1 Jaime Piccola Assessing Knowledge in Senior Citizens. Can Education Improve What is Important to Senior Citizens in Regard to the Annual Wellness Visit 2 Chapter 1 The thought of our health becomes increasingly important as we become elderly. Remaining independent and enjoying life becomes a priority for seniors. Taking that into consideration, preventative health should remain important to them. Preventative healthcare is vital in maintaining one’s health. The Annual Wellness Visit (AWV) is a great example of preventative care for senior citizens. The AWV is for adults 65 and over who are Medicare eligible. This annual service provides Medicare patients with a chance to create a prevention plan to stay healthy. It also gives them an opportunity to talk to their health care provider and ask questions about their health. The purpose of this study is to assess the knowledge of what senior citizens know about an AWV by completing a pre- and post-test using my AWV survey. Can seniors learn what is included in an AWV through an educational presentation, thus leading to an increase in participation and possible improving of overall health? Background The AWV was mandated to be reimbursed for Medicare patients over 65 years of age when the Affordable Care Act was implemented on January 1, 2011 (“MLN Matters”, 2016). The Annual Wellness Visit includes: establishment of an individual’s medical/family history, a list of current providers who are involved in the individual’s medical care, measurement of height, weight, BMI, BP, detection of any cognitive impairment the individual may have, review of the individual’s potential risks for depression or other mood disorders by using the appropriate screening instrument, review of the individual’s functional ability and level of safety based on direct observation or screening questionnaire, 3 establishment of a written screening schedule based on recommendations of the United States Preventive Services Task Force (USPSTF) and the Advisory Committee on Immunization Practices (ACIP), as well as the individual’s health status, screening history, and age-appropriate preventive services covered by Medicare, establishment of a list of risk factors and conditions for which primary, secondary, or tertiary interventions are recommended, and furnishing of personalized health advice to the individual and a referral, as appropriate, to health education or preventive counseling services or programs aimed at reducing identified risk factors and improving self-management, or community-based lifestyle interventions to reduce health risks and promote self-management and wellness, including weight loss, physical activity, smoking cessation, fall prevention, and nutrition (“MLN Matters”, 2016, pp. 2-4). The exam is very comprehensive and covers many different aspects of an individual’s health. An AWV may or may not include a physical exam as its focus is on having a conversation to address health prevention and screening. Despite the benefits available in the AWV, many elderly patients do not take advantage of this service. Although 2 million seniors qualify for Medicare every year, there are around 100,000 annual wellness exams that are billed (Fiegl, 2011). One reason is Medicare patients may not know that preventive care is covered (Beran & Craft, 2015). Other reasons include patients’ lack of understanding and perception of wellness visits being valuable (Beran & Craft, 2015). Most people think that the only reason to seek out a healthcare providers’ help is when an acute problem arises. 4 In 2011, a report was published called Enhancing Use of Clinical Preventative Services Among Older Adults, Closing the Gap. The purpose of this report was to bring attention to the preventative services available for older Americans over 65. The report described the challenges older adults’ experience that can contribute to them not getting an AWV. Besides their lack of education in not knowing what services are covered, other reasons include transportation difficulties, language barriers, culture sensitivity, and disability (Centers for Disease Control and Prevention, Administration on Aging, Agency for Healthcare Research and Quality, and Centers for Medicare and Medicaid Services, 2011). Older adults count on their healthcare provider’s expertise and recommendations. Unfortunately, because of a lack of time or forgetfulness, healthcare providers may not tell their older patients which preventative services they should receive (Centers for Disease Control and Prevention, Administration on Aging, Agency for Healthcare Research and Quality, and Centers for Medicare and Medicaid Services, 2011). These gaps in care can be reduced through education by increasing the knowledge about the AWV. 5 Chapter 2 Older adults are lacking the knowledge on health promotion and prevention. An example of this is the underutilization of an AWV. This study involved health promotion and education for the elderly. Health promotion is important for people of all ages, including the elderly. There are many things that the elderly can choose to do to promote their health. Evidence has shown that exercising, quitting smoking and limiting alcohol consumption, participating in learning activities and integrating in the community can help to inhibit the development of many diseases and prevent the loss of functional capacity, thus improving quality of life and lengthening life expectancy (Golinowska, Groot, Baji, & Pavlova, 2016, p. 367). With advancing technologies in medicine and research, people are living longer. For the elderly, there are three health promotion components that increase in importance with advancing age, and these include functional capacity, self-care, and stimulation of their social activity (Golinowska, Groot, Baji, & Pavlova, 2016). These three components play a large role in the elderly remaining at home and being independent. The conceptual framework that best fits this study is the Health Belief Model. “This model was created to promote healthy behaviors in individuals by encouraging individuals to utilize preventative care services” (Callaghan, Bieda, & Centopanti, 2013, para. 2). There are four main components to consider in regard to people’s perceptions of their health. They are “the severity of a potential illness, the person’s susceptibility to that illness, the benefits of taking a preventative action, and the barriers to taking that action” (Nursing Theories, 2012, para. 4). These components are described in detail below. 6 Perceived Susceptibility: refers to a person’s perception that a health problem is personally relevant or that a diagnosis of illness is accurate. Perceived severity: even when one recognizes personal susceptibility, action will not occur unless the individual perceives the severity to be high enough to have serious organic or social complications. Perceived benefits: refers to the patient’s belief that a given treatment will cure the illness or help to prevent it. Perceived Costs: refers to the complexity, duration, and accessibility of the treatment. Modifying factors: include personality variables, patient satisfaction, and socio-demographic factors (Nursing Theories, 2012, para. 9-12 and 14). The components are all related to people’s perceptions. Luckily, people’s perceptions can be changed through education. Patient perception is important to understand when trying to promote health screenings to older adults. Familiarizing with the patient perceptions’ will help to establish what methods one can use to provide education. For example, does verbal communication work better than written communication? Understanding their perceptions will help with providing education on why they need to get recommended screenings and vaccines. Health promotion of screening exams such as mammograms, colonoscopies, FIT (fecal immunochemical test) testing, eye exams, vaccines and DEXA scans are all topics discussed in an AWV. These screening measures provide value to the older adult. They are all preventative care measures. The lack of knowledge on the importance of these screening exams is one of the reasons why elderly people do not partake in them. For the older adult over 65, it is recommended that they receive an influenza, Herpes Zoster, pneumococcal, and Tdap vaccines. The influenza (flu) shot is recommended annually. 7 “In recent years, between 80 and 90 percent of flu-related deaths and more than half of flurelated hospitalizations have occurred in people age 65 and older, according to the Centers for Disease Control and Prevention…”(Infectious Diseases Society of America, 2015, para. 4). The pneumococcal vaccine is recommended once for older adults over 65 years. It is only recommended that patients get it a second time if they have received the vaccine before the age of 65 and five years have passed. The Shingles (Herpes Zoster) vaccine is recommended one time for adults over 60. “Almost 1 out of 3 people in the United States will develop shingles during their lifetime. About 1 out of 5 people with shingles will get post herpetic neuralgia or PHN” (Centers for Disease Control and Prevention, 2016, para. 2). It affects the nerve endings and can cause a burning pain (Mayo Clinic Staff, 2015). The risk of shingles increases with age. “Approximately 1 to 4% of people who get shingles are hospitalized for complications. Each year, about 96 shingles-related deaths occur in the United States. Almost all the deaths occur in elderly people or those with a weakened or suppressed immune system” (Centers for Disease Control and Prevention, 2016, para. 4 and 5). A shingles vaccine can reduce the complications. A Tdap (tetanus, diphtheria, and pertussis) vaccine is recommended every 10 years. With a decrease in the number of children getting vaccinated against whooping cough (pertussis), it is important for older adults to protect themselves. They are at greater risk because of their weakened immune systems. The mammogram is also a valuable screening tool that is beneficial to elderly women. In the United States, 21% of women over the age of 75 have breast cancer (Malmgren, Parikh, Atwood, & Kaplan, 2014). Early detection can help to decrease that number. A 2014 study conducted by Malmgren, Parikh, Atwood, & Kaplan showed that mammograms are still effective in detecting breast cancer in women over the age of 75. “Mammography detection of 8 breast cancer in women aged 75 years and older is associated with a reduction in advanced-stage cancer, which has few acceptable systemic treatment options in the elderly” (Malmgren, Parikh, Atwood, & Kaplan, 2014, para. 27). The DEXA scan or bone density test is a simple and cost effective test that can help older adults escape some of the injuries related to falling. A DEXA scan or bone density test is another important screening tool as it can be helpful in diagnosing osteoporosis. Unfortunately, it may not always be used. “A 2008 study using a 5 percent sample of all Medicare beneficiaries revealed that from 1999 to 2005 only 30 percent of women turning 65 (and 4 percent of men) had bone density tests (Span, 2012, para. 7)”. Another study conducted by Gourlay et. al, (2012) suggest that a DEXA scan be completed during intervals and prior to treatment of osteoporosis and a fracture of a hip or vertebrae. Colonoscopies are an invasive procedure that requires people to undergo anesthesia. The test involves a flexible scope with a camera attached to take a good look at the colon. According to the American Cancer Society, “colorectal cancer is expected to cause about 49,190 deaths in 2016” (American Cancer Society, 2016, para. 3). “However, the average age of CRC (colorectal cancer) diagnosis is 71 years, and 43% of CRC cases are diagnosed at age 75 years and older” (Helwick, 2011, para. 5). Benefits versus risks need to be weighed when considering this test. FIT stands for fecal immunochemical testing. It is a test that is used to detect blood in the stool that visually cannot been seen. The FIT is a good test if patients are refusing a colonoscopy. They are easy for adults to complete in the comfort of their own home. The last screening exam to consider beneficial for older adults is the eye exam. Adults over the age of 65 are at risk for macular degeneration and glaucoma. People who are diabetic are also at risk for developing diabetic retinopathy. “The prevalence of blindness and vision 9 impairment increases rapidly with age among all racial and ethnic groups, particularly among people older than 75 years” (CDC, 2011, para. 2). Visual impairment can significantly affect the older adult’s quality of life. “Research has shown that recommended eye care that addresses eye diseases and refractive error may remediate 50% of vision problems” (CDC, 2011, para. 7). Yearly eye exams can lead to early detection of vision problems which in turn can lead to early intervention and improved outcomes. Education on vision loss can give people the opportunity to try and prevent it. 10 Chapter 3 Methodology The aim of this quantitative study was to investigate if an educational presentation would be effective in increasing the knowledge of what senior citizens consider to be important in an AWV. Participants were recruited with the use of a flyer that described the topic of the study and informed them that refreshments would be served (Appendix 3). A 10-question survey, which includes a likert scale, was used to gather the data (Appendix 4). The study participants completed the questionnaire prior to attending the educational presentation. They then attended the presentation and completed the survey once again. Data from both surveys was collected and analyzed. Prior to completing the survey, each participant was screened for any cognitive impairment using the 6CIT. This test only takes 4 minutes to complete, has a high sensitivity, and results that are easy to interpret. Research Design A non-randomized cross-sectional study with purposeful sampling was used to ensure all participants were Medicare patients. The survey was administered twice, once before the powerpoint presentation and verbal discussion on AWVs and then once after the presentation. The pre- and post- surveys were differentiated by assigning colors, red for the pretest and green for the post-test, and corresponding numbers. Setting The setting for this survey study included two senior citizen centers, the Etna Senior Citizen, and the Lawrenceville Senior Center, both of which are located in the area of Pittsburgh, 11 PA. Both centers are located in communities where senior citizens have the ability to come from their homes and participate in various activities, as well as, have lunch. They were chosen based on their response by email and phone calls to participate in the study. Sample The study sample was comprised of senior citizens over the age of 65, regardless of sex, gender, religious affiliation, or cultural background, and who were found to be eligible to participate in the study. The minimum sample size was determined to be 34 participants who met the study criteria. This number was determined using the sample size calculator from Altherapy statistics (ALCTB, 2017). To determine eligibility for participation in the study, all potential participants took the 6CIT, a test that is comprised of 6 questions and screens for cognitive impairment. This was administered by the principal investigator, a DNP student and a FNP with a MSN. The principal investigator read the questions to each potential participant individually and recorded their answers, which were given verbally. The principal investigator then scored each test based on the guidelines of the 6CIT. Senior citizens with a score higher than 8 were excluded from the study. There were 17 participants in the study, three of whom were male and 14 of whom were female. Five participants were between the ages of 70 and 74 years, four were between the ages of 85 and 89 years, three were between the ages of 65 and 69 years, and two were between the ages of 80 and 84 years. There was one participant between the ages of 75 and 79 years and one who was 90 years of age or older. The racial composition, socioeconomic status, or cultural differences were not identified in this study. Please see the table below. 12 Table 1 Description of the Sample Characteristic Gender Male Female n % 3 14 17.6 82.4 13 4 76.5 23.5 3 5 1 2 4 1 17.6 29.4 5.9 11.8 23.5 5.9 Site Lawrenceville Etna Age 65-69 70-74 75-79 80-84 85-89 90 or older Ethical Considerations Institutional review board approval was obtained from Clarion University prior to the start of the study. Because the senior citizen centers do not have an institutional review board, a letter (appendix 1) was provided to the managers of the senior citizen centers outlining the details of the study and asking permission for the study to occur in in their respective center. Once permission was granted, study participants were recruited using flyers (appendix 3) provided to the centers. The information on the flyer included the day the study would occur and the fact that light refreshments and snacks would be available for all participants. Informed consent (Appendix 2) from the potential participants was obtained by the principal investigator. Participation was voluntary with no risks, benefits or compensation to and for the participants. Privacy and anonymity was maintained by having participants only use their gender and age as identifiable markers on the surveys. 13 Instrumentation The survey was specifically created by the principal investigator for the study. All of the questions on the survey are specific to an AWV and are required by Centers for Medicare and Medicaid Services (CMS) to be included on an AWV. Prior to the conduction of this research study, the survey was piloted to test for sensitivity, specificity, and validity. The sample size for the pilot study was 4 participants, which is about 4% of the actual study sample size. The 4 participants were senior citizens from the Lawrenceville senior center who did not want to participate in the study, but agreed to complete the survey. The survey (Appendix 4), which is comprised of ten questions, includes the gender and age of participants as well as the name of the senior citizen center. The survey responses were based on a three-point Likert scale which includes the responses of very important, less important, and not important. Reliability of Pretest and Posttest Items Cronbach’s alpha coefficient was used to calculate the reliability of the pretest and posttest questionnaire items. The reliability of the items at each administration of the questionnaire was .71 (See Table 3). The reliability of the scales is considered to be adequate (Tavakol & Dennick, 2011). Table 2 Reliability of Items at Pretest and Posttest Administration Number of items in scale Cronbach’s alpha coefficient Pretest 10 .709 Posttest 10 .711 14 Data Collection After approval from the IRB at Clarion University was obtained and permission from the senior citizen centers was given to the principal investigator, the study was conducted and the data was collected. The principal investigator collected all pre- and post- test surveys from the participants on the same day as the educational presentation was given. To assure that the data reflected the correct information for each participant, each pretest was identified by having a red dot on it, along with an assigned number and each post-test was identified by having a green dot on it, along with the number that corresponds to the respective pretest. After all data was collected from the two senior citizen centers, the principal investigator reviewed the results to ensure all surveys were completed correctly. The data was then given to the statistician for analysis of the results. Once the results of the study were analyzed and recorded they were provided to the managers of the two participating senior citizen centers. Statistical Analysis Descriptive statistics were used to analyze the data. A paired samples t-test was utilized to determine any differences in the pre- and post-survey answers. Central tendency measures were used to look at the average age of participants and their gender. A post hoc analysis using G*Power was also used to look at the sample size and the effect of their results . 15 Chapter 4 Results This study was conducted to determine if an educational presentation was effective in increasing the knowledge of an AWV for senior citizens. The 10-item questionnaire was administered to a total of seventeen participants, 3 males and 14 females between the ages of 65 and 98 years with the average of 78 years, before and after the they attended the presentation. At pretest, six of the 10 items were considered very important to 88% or more of the participants. At posttest, eight items were considered very important to 88% or more of the participants (See Table 3 below). Two items, depression and functional assessments, were considered less important to the participants at both pretest and posttest (See Table 4 below). Table 3 Pretest and Posttest Responses to Questionnaire Items Level of importance Pretest Item Very* Posttest Less Not Very Less Not Has a list of my providers 100 0 0 100 0 0 Aware of family medical history 100 0 0 100 0 0 Complete a depression screening 47 41 12 59 35 6 Complete a functional assessment 65 39 6 77 23 0 Know height, weight, BMI 94 6 0 100 0 0 Complete cognition assessment 82 12 6 88 6 6 Discuss referral options 82 18 0 94 6 0 100 0 0 94 6 0 88 12 0 94 6 0 Discuss recommended vaccines Discuss recommended screenings 16 Discuss advanced directives 94 6 0 88 12 0 * Percentage of respondents Table 4 Difference in Level of Importance at Pretest and Posttest Test n M SD Pretest 17 1.17 .20 Posttest 17 1.12 .17 t 1.35 p .20 Data Analysis The participants responded to the 10 pretest and posttest items using a 3-point Likert scale that ranged from 1 (very important) to 2 (less important) to 3 (not important). A mean score, level of importance, was calculated for the participants based on their Likert responses to the 10 items. The level of importance score could range between 1 (very important) to 3 (not important). A paired-samples t test was conducted to determine if the participants’ responses were significantly different from pretest to posttest (See Table 4). The mean at pretest was 1.17 (SD = .20), indicating many of the participants rated the items as very important. The mean at posttest (M = 1.12, SD = .17) was even closer to 1 (very important), indicating that even more of the participants rated the items as very important. However, there was not a statistically significant difference (t = 1.35, p =.20) in the participants’ level of agreement from before the educational presentation and after the educational presentation. 17 Chapter 5 Summary and Conclusions The purpose of this study was to investigate if an educational presentation would be effective in improving what is important to senior citizens in regard to the annual wellness visit through the completion of a pre and post-test. The sample size consisted of 17 seniors over the age of 65. The setting was comprised of two senior citizen centers, both near Pittsburgh, PA. Seventeen participants viewed an educational presentation about the annual wellness visit provided by Medicare. The participants responded to a questionnaire asking them to indicate the level of importance they placed on components of the AWV. After the educational presentation, the same participants were asked to respond again to the questionnaire. An analysis of their responses found that the seniors considered six of the components of the AWV very important at pretest, but after the educational presentation they indicated eight of the components were very important. Before the presentation, the participants had considered the following components important; has a list of my providers, aware of family medical history, know height, weight, BMI, discuss recommended vaccines and screenings, and discuss advance directives. After the presentation, the participants considered the following components important; has a list of my providers, aware of family medical history, know height, weight, BMI, complete cognition assessment, discuss referral options, discuss recommended vaccines and screenings, and discuss advance directives. Although there was positive change in knowledge after the educational presentation, the statistical analysis of the change was not significant. Several reasons may have provided a lack of statistical significance. First, the participants indicated many of the items on the AWV were very important before the educational presentation. Therefore, the analysis could not find a statistically significant change in knowledge after the presentation because the participants’ knowledge was already high at 18 pretest. Another possible reason for lack of significance could be low sample size. A post hoc analysis using G*Power found the power of analysis with 17 participants was low at .25. The results revealed a positive change in knowledge after the educational presentation. However the statistical analysis of the change was not significant. Prior to the educational presentation, 88% of seniors viewed six out of the ten items on the survey as very important. These six items included the following: that their healthcare provider: 1) has a list of all their other providers, 2) is aware of their family medical history, 3) knows their height, weight, and BMI, 4) can provide recommendations for vaccines, 5) can provide recommendations for screenings, and 6) could have a discussion on advance directives. The educational presentation included a discussion on all ten of the survey items. After the educational presentation was completed, 88% of seniors viewed eight out of ten items on the survey as very important. The two additional items seniors felt important are a completed cognition assessment and discussion of referral options. Recommendations For Further Research For the future, education on AWVs should continue despite the age of the population. Health care providers need to utilize any opportunity that arises to provide education on the benefits of preventive health care. AWVs are one method of addressing the preventative health care needs in the elderly. Despite the small sample size, results did indicate a positive change in what is viewed as important by senior citizens as to what is important in an annual wellness visit. Because of these results this study may be used as a stepping stone for further research related to AWVs. In future studies more senior citizen centers should be included along with a larger population sample. 19 Although these study results were statistically insignificant, it can be concluded that an educational presentation may increase what senior citizens find to be important in an annual wellness visit. 20 Appendix 1 Jaime Piccola, FNP-C Clarion and Edinboro Universities (Date) Dear (name of manager of senior citizen centers), Your senior citizen center is being invited to participate in a research study that aims to investigate if seniors can learn what is included in an annual wellness visit (AWV) through an educational presentation, thus increasing participation to achieve optimal health. The research study should take approximately 2 hours. During this time, a pre- survey will be given to the senior citizen residents at the center. Following the pre- survey, the researcher will be presenting a 15-20 minute power point presentation to the senior citizens on AWVs. After the power point presentation, the study participants will be given a post survey to complete. Privacy and anonymity will be maintained by only requiring the sex of the participants and their age. Information will be kept confidential to the researcher and the statistician who will be helping sort out the data results. The results of the study will be mailed to all participating senior centers once all of the data is collected and analyzed. I have read the above information regarding this research study on investigating if seniors can learn what should be included in an annual wellness visit (AWV) through an educational presentation and consent to participate in this study. ______________________________________________(Printed Name) ______________________________________________(Signature) ______________________________________________(Date) 21 Appendix 2 UNIVERSITY AFFILIATION: Clarion University of PA IRB Administrative Office, Carlson125, Clarion University, Clarion, PA 16214, 814-393-2343 STUDY TITLE: Assessing Knowledge in Senior Citizens. Can Education Improve their Knowledge on Annual Wellness Visits? PRINCIPAL INVESTIGATOR: J a im e Pi cc ol a , 123 Syc a m ore Dr., Pi tt sburgh, PA 15237, 412 -414 -9228, J .L.Pi c c ol a@c la ri on.e du DESCRIPTION: I understand that I have been asked to participate in this research project which is a study th at aims to investigate if seniors can learn what is included in an annual wellness visit (AWV) through an educational presentation, thus increasing participation to achieve optimal health. The research study should take approximately 2 hours. During this time, a pre- survey will be given to me at the center. Following the pre- survey, the researcher will be presenting a 15-20 minute power point presentation on AWVs. After the power point presentation, I will be given a post survey to complete. RISK AND BENEFITS: There are no risks associated in my participation in this study. I may benefit from this study by increasing my knowledge on what an annual wellness visit is for senior citizens. COST AND PAYMENTS: There is no cost to participate in this study. No payment will be offered to me for my participation. CONFIDENTIALITY: I understand that any information about me obtained from this research will be kept strictly confidential. Privacy and anonymity will be maintained by only requiring the sex of the participants and their age. Information will be kept in locked files and only (the principal investigator and statistician) will have access to it. It has been explained to me that my identity will not be revealed in any description or publication of this research. Therefore, I consent to publication for scientific purposes. DISCLOSURE: I understand that any information about me obtained from this research may be disclosed. It has been explained to me that my identity may be revealed in any description or publication of this research. Therefore, I consent to publication for scientific purposes. RIGHT TO REFUSE OR END PARTICIPATION: I understand that I may refuse to participate in this study or withdraw any time. I also understand that I may be withdrawn from the study any time by the investigator(s). 22 Signature of Subject: _____________________________________ Signature of Investigator: IRB Research Approval # 23 Appendix 3 Attention Seniors over 65 Free seminar Are you interested in learning more about your health and what an Annual Wellness Visit is? Come to the center on (date of study and time insertion here). A certified nurse practitioner (CRNP) will be here presenting information on what an Annual Wellness Visit is and why they are important. Light refreshments and snacks will be provided. 24 Appendix 4 Please read the following questions in response to your Annual Wellness Visit that you receive from your health care provider. Answer the questions to the best of your ability. Thank you. ____Male or Female_______ Age________ Senior Citizen Center name_____________ 1. It is important that my primary care provider have a list of all my health care providers. Very important Less important Not important 2. It is important that my provider is aware of my family medical history (mother, father, brother, sister). Very important Less important Not important 3. It is important that I have a depression screening. Very important Less important Not important 4. It is important to complete a functional assessment (this can include home safety, your fall risk, and activities of daily living like dressing, bathing, grocery shopping, etc.) with my provider. Very important Less important Not important 5. It is important that my provider obtain my height, weight, and body mass index (BMI). Very important Less important Not important 6. It is important that my provider completes a cognition (memory) assessment test with me. Very important Less important Not important 7. It is important that my provider discusses referral options (for example, the Area for Aging) with me. Very important Less important Not important 8. It is important that my provider discusses recommended vaccines with me. Very important Less important Not important 9. It is important that my provider discusses recommended screenings for me including mammograms, DEXA scans, a colonoscopy or occult stool testing, and an eye exam. Very important Less important Not important 10. Is it important that my provider discusses advanced directives with me. Very important Less important Not important 25 References ALCTB. (2017). Sample Size Calculator. Retrieved from https://www.ai-therapy.com/psychology-statistics/sample-size-calculator American Cancer Society. (January 20, 2016). Key Statistics for Colorectal Cancer. Retrieved from http://www.cancer.org/cancer/colonandrectumcancer/detailedguide/colorectal-cancerkey-statistics Beran, M., & Craft, C. (March, 2015). Medicare Annual Wellness Visits Understanding the Patient and Physician Perspective. Minnesota Medicine. pp. 38-41. Retrieved from https://www.researchgate.net/publication/275054301_Medicare_annual_wellness_visits_ Understanding_the_patient_and_physician_ perspective Callaghan, N., Bieda, S., & Centopanti, J. (2013, January). Mid Range and Borrowed Theory. The Health Belief Model:background. Retrieved from http://midrangeborrowedtheory.weebly.com/background-health-belief-model.html CDC. 2011. The State of Vision, Aging, and Public Health in America. Retrieved from http://www.cdc.gov/visionhealth/pdf/vision_brief.pdf Centers for Disease Control and Prevention, Administration on Aging, Agency for Healthcare Research and Quality, and Centers for Medicare and Medicaid Services. Enhancing Use of Clinical Preventive Services Among Older Adults. Washington, DC: AARP, 2011. Retrieved from http://www.cdc.gov/aging/pdf/Clinical_Preventive_Services_Closing_the_Gap_Report.p df Centers for Disease Control and Prevention. (August 19, 2016). Shingles Surveillance. Retrieved 26 from http://www.cdc.gov/shingles/surveillance.html Fiegl, C. (May, 2, 2011). Medicare’s Missed Checkups: Few Seniors Get Wellness Exam. American Medical News. Retrieved from http://www.amednews.com/article/20110502/government/305029954/4/ Golinowska, M., Groot, W., Baji, P., & Pavlova, M. (September 5, 2016). Health Promotion Targeting Older People. BMC Health Services Research, 16(Suppl 5). pp. 367-369. DOI:10.1186/s12913-016-1514-3 Gourlay, M, Fine, J., Preisser, J., May, R., Li, C., Lui, L., Ransohoff, D., Cauley, J. & Ensrud, K. January 19, 2012. Bone-Density Testing Interval and Transition to Osteoporosis in Older Women. New England Journal of Medicine. (366). pp. 225-233. DOI: 10.1056/NEJMoa1107142 Helwick, C. June 1, 2011. Screening Colonoscopy May Benefit Elderly Patients. Retrieved from http://www.medscape.com/viewarticle/743816#vp_1 Infectious Diseases Society of America. September 10, 2015. Where flu vaccination rates are higher in adults under 65, lower flu risk for seniors: Study suggests association between immunizations of younger adults against flu and flu related illnesses in the elderly. ScienceDaily. Retrieved from www.sciencedaily.com/releases/2015/09/150910084557.htm Malmgren, J., Parikh, J., Atwood, M., & Kaplan, H. December 2014. Improved Prognosis of Women Aged 75 and Older With Mammography Detected Breast Cancer. http://dx.doi.org/10.1148/radiol.14140209 Mayo Clinic Staff. (September 16, 2015). Postherpetic Neuralgia. Definition. Retrieved from http://www.mayoclinic.org/diseases-conditions/postherpetic- 27 neuralgia/basics/definition/con-20023743 MLN Matters. (March 2, 2016). Annual Wellness Visit (AWV), Including Personalized Prevention Plan Services (PPPS). Retrieved from https://www.cms.gov/Outreach-and-Education/Medicare-Learning-NetworkMLN/MLNMattersArticles/downloads/MM7079.pdfNational Center for Health Statistics, July 6, 2016. Pneumonia. Retrieved from http://www.cdc.gov/nchs/fastats/pneumonia.htm Nursing Theories, (2012, January 31). Health Belief Model. Retrieved from http://currentnursing.com/nursing_theory/health_belief_model.html Span, Paula. January 18, 2012. Older Women and Bone Tests. Retrieved from http://newoldage.blogs.nytimes.com/2012/01/18/older-women-and-bone-tests/?_r=0 Tavakol, M., & Dennick, R. (2011). Making sense of Cronbach’s alpha. International Journal of Medical Education, 2, 53‒55.