Interest in the prevention of secondary conditions experienced by people with disabilities has increased the demand for empirically-derived, cost-effective programs and procedures to achieve enhanced health and wellness outcomes. 

Health promotion programs must be developed and evaluated for widespread adoption and implementation. Successful programs are expected to produce desirable results, be acceptable to consumers, be compatible within a delivery context, and be cost-effective.

Over the past several years, researchers at the RTC: Rural at The University of Montana and the Research & Training Center on Independent Living at the University of Kansas have collaborated on developing the Living Well with a Disability program (Ravesloot et al., 1994; Seekins et al., 1999). This program has been designed for delivery through centers for independent living (CILs) for adults with mobility impairments. It produces desirable health outcomes, is favorably reviewed by consumers, is compatible with independent living philosophy, and is effectively delivered through CILs. This report summarizes preliminary data addressing the cost-effectiveness of Living Well with a Disability.

Research Goal:

Our goal was to assess the cost-effectiveness of a community-based model for preventing and managing secondary conditions experienced by adults with physical disabilities. To accomplish this, we established several objectives: 

• Replicate "Living Well" to evaluate cost-effectiveness, and generalization across settings and impairment type.
• Conduct longitudinal evaluation of the intervention effects of preventing and managing secondary conditions.
• Develop and evaluate methods for participant recruitment.
• Develop and test measures to assess "readiness" to participate in the program.
• Develop and evaluate procedures consumers can use to maintain and generalize health gains over time.
• Disseminate successful methods and materials to public health agencies, managed care providers, and community-based disability service programs.

Key Terms and Concepts

A secondary condition occurs when a person with a disability develops a complication related to his or her impairment (Marge, 1988). Measured in "hours of limitation per week", the secondary condition adversely affects health and independence.

Cost-effectiveness analysis is a methodology to assess the comparative impacts of expenditures on alternative health interventions (Gold et al., 1996).

Health refers to the status of multiple factors, both internal and external, not simply physiological status. Underlying the Living Well program is the belief that health is not an end in itself but a means to an end.

Center for Independent Living is a community-based, non-profit, consumer-directed, non-residential organization designed to both advocate for and provide support services to people with disabilities to help them live independently in their communities.

Living Well with a Disability is a wellness program focused on helping adults with disabilities manage secondary conditions that limit their participation in daily life. Individuals follow a copyrighted text to develop health behaviors for reducing secondary conditions.

Methods:

The Living Well with a Disability program is an eight-week course taught by trained facilitators to groups of 8 - 12 adults with disabilities. The program begins by helping participants identify how daily health behaviors contribute to the pursuit and attainment of long-term goals. Then, using a variety of problem-solving techniques including solution generation, depression prevention, and communication, the program helps participants make progress toward goals. During this process, the participants develop healthy behaviors such as physical activity and proper nutrition as steps toward their goals.

This research began with a national competition among CILs in response to a request for proposal from two research institutions (The Universities of Montana and Kansas) through the Association of Programs for Rural Independent Living and the National Council on Independent Living. A total of 106 applications were received. A national advisory group selected nine applicants to serve as replication sites. Each site received contracts to conduct four Living Well workshops. The contracts reimbursed the CILs a total of $2,430 for each workshop conducted. Additional monies were disbursed to cover costs associated with data collection efforts.

Two individuals from each CIL received training in the application of the Living Well program. These individuals included either two staff members, or one staff member and one consumer leader. After training, Living Well facilitators began recruiting participants from their local communities. Potential participants were randomly assigned to one of two groups. Participation in the Living Well program was staggered in time across the two groups. The first group completed a pre-measure and immediately began the Living Well program. The second group completed two pre-measures two months apart and then began the Living Well program. Both groups completed post- test measures immediately after completing the program, and at two months, four months, and one year after participation. This staggered schedule was then replicated with two additional groups. To date, a total of 162 people with disabilities have participated in the program.

Measures were collected using the Secondary Conditions Surveillance Instrument. The instrument collects self-reported data on the extent of limitation due to 44 secondary conditions. It also collects data on the utilization of a variety of medical and social services. This preliminary report is based on 77 participants from the first two waves of intervention who completed pre-measures and a 4-month follow-up measure.

Evaluating Disability Outcome: The Living Well with a Disability program reduces limitation experienced by adults with mobility impairments. Participants' ratings of their limitation due to secondary conditions are 10.4% lower 4 months after the intervention than they were prior to it (p <.05). These results are paralleled by an 11.3% increase in health behaviors such as the participant's tendency to take more responsibility for his or her own health outcomes (p < .05). Finally, participants reported 1.77 fewer days per month with poor mental status (p < .05).

Estimating Cost Effectiveness: The Living Well cost estimates are based on survey data collected upon entry into the program and from the 4-month follow-up measure. The cost estimates in Table 1 were calculated by multiplying mean values for different categories of health utilization by respective Medicare "price", or fees, based on 1997 national data for the Medicare program. Overall, the average expenditure for medical services used by participants during the two months before the Living Well program was $4,098. Four months after participating in the Living Well program, reported cost of medical services averaged $3,704. Table 1 presents the average expenditure per participant across seven medical service categories both before and after the Living Well intervention.

Description of Table 1

Table 1. Average Health Resource Utilization Costs

	Entry	4 Months Post-Participation
Inpatient Days	$2,590	$2,170
ER Visits	$58	$26
Outpatient Visits	$199	$262
Physician Visits	$176	$155
Medications	$231	$244
Lab Tests	$226	$243
Therapy and Services	$616	$604
Average Costs per Person	$4,098	$3,704

Source: Living Well Program, The University of Montana Rural Institute and 1997 Medicare data.

Preliminary Observations:

Although participants continue to report significant health improvements and reduced incidence of secondary conditions, the magnitude of change is smaller than earlier pilot test data. The differences may be due to several factors, including a shorter time unit of evaluation and other measurement changes.

In previous research, we reported a significant decline in medical service utilization as measured by the number of times participants reported seeing a physician for a list of medically-related secondary conditions. These data present a similar pattern but offer a more sophisticated view. The data suggest that participation in the Living Well program is associated with a 10% decline in cost for medical services. Specifically, use of emergency rooms and hospital stays declined significantly, while out-patient and physician visits increased slightly. As such, participants may be accessing more appropriate medical service options and getting better medical care.

Assuming the Living Well program is delivered to a full class (12 participants), the cost and expenditure data suggest cost savings sufficient to pay for the program in 2-4 months. Additional return on investment may be realized over time if program interventions are maintained. These cost figures provide sufficient justification to include such a program as a reimbursable service for beneficiaries.

Limitations:

These are preliminary data from a larger sample and represent only a brief period of time after intervention. The measures of both outcome and cost-effectiveness are simple. In particular, the economic calculations do not include other costs associated with participating in the program, such as time of participants, training costs, and materials. Further, these data do not come from a random population of adults with mobility impairments. As such, the generalizability of these results is not known. 

Next Steps:

During the coming year, we will be completing the final waves of data collection. These data will be analyzed to construct cost-effectiveness ratios and to identify factors associated with treatment outcomes. We are also assessing the utility of Maintenance Plus -- a program designed to enhance retention of gains through group support.  Finally, we are examining these data and collecting other data in an attempt to identify "readiness" factors (such as accessibility and transportation) that may predict the likelihood of an individual benefiting from participation in the Living Well program.

Gold, M., Siegel, J., Russell, L., & Weinstein, M. (1996). Cost-effectiveness in health and medicine. New York: Oxford University Press, Inc.

Marge, M. (1988). Health promotion for persons with disabilities: Moving beyond rehabilitation. American Journal of Health Promotion, 2, 29-44.

Ravesloot, C., Young, Q.-R., Norris, K., Szalda-Petree, A., Seekins, T., White, G.W., Lopez, J.C., & Golden, K.  Living well with a disability: A workbook for promoting health and wellness. 1994. Missoula, RTC: Rural.

Seekins, T., White, G.W., Ravesloot, C., Norris, K., Szalda-Petree, A., Lopez, J.C., Golden, K., & Young, Q-R. (1999). Developing and evaluating community-based health promotion programs for people with disabilities.

In R.J. Simeonsson & L.N. McDevitt (Eds.), Issues in disability & health: The role of secondary conditions & quality of life. (pp.221-238). Chapel Hill, NC: University of North Carolina, FPG Child Development Center. publications@mail.fpg.unc.edu

Resources

Living Well with a Disability Health Promotion Program for People with Disabilities 

June Isaacson Kailes, Disability Policy Consultant on Health, Wellness & Aging with a Disability

National Center on Physical Activity and Disability (800) 900-8086

Disability and Health Branch , National Center for Environmental Health, Centers for Disease Control and Prevention

National Center on Medical Rehabilitation Research

National Institute on Disability and Rehabilitation Research (NIDRR)
U.S. Dept. of Education, Office of Special Education and Rehabilitation Services

National Rehabilitation Information Center (NARIC)

National Rehabilitation Hospital  | Center for Research on Women with Disabilities 

National Rural Information Center Health Service | HealthWeb: Rural Health

Research & Training Center on Independent Living 

National Council on Independent Living

The Research and Training Center on Disability in Rural Communities conducts applied research designed to build upon the strengths of rural individuals and communities to solve problems of daily life.  This series of reports makes research results available as soon as is practical.  Note that data presented are preliminary and must be interpreted with caution.  The major limitations are reported. 

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Please contact project staff to discuss issues presented:

Craig Ravesloot, Ph.D., Director of Health Projects
Research & Training Center on Disability in Rural Communities
The University of Montana Rural Institute: A Center of Excellence in Disability Education, Research and Services,
52 Corbin Hall,  Missoula, Montana 59812-7056
(303) 774-6196 Voice; (406) 243-4200 (TTY);  (406) 243-2349 fax;
(888) 268-2743 toll-free
email Craig Ravesloot

Funding for this research has been provided primarily by a grant from the Office of Disability and Health, Centers for Disease Control and Prevention (RO4/CCR814204).   Additional funds have been provided by a grant from the Office on Rural Health Policy (CSDR00046) and NIDRR Grant H133B970017.  Opinions expressed are those of the authors and not those of the funding agencies.

This report is available in Braille, large print and ASCII DOS text formats on request. The Rural Disability and Rehabilitation Research Progress Report Series is edited by Diana Spas.

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