How Mississippi Is Changing Public Health

In 2019, Kathy Burk, the Health Services Director of Mississippi's State Department of Health, was retiring early to care for her mother who lived in a rural part of the state. Her mother's growing needs were broad – social, economic, transportation-related, and health. Like other states, Mississippi did not have a coordinated system to help meet these needs and increase the chances her mother could continue to live independently. Burk was struck by how many of her friends were in the same situation. There simply was nowhere to go to get help with the complexity of issues. So, it was with a great deal of interest that Burk learned about an alternative approach that was just being piloted in one state. Its goal was to mobilize the public health sector to help fill the missing gap – that is, to support older adult health and well-being and link with other partners to create a system to maintain independence as long as possible. Given Mississippi's historically low per capita investments in public health, as well as the high-poverty rates in the state, Burk was skeptical of whether such systems change would be possible. Furthermore, the older adult population in Mississippi grew from 12 percent in 2000 to 17 percent in 2022, posing an even greater challenge in meeting the needs of this population through public health approaches.1,2 But she could not let go of the idea of mobilizing the sector she knew so well to focus on the older adult population. And after connecting with those involved in the early pilot, the idea of engaging Mississippi in the nascent Age-Friendly Public Health Systems (AFPHS) movement was born. Today, Mississippi is building a multi-sector initiative to support older adults, engaging leaders across the state in a collective impact approach to healthy aging. The leaders of that effort believe that if it can happen in Mississippi, it can happen anywhere. And, it needs to because Mississippi is not alone in experiencing these challenges, all states are seeing growth in their older adult populations. By 2030, nearly 20 percent of adults will be 65 years or older and by 2040, the number of adults 85 years or older will more than double, to more than 14 million.3,4 The groundwork for an AFPHS arose by observing earlier action steps to establish an age-friendly health care system. In 2016, the John A. Hartford Foundation (JAHF) partnered with the Institute for Healthcare Improvement (IHI) to establish standards to guide the provision of health care services to older adults and improve health outcomes in all settings. They created an Age-Friendly Health Systems framework to center clinical practice on older adult needs based on four core, evidence-based elements, commonly referred to as the 4Ms: what matters, medication, mentation, and mobility (see Figure 1 Supplemental Digital Content, available at https://www.ihi.org/initiatives/age-friendly-health-systems).5 In just 7 years, the Age-Friendly Health Systems movement has seen remarkable success, bringing age-friendly health care to over 2.7 million older adults across the United States and worldwide. Figure: Trust for America's Health (TFAH), in partnership with The John A. Hartford Foundation, developed the Framework for Creating Age-Friendly Public Health Systems (AFPHS). This Framework is based on 6Cs that outline six areas of age-friendly public health activities. This figure is available in color online (www.JPHMP.com). Age-Friendly Public Health Systems Framework The launch of the AFPHS initiative was seen as a natural extension of the Age-Friendly Health Systems, since the patients in health care systems had critical needs that involved broader social, environmental, and economic conditions. Support for this expansion came through a partnership between Trust for America's Health (TFAH) and JAHF (Figure). As with the Age-Friendly Health Systems initiative, the starting point was the development of a framework to guide the work. The AFPHS Framework has six tenets that outline the roles of public health in aging, known as the 6Cs framework.6 The 6Cs, which have been discussed in a previous paper are not intended to be prescriptive but adaptable to the needs and challenges of older adults within a specific state or local community.7 The framework is being used to identify needed system changes, create new state- and community-wide coalitions, guide the development of new tools and resources, induce broader governmental assessment of data needs, and catalyze cross-sector partnerships to improve the health and social well-being of older adults across the country. An initial pilot began in Florida in 2018 where it showed progress in a short period of time. It was this early success that caught the attention of Kathy Burk and others in Mississippi in 2019. The Story of How Mississippi Is Taking a Lead The following year, the Mississippi State Department of Health (MSDH) successfully competed to become one of the next adopters of the AFPHS, along with four other states more associated with public health innovation (California, Michigan, New York, and Washington). This surprised some people because the state of Mississippi is often near the bottom of the list when ranked for health outcomes. However, the MSDH has had a history of strong leadership and evidence-based public health services. Led by the Community Health Improvement unit at MSDH, the state has become one of the leaders in the nation in developing an AFPHS. They have engaged multiple agencies and sectors in standing up an age-friendly ecosystem to prioritize healthy aging in health care, communities, universities, and public health. An AFPHS Advisory Committee was formed to provide multi-sectoral support for age-friendly efforts, including the development of a state-wide action plan based on the AFPHS 6Cs Framework. Among the early achievements, the MSDH has developed a Healthy Aging Data Report and county data profiles with 125 indicators across 82 counties (see Figure 2 Supplemental Digital Content, available at https://msdh.ms.gov/page/resources/19856.pdf). Prior to the development of the profiles, data on older adults had not been compiled and analyzed. The county-specific population summaries have served as catalysts for action by documenting and quantifying the unmet needs of older adults in every county. The data have motivated partners from various sectors such as housing and transportation to join with public health to adopt new policies and actions to improve opportunities for healthy aging. The MSDH has led the effort to build bridges with and between external partners like the Mississippi Public Health Association (MPHA), Area Agencies on Aging, AARP, and the faith communities. In partnership with MPHA and AARP, the development of a champion program for older adult volunteers has promoted community engagement, led to age-friendly and intergenerational activities, and encouraged communities to seek AARP recognition as age-friendly communities. In May 2022 during Older Americans Month, MSDH hosted the 1st Annual Healthy Aging Summit with national, state, and community leaders to share healthy aging accomplishments and prepare for future opportunities to advance multi-sector healthy aging initiatives across the state. MSDH is preparing to host the 2nd Annual Health Summit in May 2024, with the publication of a special issue of the Journal of Public Health in the Deep South (JPHDS) dedicated to healthy aging research and practices. Mississippi's Age-Friendly Ecosystem Mississippi's age-friendly public health efforts are not isolated. They are connected to other sectors in the state including those dedicated to working on age-friendly health care services, universities, and communities. The ultimate goal is to establish a well-functioning age-friendly ecosystem. The components of such an ecosystem in Mississippi include: Age-Friendly Health Systems: Three participant sites (G.V. Sonny Montgomery VA Medical Center – Community Living Center, Marion General Hospital, and Safe at Home) are currently recognized as age-friendly health care sites by IHI. With encouragement from the AFPHS leadership team, the MIND Center, and Geriatric Clinic at the University of Mississippi Medical Center – the state's only academic health science center – is pursuing the ambulatory age-friendly designation. Age-Friendly Communities: Five local communities in the state have been successful in being recognized within the AARP Network of Age-Friendly States and Communities. AARP is actively engaged in age-friendly ecosystem development. MSDH and AARP Mississippi are promoting AARP's Better Together approach to expand the number of age-friendly communities in tandem with the development of Dementia-Friendly Communities. Age-Friendly Universities: In September 2023, Mississippi State University (MSU) joined the Age-Friendly University Global Network, with a pledge to prioritize recognition of the educational needs of older adults, promote career development in the second half of life, and ensure regular dialogue with organizations representing the interests of the aging population. MSU leadership has been engaged in the development of the state's age-friendly ecosystem through innovative educational programming, research, and creative discovery. Dementia-Friendly Communities: In May 2023, MSDH became recognized as the leader in the state's Dementia-Friendly America initiative. To achieve collective impact, age- and dementia-friendly community strategies have become aligned to expand the age-friendly blueprint in the state. In all these components, there is a shared vision and mission to offer healthy aging to all residents. Among other things, this means paying attention to disparities by race, gender, income, and other characteristics that may influence the health of the state's older adults. For example, the state's Black older residents are more likely to lack health insurance, struggle to find affordable housing, and live on a low fixed income. Those characteristics are likely to elevate their risk of preventable illness, injury, and death. With more than half of Mississippi's population residing within a rural community, the lived experience of these individuals demand increased efforts toward the delivery of age-friendly resources and services. To address the uneven impact of the social determinants, each of the components of the state's age-friendly ecosystem has equity at its center to ensure that policies, programs, and services are targeted toward underserved communities. The Mississippi AFPHS initiative is still in its early stages. Many of the services needed by Kathy Burk's mother and other older adults in that state are still unmet, as they are in most states. But progress is being made and, perhaps most importantly, a forum exists for those who want to work to fill those gaps. There are people throughout the state that have the tools, the training, and the access to experts who can help. The story of how Mississippi became a national AFPHS leader can provide a map for how other states can review, rethink, and revamp their activities to ensure that those over 65 years of age are not neglected. Historically, there has been limited public health focus on older adults and limited collaborations with health care systems and the aging sector, but leaders in Mississippi and other age-friendly states are paving a path for public health to embrace its role in meeting the needs of its aging populations. TFAH and JAHF are planning to further expand AFPHS nationally and make the health and well-being of older adults a core component of public health at federal, state, and local levels with people like Kathy Burk's mother in mind.