Additionally, the AAI is currently exploring opportunities for community physicians (internal medicine and family practice) to seek geriatric fellowships. If this is not possible, physicians will receive opportunities to increase their geriatric expertise through the Arkansas Geriatric Education Center or other continuing education offerings. Of special note, all Title 8 funding for geriatric education centers has been eliminated. Some experts think that this funding may be restored during the next federal budget cycle. However, if this does not occur, it could severely hamper the AAI's ability to educate health professionals.

The AAI is also actively recruiting family practice residents from the seven Area Health Education Center sites to continue their education by entering a geriatric fellowship. The regional partner hospitals have all expressed an interest in financially assisting residents through this 1-year fellowship. The AAI is currently in discussions with the Geriatric Nurse Practitioner program at the University of Arkansas for Medical Sciences College of Nursing to assist in recruiting students who will commit to practice in the AAI's senior health clinics.

Replicability
The AAI model should be replicable in other states. However, the major barriers to replicability by other sites will continue to be the availability of geriatric expertise and financial resources. Currently, senior health clinics operate as provider outpatient clinics using an interdisciplinary team approach. The more rural the center is, the more difficult it is to recruit physicians and nurse practitioners. Replication sites may need to explore other options to fill these positions, such as those described previously. It is difficult to generate revenue for education, making education funding a major concern. Ideally, early in the development phase, replication sites should aggressively identify and seek funding from a variety of sources such as private foundations and government entities.

Rapid Implementation
Although mandated by law to open within 5 years, all seven sites opened within approximately 3 years, which may have been overly ambitious. The haste in opening the sites was influenced by the need for legislators to see tobacco settlement funds used in their region, the inability to carry over funds from each biennium, and the eagerness of the regions to get their share of the dollars. Opening the sites more gradually would have allowed the community advisory boards to mature at a more reasonable pace, and, most importantly, officials would have better known the trend in the flow of tobacco dollars from the national settlement. Given the reality of funding today, leaders should have begun a more aggressive effort to diversify the revenue stream in Year 1 and continued this effort each subsequent year.

Branding
In an effort to engage all of the partners and participants at the community level, each regional leadership team named its own COA and developed a logo reflective of the local partnerships. However, the logos had no identifying connection to the larger AAI program; therefore, identification with the overall program has been a constant struggle. Work is currently underway to develop an AAI brand for each site.

Difficulty of Master Planning
Arkansas is in the unique position of having strong health and social service networks. Discussion is currently underway with lead state agencies to develop a master plan for aging. Within the context of the overall master plan, each regional COA and Area Agency on Aging would either continue the already strong collaboration or begin initiating one to develop and implement a master plan for aging in each region. This has the potential of integrating the health care and social services systems statewide, thus maximizing the scarce dollars and better meeting the needs of Arkansas's seniors.

Clinical and Educational Outcomes
Leaders intended tobacco settlement funds to support education and the overall AAI structure. Officials designated no funds for evaluation; this has severely hampered researchers' ability to study the impact of the AAI. However, as noted previously, there have been several internal and external evaluations of the AAI. Although these were not true measures of effect, future evaluation efforts will be augmented through the implementation of more scientifically rigorous evaluative programs, which will help investigators more objectively determine the value added by the AAI, both in terms of improving patient care and providing fiscally sound educational and clinical programs.

Toward this end, our efforts have already changed from start-up activities to implementation of an outcomes-focused approach. Currently, we are aggressively seeking funding to support evaluation efforts, especially with respect to recruiting a senior-level researcher in rural aging. We have already employed a researcher in the University of Arkansas for Medical Sciences College of Public Health to begin developing a research plan and to lead our research efforts. Our first step is to seek funding for a project in which we will use a tracer condition of diabetes in those sites with electronic health records. Using an experimental approach, and following Centers for Medicare and Medicaid Services and American Diabetes Association best-practice guidelines for diabetes, we will determine if there is a difference in patient outcomes when care is provided by an interdisciplinary team of geriatric specialists versus in a more traditional way. We have submitted this proposal for pilot funding. Our second initiative is to use the methodology developed by Dr.McAtee to examine the financial viability of four partner hospitals over a 2-year period. The results from this study, combined with those from the previous case study, should provide enough cumulative data to draw more detailed and accurate preliminary conclusions regarding the financial viability of the senior health clinics within our partnered hospitals.

	Conclusion

TOP Abstract Introduction Arkansas Aging Initiative (AAI)... Evaluations of the AAI Challenges and Lessons Learned Conclusion References

 
The AAI addresses the needs of rural older adults, is multifaceted, and brings together two components essential to improving the quality of elders' health status: education and clinical health care. Merely having clinical and educational offerings available is not enough. Providers must encourage elders to engage in healthy lifestyles and empower them to actively participate in their own health care. By helping to provide the requisite education and access to care, and by being involved in the community, programs such as AAI can have a dramatic positive impact.

A strong commitment to evaluation and outcomes research is imperative to determine if efforts are cost effective, are beneficial, and improve the health of older Arkansans. Key to this initiative is the implementation and evaluation of best practices in both education and clinical care. Therefore, one of our primary goals is to secure sufficient information and outcomes data to clinically and financially validate the AAI program and to support replicability in other states.

	Footnotes

 
This study was funded by U.S. Department of Health and Human Services Administration on Aging Award 90AM2518 and Initiated Act 1 of the 2000 Tobacco Settlement Proceeds Act. We acknowledge the citizens of the state of Arkansas who, by a vote of 65%, dedicated all of the Master Tobacco Settlement dollars to seven health programs. The Arkansas Aging Initiative (AAI) is one of those programs. AAI funds support the salaries of Dr. Claudia Beverly (30%), Dr. Robin McAtee (80%), Dr. Ronni Chernoff (less than 5%), Gwynn Davis (25%), and Susan Jones (50%). We thank the Donald W. Reynolds Foundation for its continued and overwhelming support for geriatric programs at the University of Arkansas for Medical Sciences. The Foundation's support made it possible to create the environment necessary to be selected to implement the AAI. We also acknowledge Senator Blanche Lincoln, who made it possible to develop and initiate evaluation of the AAI through funding from the Administration on Aging. Finally, we thank the directors of the Center on Aging, education directors, and all related partners for their work to make the AAI a robust program serving the citizens of the state.

¹ Donald W. Reynolds Institute on Aging, University of Arkansas for Medical Sciences, Little Rock.

² John A. Hartford Center for Geriatric Nursing Excellence, New York.

³ Arkansas Aging Initiative, Little Rock.

⁴ University of Arkansas for Medical Sciences, Little Rock.

⁵ Arkansas Alzheimer's Disease Center, Little Rock.

⁶ Geriatric Research Education and Clinical Center, Little Rock, Arkansas.

⁷ Central Arkansas Veterans Healthcare System, Little Rock.

⁸ Arkansas Geriatric Education Center, Little Rock.

Decision Editor: Nancy Morrow-Howell, PhD

Received for publication June 8, 2006. Accepted for publication September 25, 2006.

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TOP Abstract Introduction Arkansas Aging Initiative (AAI)... Evaluations of the AAI Challenges and Lessons Learned Conclusion References

 

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