Healthy Aging: Healthy Brain Initiative Road Map and Role of State Leaders

Author: ASTHO

Hi, and good afternoon, again, everybody. Thank you for joining. This is Lynn Shaull with the Association of State and Territorial Health Officials, and today's webinar is focusing on the Healthy Brain Initiative Road Map and the role of state health leaders.

And just as a head's up, as you've probably discovered, all participants on mute. So if you have a question at any point during the presentations, please feel free to type it into the chat box, and then at the end, we'll have an open Q&A discussion section, so during that time, you can press "*7" to unmute your line or continue to type questions in the chat box. Also, following today's webinar, I will send a link out so everybody can access the PowerPoint presentations, as well as the recording. And so for today's agenda, our first presenter will be Lynda Anderson. She's the director of the Healthy Aging Program in the Division of Population Health at the National Center for Chronic Disease Prevention and Health Promotion at the Centers for Disease Control and Prevention. Then, we'll have Jewel Mullen, the commissioner of the Connecticut Department of Public Health; and then Katherine Morrison, a senior associate director of public health at the Alzheimer's Association in their public policy division. So thank you again, everyone, for joining. And with that, I will introduce Dr.

Lynda Anderson and ask her to please begin. Thank you and I just wanna do a sound check for my voice. Is it loud enough? I can hear you well, Lynda. Excellent. Well, we're very pleased to be with you this afternoon, and I really want to extend a special thank you for ASTHO for sponsoring this webinar and giving us an opportunity to speak with you. What I want to do today is to provide a brief context, first, before I describe the new Public Health Road Map.

I wanna talk a little bit about the changing demographics that we're seeing in our country, as well as how we begin the Centers for Disease Control and Prevention Healthy Brain Initiative. Okay, I'm hitting on the arrow, and I'm not being able to move it. Okay, let me go back. Excuse me for a second. I'm getting used to the technology. So let me begin by talking about the population who are over the age of 65, as well as those over the age of 85, and you'll see a graph that starts from 1900 and really goes up and projects until 2050. And you'll notice that the 65 and older have been gradually rising since 1900, and there are currently in 2011, which is shown by the red arrow going up, about 35 million adults over the age of 65. And what we'll see, it's projected that by 2030 that that number will double to about 72 million older adults, and you'll also notice how the line really sharply increases between that time, and this is because, really, the baby boomers, those born between 1946 and '64 are now reaching that age after 2011 in that growth in that population.

Healthy Aging: Healthy Brain Initiative Road Map and Role of State Leaders

But what's also important to note in this is for the lower one, the one that it's in light purple, the 85 years and older are one of the fastest growing populations of any age group, and they will be increasing from about 4.2 million to about 9 million. And I point this out because those who are 85 and older look quite different from the 65 and older ñ 65- to 84-year population because, one, they have more health risks and, again, are generally more frail and more likely to experience institutionalization. So on the next slide, we just wanna point out, from a public health perspective, the importance of looking at the leading causes of death, and this is a slide from 2010 statistics, and you'll note that Alzheimer's disease is now the 6th leading cause of death among all ages. And just recently, in 2007, it overcame diabetes, and so what we're seeing is increase in the number of people who have Alzheimer's disease, where some of these other major chronic conditions are decreasing, so, again, pointing out the importance of really, as a public health issue, Alzheimer's disease and dementia is.

So let me turn, now, to the CDC Healthy Brain Initiative. In 2006, Congress appropriated funds to CDC's Healthy Aging Program to really address brain health with a focus on lifestyle issues. So CDC formed a partnership with the Alzheimer's Association, the National Institutes of Health and their Institute of Aging, the Administration for Community Living ñ many of you will know that the Administration of Aging is a component of that, as well as AARP and other national partners, to collaborate on a multifaceted approach to addressing cognitive health. And so the goals of this initiative, really, are threefold. One was really to understand, "What does the public think about cognitive health, as well as the burden the cognitive impairment?" and looking at this through a public health lens, and one of those systems that we use is, of course, the Behavioral Risk Factor Surveillance System. And then the second component is to build a strong evidence base for policy, for communication, and programmatic interventions for addressing impairment, as well as maintaining cognitive health, and we tend to think of cognition, really, along a continuum, meaning that people will have good health and good functioning in terms of thinking, executive function, in terms of memory, in terms of organizational aspect. And then, on the other far end, we think of it as impairment and think of things like dementia, as well as Alzheimer's disease.

And then, really, the third component was to translate what we learned through those into effective public health practice, both by public health partners, as well as our partners in states and communities. So in 2006, we held a meeting with many of these partners to really look at the state of the science. All of our work at CDC, of course, is science driven, and we have a foundation of science, so we held a public health research meeting, which was put out in a publication, really, to begin to look at what the issues were around vascular health, as well as some of the prevention opportunities such as physical activity, and other known things. And with that, then, and that science foundation, we created the first Road Map which was the Healthy Brain Initiative: A Road Map for Public Health. And within that, there were 45 action items related to surveillance, related to applied research, policy, and communication. And so from 2007 until 2012, CDC and our partners did a number of efforts and initiatives, and one of those you might ñ and I hope that you're familiar with, and we can talk about more later ñ is the Healthy People 2020 now has a topic area on dementias, including Alzheimer's disease, as well as the topic areas in older adult health, have several objectives that now include cognition.

So in 2013, we created a new road map, first, because it was really time for that initiative to look at and begin to think about the roles of others, and very ñ two important efforts were going on. First, in 2011, there was the National Alzheimer's Project Act, which is really a way to bring ñ headed up by the ASPE at the Health and Human Services ñ to really bring together federal partners and private entities to really make a difference in terms of addressing Alzheimer's disease and related dementias. And then, as part of that, is the national plan to address Alzheimer's disease, and there have been ñ the initial plan came out in 2012 and then a subsequent plan is in 2013, and this national plan is updated yearly to look at the progress that's being made.

So given that this national focus, we really decided it was very important to begin to reach out to states and local entities, many who are already leaders in some of these areas, but to bring together sort of a state and local focus and abilities to begin to talk about states. So we formed a leadership committee. And I'll just point out that the Association of State and Territorial Health Officers were well represented on our leadership committee, and we had others, such as the National Association of Chronic Disease Directors. And about half of our leadership committee was made up of state and local leaders to really help us to plan and to make sure we heard the voices from the state and local communities. And quite briefly, we used a participatory process to develop this Road Map. It was very important that we, as a leadership committee, just didn't come together and say what states should be doing. We really wanted to hear what states thought was happening in there and where they should be moving forward.

So we used a process called concept mapping which really involves an idea generation, where we heard from about 280 stakeholders getting their views about what actions we should be taking in states and local communities in partnership with national organizations and others. And then those were synthesized down to a more manageable set of ideas and then put back out to the stakeholders to get their input. And what would the priorities be, as well as how would this look? And how would we conceive of these different ideas? So initially, there were about 54 ideas that went back out to states, and those were subsequently narrowed down to about 35 actions for public health community to really have that focus over the next five years. And so pictorially, what I have on the next slide is just showing you how this map looks, and this is really kind of in a two-dimensional space, but all of those numbers represent an individual action item that was recommended and came through this process, but they really cluster around some specific components. They don't just individually float out there, and, really, they hang together in four particular ways.

So one was to ensure a competent workforce. The other is to educate and empower the nation. The third theme was to monitor and evaluate, and the fourth theme was to develop policies and mobilize partnerships. So, as you all know, you're very familiar with the ten essential services of public health and including the three core public health functions of assessment, policy development, and assurance, and this wheel is important, and I'll link it back to our concept map in a minute.

But, really, we want to make sure that our work focuses on population health, that we really stick to our core function in public health of the identification and monitoring of health, and then making sure that we align our resources and protect health. So, in using this public health framework, we've really aligned, and that is the blue circle that you'll see in the middle that has, at the core, applied research and translation, how we obtain and sort of gain knowledge, along with how do we assure in terms of the assurance function, the assessment function, and policy development. And then placed around this are the four components of the concept map ñ again, monitoring and evaluating, educating/empower the nation, developing policy and mobilizing partnerships, and then ensuring a competent workforce. And so in this slide, I really just provide, again, there are 35 different action items in the Road Map, and we'll talk about those more as we progress today, but I just wanted to give you four examples, and this is including some work that we're currently doing with ASTHO. So one example of an action item ñ and these action items, it's very important that they're not so specific that they wouldn't apply to some states. They're at a level where specific actions could be placed within them. So again, we want these to be able to apply across all states and be able to, then, resonate at the local level, as well. So in terms of "monitor and evaluate," an example is to conduct a national-level review of the caregiver programs and policies that are consistent with The Guide to Community Preventive Services and methodologies.

An important issue is, "What is the public health role in looking at this in partnership with many other national partners?" Another ñ "education and empower the nation" ñ would be to create awareness by contributing public health information and data about cognitive health and impairment to national reports and partners. And again, this is a function that many states do, and so this is a way to get cognitive health a part of thinking about not only the physical health, which we're very used to doing in public health, as well as the mental or emotional health, but really having cognition be the third leg of that three-legged stool. And then, in terms of "develop policy and mobilized partnerships," an example there would be to integrate cognitive health and impairment into your state and local plan. So some of you may have an aging plan, and you work with them to look at that and make sure that impairment is there, to look at coordinated chronic disease plans, and, in addition to physical health and mental health, do they have cognitive health? Preparedness, an important area for all of us in thinking about, both, at the local and the state level, and then falls work, as well as transportation plans. So there are many sectors where this could be involved and has state leaders involved and influencing. And then an example from the "workforce" would be to develop strategies to help ensure that state public health departments have expertise in cognitive health and impairment related to research and best practices. And this seminar is one of those ways to begin to talk about that. And so I'll just mention, in my final slide, some of the current implementation activities by CDC, and we're develop, now, sort of for our whole initiative, a logic model and narrative to begin to share with others who may want to use some components of that to sort of think about this work and how it can be forwarded and how it relates together.

And then, we're selecting priorities at CDC that meet our mission. And then just a couple examples of one of our big goals is to enhance our own partnerships and developing new funding opportunities with states and partners. So with ASTHO, we are reviewing, currently, caregiver strategies. Using a public health lens, we're developing a number of case studies, as well as sponsoring webinars such as this one. And then our colleagues at the National Association of Chronic Disease Directors have out a new opportunity grant to implement to selected action items from the Healthy Brain Initiative, and I've given the RFA number there, and I hope that we can talk a little bit more about that at the question-and-answer period. And so with that, I'll just give you our contact information and then turn it back to Lynn. Great. Thank you so much, Dr.

Anderson, and, yes, we can definitely discuss that a little bit more at the end. And if folks have questions right now, again, feel free to type those in the chat box. And up next, we have Dr.

Jewel Mullen, the commissioner of the Connecticut Department of Public Health. Thank you and good afternoon, everyone. I hope you can hear me all right, as well. Mm-hmm. We can.

Thank you. So I am especially pleased and privileged to be included in this presentation. I've been commissioner in Connecticut for 3 years, but it's been almost 20 years since I did a postdoc as I got my masters of public health degree, and my focus was, then, what was called "successful aging" with a big focus on community dwelling, older adults, and what I would think about as the sort of the social determinants of healthy aging. So 20 years later, I have to say that, periodically, when I, as a public health commissioner, talk about my interest in healthy aging, people still wonder what public health has to do with that, particularly as they think about older adults from the framework of a health care system and hospital readmissions or long-term care or when they throw their hands up and aren't sure what to do about the booming age of the baby-boom population that Dr. Anderson just characterized in her presentation. So it's wonderful to be having this conversation, understanding that the National Public Health Road Map to maintaining positive health is a call to action and the guide for implementing a coordinated approach to moving cognitive health into the national public health arena.

And it's wonderful to have the shared leadership of CDC and the Alzheimer's Association because this collaboration of synergistic thinking is really essential to moving the work forward. So what we're seeing is a shared vision that's still a work in progress but that builds on a foundation of work that's been done already, established a framework within which we can view findings of that work, and helps lay out an agenda for the future. And, for me, as we have this focus on the Healthy Brain Initiative, it's part of what's important to me to think about in considering what it takes for people to live and age well in their community. So just a little bit about Connecticut ñ Connecticut is a relatively small state ñ 3.5 million people, and 14.2 percent of us ñ or, well, I'm getting there ñ are 65 or older. That 14 percent is actually a 7.7 percent increase from the 2000 to 2010 census. Data from the American Community Survey show that 18.2 percent of Connecticut residents are veterans, and half of those veterans are greater or equal to 65 years of age. And from the American Community Survey, 33 percent of adults greater or equal to the age of 65 report having a disability, and among them, 11 percent report that that disability is a cognitive one that causes them problems with their daily living.

You may have seen, last summer, the America's Health Rankings from the United Health Foundation. The senior report that accompanied the overall health rankings in which Connecticut was ranked seventh overall in the health of seniors, and two areas in which we were cited as ranking highly were in the high prevalence of dental visits and health screenings for our older adults and the low prevalence of teeth extractions. And as we do this work in Connecticut and always keep a health equity focus on it, I do want to point out that, along with those data, what we also understand from a National Association of Chronic Disease Directors-funded project that enabled us to go out into long-term care facilities and a community congregate meal settings, like at senior centers, we actually saw a little bit deeper picture of what the oral health status of adults ñ older adults in Connecticut was because almost half of the adults in the outpatient meal settings reported that they had poor condition of their teeth or dentures, and about half had had partial or full extractions. So we like to look at our aggregate data and continue to look deeper at the same time. Also noted in that seniors report as that Connecticut was cited as having a low percentage of hospice care, not enough hospice care available to our older ñ or to our communities, in general, that more than a third of people had multiple chronic conditions, and almost a third reported physical inactivity.

Those latter two, the multiple chronic conditions and physical inactivity, are certainly important for us to continue thinking about as we think about overall health and the contributions to cognitive dysfunction and decline. The long-term goal with the Healthy Brain Initiative, to maintain or improve cognitive performance of all adults, only can be achieved through collaborative and effective partnerships at the national, state, and local level. On this slide, for the domain of developing policies and mobilizing community partnerships, we see the Alzheimer's disease plan, having a state plan on aging, a task force on Alzheimer's disease and dementia, and legislative commission on aging as some of the strategies that are really key to getting the work done in this domain. The coordination of contributions by private, nonprofit, and governmental partners may provide leverage for synergistic opportunities and more comprehensively address and promote cognitive functioning and the needs of care partners. I wanna point this out because a lot of times in public health, when we do our work across the lifespan, after we start to see how we frontload our efforts and budgets on maternal-child health and early childhood work, you can almost feel as if there aren't enough resources to get anything done once you get to middle- and older-age adults. So those community partnerships and public-private partnerships are especially important for us to continue to develop to answer questions such as, "Well, how are we ever gonna have the resources to move this work forward?" And beyond that, these are multisectoral efforts that cross so many elements of people's lives and communities that it's important to have the partnerships working. Partnership with primary care and public health is especially important for a lot of reasons which are pretty obvious, and I just wanna point out that part of that also comes to the issue of early detection and diagnosis in order to provide the best medical care and outcomes for people at any stage of the disease.

And many times, it's going to be in those communications with the primary care world that people will start to disclose or family members will bring to light problems that people are having at home with their memory, with confusion, and with those situations worsening. Opportunities for partnerships at the national, state, and local level have been talked about in a number of ways in public health, as we've talked about ñ state innovation model grants, community health needs assessments, and the integration of public health primary care or state, or local health agencies move towards accreditation. So within the Affordable Care Act, the IRS requirement for health care facilities, hospitals, to do community health needs assessments and collaboration with their local partners gives us another opportunity to ensure that there's a focus to ask the question whether or not those assessments and plans include support of Alzheimer and dementia's work. In the domain of educating and empowering the public, here in Connecticut, there are some specific things that we have been working on. First, our state health assessment and state health improvement planning that's been ongoing for about a year and a half now involves over 100 different organizations who are our partners.

We have identified some metrics and goals that we're going to finalize next month, and in those are some very aging and cognitively focused measures that we're going to be including. We also have very strong relationships with home care providers who are partners in helping define what else needs to happen to ensure healthy living and aging in communities. Last year, our governor restored the Connecticut Department of Aging, an agency which had been sunsetted almost two decades ago, and they are a key partner for us in addressing issue for individuals, as well as the population health of older adults. We have growing, strong partnerships with foundations in the state who are either funders for aging research and are now, as well, moving into an emphasis on healthy aging and communities. There's been strong representation from AARP on our health-reform-related efforts, and we're about to create our own Connecticut healthy aging state plan. So all these are partnerships.

They're the kinds of partnerships that we also need to continue the work of educating and empowering not just the nation but people in our own state. The issues around ensuring a competent workforce have been particularly important to us because we are in the process of transforming our health care system and the way that has identified gaps in the health care workforce in a number of domains, and there's been intense conversation about how we, as a state, are going to prepare the medical community to be there for our aging population through training for medical students and expanding the numbers of geriatrics providers in the state. But along with that, knowing that the shortages of providers are in the thousands, we're focusing a lot on effective team-based care. This year, we also have legislation just introduced by the governor last week around expanding scope practice for nurse practitioners. Many of you probably know that this is a somewhat contentious issue for a number of reasons in many states as people look at what level of providers should be delivering what type care. Along the way, as we have these conversations, though, I believe we're going to be able to define a number of ways in which nurse practitioners can really fill some gaps in our workforce.

At the same time, we have a strengthening, effective collaborate with our AHEC ñ our Area Health Education Centers ñ who are going to be working with us around a formal curriculum for training community health workers and navigators who, as we transform health care system, should become part of the team and whose work should be possibly licensed but also reimbursed. That's another key workforce component that's going to be necessary for our older population. The last thing that I would say as a state health official is that it's so important for us to really stay in touch with work that's being done in our agencies across programs, work our staff might be doing that we're not even aware of, whether or not it's contributing to efforts around patient-centered medical homes, chronic disease self-management program, injury prevention with a focus on falls prevention, community transformation grants, and good land use or transportation, oral health ñ as I alluded to before ñ are strengthening the local health system to work with area agencies on aging who can be especially helpful to adults with cognitive impairment and particularly essential partners for the caregivers of those individuals. I feel as if I could go on because I'm so passionate about this, but I know that it's time for me to actually, if not present, at least pave the way for Katherine Morrison for the next part of the presentation. Thank you. Excellent.

This is Catherine Morrison. I'm with Alzheimer's Association. Can everyone hear me? Yes. Just a sound check ñ can everyone hear me? Yes. Okay, great. Excellent.

Sorry ñ new system to learn. Well, thanks so much for joining us today to hear about the Road Map, to hear about all the good things associated with it. Thank you, ASTHO, for inviting the association to be part of this webinar and to Lynda for doing the setup and explaining how we got to this place, and Dr. Mullen did such a great job of talking about how the Road Map and the domain really fit nicely into our broader public health work. And there's so much opportunity, as she was saying in the notes that she ended with, that there's a lot of opportunity ñ just use the Road Map to integrate cognitive health and Alzheimer's disease and address the needs of caregivers into our broader public health work.

But I wanna talk about, today, some very specific examples within the four domains, again, of what states are already doing to implement the road map, and just as a first note, I would say the biggest thing the states are doing is using the road map as a convening tool, using it as a booklet and a set of ideas to think about addressing these issues in the broader public health context. So there's a lot of really exciting work going on around specific action items. I'm gonna speak to that real shortly, but, also, I would just say the biggest piece right now, and it's very, very early implementation stage, is that people are using it to think about and assess their own department's work on these issues, and that is a critical first step in thinking about the Road Map. So going to my first slide here, Assure a Competent Workforce, we just heard about how important that is. I wanna pull up this example from New York State, and W-06 details making sure physicians are aware of validated cognitive assessment tools. In New York, the commissioner of health issued a "Dear Colleague" letter to all doctors, hospitals, clinics, medical schools, and managed care plans for the state detailing the importance of early detection and those validated cognitive assessment tools. Now, you can find this on the New York Department of Health's webpage under their Alzheimer's page.

They're one of the few state departments of health that already have information on Alzheimer's disease on their website. This has stirred a lot of conversation in the state of New York. People have asked questions. They have asked to be linked to resources, looking for training, so this has been a real too for helping inform physicians and other medical care providers and make sure they're connected to resources. I'd also say that in Georgia the commissioner of health there has also agreed to do a "Dear Colleague" letter, so this is a very easy thing to do ñ use systems that are already in place to communicate with these individuals and make sure they know what resources are available out there. So what is the "monitor and evaluate"? This is obviously the foundation of assessment and the work that public health does, and we've seen states already using data from the BRFSS in their needs assessment among all counties of public health. So in the state of Missouri, a survey went out to all local counties of public health to assess what are the diverse needs among their constituents, their population among racial, geographic, different kinds of breakdowns, and so they started that in early January, and they're going to present the results back to the community in early March.

So again, just a very simple survey looking to ñ it was sent to all public health administrators in each local public health county in the state of Missouri asking about their needs around cognitive health and addressing the needs of caregivers. M-02 talks about BRFSS data and putting it to work, so thinking about how we can incorporate in all the public health work that we do. And we've seen in a few states ñ in California and Oregon ñ where they're taking the data to influence their preparedness efforts and also falls prevention, so specifically in California speaking about the numbers of individuals who live alone with that increased confusion on memory loss and how to reach those individuals in terms of falls prevention. Educate and empower ñ so in all the presentations that we've done, as an association, this is always the domain that really seems to speak to public health in the biggest way, and I have a couple pictures here from symposium events that have been conducted around this domain and around the road map, generally, to really talk about these issues and start to track priorities. So the topics you'll hear from Minnesota has some very diverse participants ñ schools of public health, aging public health, academics ñ to come together to really focus on two or three priorities within that. They're having a follow-up meeting to that at the end of February. And then the other picture is from Saint Louis University in Missouri, again a symposium event, invited public health practitioners, aging officials, into groups to determine priorities, so within this action item really using the Road Map as a convening tool to establish priorities and to focus energies. So finally, in Develop Policy and Mobilize Partnerships, P-01 is probably where an area where we've seen the most impact of the Road Map.

And Connecticut and several other states where the task forces that we're in the midst of planning their state plans ñ or writing them ñ have really used the Road Map as a tool to think about what should be incorporated into those state plans, the state Alzheimer's disease plan. So we see a lot of language that mirrors from those plans and the Road Map, and that's nice to dovetail as many things as possible so we're coordinating our work. And then P-03 talks about expanding programs to consider issues like cognitive health and impairment, and something that we've seen in Oregon, again, is expanding their preparedness work to address individuals of cognitive impairment specifically to include these issues in a toolkit that goes off to their local counties of public health.

So these are just a few ideas of how to incorporate the Road Map into the work that you're doing, how to use it, some ideas that you can copy off of. The slides that will be sent off have some links to find these resources, to find what other states are doing in this area, so quick and short 'cause I think ñ I'll just pass that along for Lynn to take over, now. Mm-hmm. Great. Thank you so much to all of our presenters ñ Katherine Morrison, Jewel Mullen, and Lynda Anderson. So, yes, we definitely ñ we have a few moments for questions or comments.

I wanted to let folks know one has come through the chat box, and Jewel answered via chat, but it would be great if you could answer verbally, as well. The question was, "How is mental health integrated in your work?" So if Dr. Mullen could start and then if Miss Morrison or Dr. Anderson have comments to add, that would be great. And I have a comment, as well ñ this is Lynda. Okay. Perfect. Okay.

Can you hear me? Yes. Yes. Great.

So we're tackling this from a few different directions. Our epidemiologists are taking a deeper look at the responses that we received to the BRFSS Cognitive Impairment Module and is going to make a fact sheet which is going to help us highlight for primary care providers and others what the needs are and what problems we've identified among both adults who have identified themselves as cognitively impaired and their caregivers because when we think about the behavioral health side, we're thinking about it from the perspective of the affected individual and the family and others that support them. So that's one piece of it.

Another is that we are ñ because Connecticut has been among the states cited for inappropriate use of psychotropic medications among older adults, particularly in long-term care, we've had a number of work groups dealing with that right now, and that's really gotten us to do more trainings with providers around appropriate management ñ behavioral management folks. Through our state health assessment, we've also identified in Litchfield County, which has the population with the highest average in median age, issues around binge drinking, suicide and social isolation, particularly where there's not great transportation. So that's going to be work that we'll be talking with our area agencies on aging about how to address some of the social support needs there. But that's, in certain ways, just scratching the surface, but those are some of the ways in which we'll be doing that from public health. Of course, we always have to partner with the Department of Mental Health and Addiction Services, too. Oh, excellent, Jewel. And this is Lynda Anderson.

I'll add on a little bit to that. One of the things, when we started working on cognitive health, is I said we really sort of looked at both physical health, mental health, and cognitive health, and our work here at the Healthy Aging Program, we've actually done a considerable amount of work in mental health, and we have several briefs on our website that talk about the data on mental health in terms of states. We have the State of Health in America report that includes measure of well-being and issues, plus the Guide to Community Preventive Services, which is really CDC's way to get out information about evidence-based programs. We had sponsored a review of looking at depression interventions, and, on the site, now, it talks about those that are evidence-based and what's recommended, and I think your point is well taken.

It's really the cognitive ñ emotional health are very closely intertwined just as physical health, mental health, and cognitive health. So we're just trying to, in a sense, add cognitive health to the areas that public health has really done a lot of work in and so a really excellent question. Thank you. Great. Thank you. And one other question that has come through the chat is, "Are any states funding state or local public health to address cognitive impairment?" Kate, do you know? This is Lynda Anderson. I'm not familiar.

Angie Deokar's in the room with me, and both of us said we're not familiar with that, but I think that would be an important thing to begin to look at as part of this initiative, as the Road Map was just released in July, so many of the implementation pieces that Kate has talked about are beginning, and so that's one of the things that I think we'd love to get a better handle on ñ is looking at that and being able to share that. I don't know of any states ñ this is Kate Morrison from the association ñ that are directly funding ñ have created a funding stream. Now, I know there's a few states that have someone in their health departments doing Alzheimer's disease work. It's usually paired with arthritis or some other chronic disease, and it's not a full program.

It's just part of someone's responsibility. So in Texas, they have an Alzheimer's disease coordinator, for example. The state of Iowa has tried to create a role, and FTE to do ñ to have a program coordinator, so I think there is definitely some interest and some examples out there of why that's so important. But again, like Dr. Anderson, I think it's an important thing for us to do is scan to see ñ where are those resources and capabilities? And how can the Road Map and the Association, the CDC, and ASTHO all support that? And this is Jewel Mullen.

I would call this question a great ñ a call for a "silo buster" opportunity because it may be that there is some funding some place, but people don't think of including public health in it, and it may depend, state-by-state, how strong partnerships are. I think the AARP can be a great partner at the state and local level helping reinforce that public health has a role here, particularly if, for many people, the issues become those around nursing homes, long-term care, without getting enough conversation about the growing number of people who are going to age in place with or without cognitive decline. And similarly, if cognition considered a disability, it may be that the work is thought of as being in a disability agency as opposed to public health. So we, inside government, you know, are responsible for creating partnerships and breaking down fences between ourselves, and I think our other partners outside of government can help us do that, as well. This is Kate again, and a couple people just sent chat messages.

North Dakota has funded care coordinators to augmenting this new staff in the state, and they have a phenomenal care coordination program that's actually featured ñ highlighted in the Road Map itself. And then in Mississippi, they have a division, an Alzheimer's division. They do a ton of great work in the Department of Mental Health around Alzheimer's disease, so definitely two places to look up and the good work being done in those states. And as Dr. Mullen said, looking to creative places to find out where those partners are to move the issue forward. And Lynn, this is Lynda Anderson. I think one of the other things that would be nice ñ if we could distribute of opportunity grants to implement selected actions out to people on the phone today in case they haven't seen this.

I think that would be helpful, and they could see where they could partner with others in the state, and those applications are due on March 14th coming up, but there's still time to reach out and think about particular projects. Mm-hmm. Definitely. Yeah, I can include that in the follow-up e-mail with some of the resources that have been discussed today, as well as the recording. I didn't know if you wanted to give a little more background on that in case folks haven't heard of it before ñ of the opportunity grants. If there's no other questions, let me just take a minute to do that. Mm-hmm.

Yep. Yep. This is the National Association of Chronic Disease Directors with support from CDC, the availability of funds for state and territorial health departments, and, really, what we're trying to do with that is to ñ we have six priorities which were done through a subsequent process after the concept mapping was done, some Delphi process was done. And so the key areas that we're looking at is in promote incorporation of cognitive health and impairment and to state and local health burden reports, you know, again, using the surveillance data to enhance awareness and action in public health programming, to develop strategies to ensure that public health has expertise in cognitive health, about developing and maintaining state Alzheimer's disease plans, and then engaging national and state organizations to examine policies that may differentially impact persons with dementia, and then to integrate cognitive health and impairment into state and government plans, and several of those were ones that I had mentioned.

And so the funds will really support those actions. If there are other actions that states would like to include, they can go through the Road Map, which everyone has a link to and look at that and align that with your programs and then make a case for why that would be an important thing to do. The other thing I'll point out is we're anticipating around 11 grants, and they will vary between $15,000.00 ñ kind of a mini sort of grant to get some things going ñ to $50,000.00 to do some more intensive, and our hope is really, again, for these to serve some synergy across the efforts that Kate had talked about and other initiatives working with those partners to really, again, that integration of cognitive health into what we're doing ñ not a new siloed program but to make cognitive health a part of what public health does to serve the needs of people in their states. Hello? Yes, this is Jody Mishan. I'm from Hawaii. Yes? I coordinate the state plan on Alzheimer's disease and related dementias that's about to come out.

It's at the designer, right now. I just wanted to share that the Department of Health, the Executive Office on Aging, is who I work for, and they're a branch of ñ a department in the Department of Health. The State Health Planning and Development Agency has subarea councils for every county here, and the Honolulu County subarea council, I presented to them about the Road Map. And, as you said, as a tool for convening, it's really effective with great suggestions, and they decided to adopt, as their yearly project, to do a public awareness campaign. And it's been expanded recently to include education of PCPs involving the Department of Geriatrics at the medical school here to create a curricula for early diagnosis and detection ñ accurate diagnosis. And so it's just at the very beginning, but it's wonderful because a doctor came; a neurologist said that it would be important to also do the professional training along with that.

So it's kind of exciting. And it really did all start with this booklet, and it's a wonderful tool and really appreciate having it. Thank you so much, and we'd love to find out more and continue to follow your initiatives, as well as others in the states that are doing that. This is exactly what we're hoping that this will serve ñ as a guide to bring people together and think about these very issues, so thank you so much.

You're welcome. Thank you. This is Lynn again, and I know we're reaching the top of the hour.

But if anybody has any last minute questions, please feel free to ask by pressing "*7," and I've also included my contact information:, and I can get in touch any of the presenters if you have any follow-up questions that come to you later today as you're eating dinner or driving home. I just wanted to thank, again, everyone who participated on today's webinar. Everybody who attended and presented, thank you very much for joining us. Following, once you close your side box, you'll be taken to a survey ñ evaluation.

So if you could, please fill that out for us. That would be fantastic. As you've said, this is the first of many webinars that we'll be convening.

So the more we learn from you ñ the earlier, the better. And with that, please plan on joining us next month on March 17th at 3:00 PM Eastern Time, where we'll have the 2nd webinar, and it will be focused on cognitive health and injury prevention. So thank you again, everyone, for attending and have a wonderful afternoon. Thank you very much everyone. Bye-bye.

Bye. Thank you. Please standby. [End of Audio].

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