Why We Need Age-Friendly Public Health Systems

The vision for an age-friendly ecosystem encompasses the lived environment, social determinants of health, the health care system, and a prevention-focused public health system.

By Nadine Gracia
President and CEO
Trust for America’s Health (TFAH)
Terry Fulmer
The John A. Hartford Foundation

The authors would like to thank Megan Wolfe, Jane Carmody, Karon Phillips, and Katie Cunningham for contributing to this article.

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Driven by the Baby Boomer generation, the growth of the older adult population is unprecedented in U.S. history. The number of people ages 65 years and older is projected to nearly double between 2021 and 2060, rising from 54 million to 95 million, and increasing older adults’ share of the total population from 16.5 to 23 percent.1 Eighty percent of older adults will experience at least one chronic condition such as heart disease, arthritis, diabetes, or depression2 and over 60 percent will face at least two.3 A robust public health system focused on prevention, preparedness, and wellness could mitigate these health challenges and inform effective strategies to promote health and well-being and advance health equity for older adults. Yet chronic underfunding consistently hinders public health efforts, despite overwhelming evidence from programs that are successfully preventing disease and injury and effectively preparing for disasters and health emergencies with strategies specifically for older adults. 

We can do better. An effective age-friendly ecosystem can be formed through collaboration among sectors and stakeholders so that the strength of public health systems can truly be realized. One particular organization, and the framework it developed as well as other efforts, are combining to help make that happen, and the impact is being felt in multiple states.

Age-Friendly Public Health Systems

Trust for America’s Health (TFAH), a Washington, DC-based non-profit, nonpartisan public health policy, research, and advocacy organization, prioritizes older adult health and, in partnership with The John A. Hartford Foundation and others, developed a Framework for Creating Age-Friendly Public Health Systems (AFPHS).4  This Framework is designed to create a culture of healthy aging within state and local public health departments and support the expansion of public health policies and programs to improve older adult health and well-being. It is not a prescriptive guide to action or a declaration of the public health sector’s oversight of certain activities. There are many agencies and organizations in other sectors that are already actively engaged in healthy aging but are not leveraging the expertise of public health professionals. Public health departments can work in partnership with these organizations to promote healthy aging. These include AARP, with its focus on building livable communities, and Area Agencies on Aging, focused on service and program delivery to meet older adult needs. Additional roles for the public health sector include improving data systems to better identify crucial health interventions and adapting emergency preparedness plans to accommodate the health challenges of older adults and caregivers.

To test the Framework, TFAH conducted an 18-month pilot project in Florida in which it worked directly with two-thirds of the state’s county health departments. Among the first steps of these public health practitioners was assessing the health status and needs of Florida’s older adult population, as well as identifying opportunities for partnership and expansion of existing programs and services to include older adults. TFAH helped to facilitate the creation of Aging in Florida profiles for every Florida county that provide extensive data on the health, socioeconomic, and family status of those 65 and over. Many of these practitioners were not previously aware of the demographics of this population in their jurisdictions but have now been able to use this data to develop interventions to reduce the risk of falls, enhance emergency plans to accommodate older adults and their caregivers, and incorporate the views of older residents into planning processes. In some counties, the public health departments have led engagement with the Age-Friendly Communities movement, often serving as the convener of multi-sector coalitions to address the movement’s eight domains of livability.

The success of the Florida pilot led to expansion of age-friendly public health efforts in other states, and further engagement with federal, state, and local policymakers. Efforts are now under way in Michigan, with funding from the Michigan Health Endowment Fund, to support AFPHS work at the local level, and to build a model for a seamless older adult care journey. Public health leaders in Colorado, Georgia, Mississippi, Washington, Wisconsin, New York, and other states are working to expand public health policies and programs to better meet the needs of people in those states who are living longer lives.

AFPHS National Recognition Program

TFAH continues to prioritize older adult health needs and is encouraging state and local public health departments to put these needs at the core of their work. The AFPHS Recognition Program was developed to provide guidance and support for the public health sector through a series of action steps that, if completed, will demonstrate meaningful and sustainable policy and practice changes to promote and support older adult health. The program’s action steps include data collection, collaboration across age-friendly movements to improve older adult health, and listening directly to older adults to learn what matters to them. By completing the 10 foundational steps of this program, departments of health can expand the services they offer, build effective partnerships, and demonstrate a commitment to healthy aging. The New York State Department of Health received the first state-level recognition, and the Department of Health in Sarasota County, Florida was the first local health department to be recognized for this achievement.5

COVID-19 Response

State and local health departments have played a vital role in the pandemic response, working diligently to address the needs of all people, including older adults living in the community and those who reside in long-term care facilities. The pandemic has had a disproportionate impact on older adults in general and has posed an even greater burden on older adults of color. Data from the Centers for Disease Control and Prevention show that in 2020, race and ethnicity were strong predictors of increased risk of severe outcomes among older adults.6 Among adults 65 and older, the risk of COVID-19 hospitalization was two or more times higher among non-Hispanic American Indian or Alaska Native, non-Hispanic Black, and Hispanic or Latino populations 65 and older compared to non-Hispanic Asian or Pacific Islander or non-Hispanic White populations 65 and older.7 As of this writing, eight of ten deaths attributable to COVID-19 are still occurring in the 65 and over population.8

Multi-stakeholder coordination becomes all the more important in reaching such groups. One of the most significant outcomes of the AFPHS pilot in Florida was the value and significance of the partnerships formed between the county health departments and aging services organizations. The trust built among these stakeholders contributed to a more effective and efficient response to meeting the needs of isolated older adults during the pandemic’s early days and beyond. Coordinated activities included meal and supply deliveries, identifying individuals who needed the COVID-19 vaccine administered in their homes, and helping to ensure access to health care, whether through transportation support or telehealth assistance. Public health departments also helped to coordinate other sectors to meet the needs of older adults, including emergency responders, home-based health care providers, and faith community leaders.

In-Home Vaccinations Initiative

In partnership with The John A. Hartford Foundation and the Cambia Health Foundation, TFAH facilitated an initiative to improve access to the COVID-19 vaccine for older adults who needed vaccines administered in their homes. TFAH engaged health care, public health, home-based care, emergency management and federal officials from multiple agencies to identify the challenges and barriers to in-home vaccines. TFAH then worked with these stakeholder groups to identify solutions and develop policy recommendations to expand access, including ensuring that appropriate reimbursements were available to cover all costs, allowing caregivers and other family members to benefit from at-home vaccinations, and engaging with community and faith leaders to overcome vaccine hesitancy. These efforts contributed to the adoption of new practices and policies to support older adults who need vaccines administered in their homes.

Age-Friendly Ecosystem

The Administration for Community Living (ACL) expects the number of older adults of color to rise by 217 percent in the coming decades.9  As the aging population grows and becomes more diverse, it will be crucial to embrace this demographic shift and develop policies and interventions that address the complex challenges and needs of a diverse aging population. Public health departments across the country are committed to eliminating disparities and ensuring all people have the opportunity for optimal health and well-being and that the public health sector is experienced in delivering services in a culturally and linguistically sensitive manner. Lessons learned from the successful AFPHS and in-home vaccine initiatives underscore the value of partnerships in improving the health and well-being of older adults, in large part with the expertise of public health in reaching diverse populations. Additionally, an integrated age-friendly ecosystem with collaboration and synergy between and among age-friendly initiatives can spur the necessary momentum for innovative change. The vision for an age-friendly ecosystem encompasses the lived environment, social determinants of health, the health care system, and a prevention-focused public health system. The opportunities associated with more people living longer lives can be harnessed and nurtured through an aligned age-friendly ecosystem that benefits from strong leadership, sustained commitment and investment, and national momentum. 


1 Vespa, Jonathan, Lauren Medina, and David M. Armstrong, “Demographic Turning Points for the United States: Population Projections for 2020 to 2060,” Current Population Reports, P25-1144, U.S. Census Bureau, Washington, DC, 2020.

2 Centers for Disease Control and Prevention. Healthy Aging at a Glance 2011. http://stacks.cdc.gov/view/cdc/22022 

3 Chronic Conditions Charts: 2015. Baltimore, MD: Centers for Medicare & Medicaid Services. https://www.cms.gov/Research-Statistics-Data-and-Systems/Statistics-Trends-and-Reports/ChronicConditions/Chartbook_Charts.html 

4 Anne De Biasi, MPH, Megan Wolfe, JD, Jane Carmody, DNP, MBA, RN, Terry Fulmer, PhD, RN, FAAN, John Auerbach, MBA, Creating an Age-Friendly Public Health System, Innovation in Aging, Volume 4, Issue 1, 2020, igz044, https://doi.org/10.1093/geroni/igz044 

5 https://www.johnahartford.org/dissemination-center/view/new-york-state-department-of-health-achieves-age-friendly-public-health-systems-recognition

6 Centers for Disease Control and Prevention. 2021. COVID-19 Racial and Ethnic Health Disparities. https://www.cdc.gov/coronavirus/2019-ncov/community/health-equity/racial-ethnic-disparities/index.html 

7 Rossen LM, Ahmad FB, Anderson RN, et al. Disparities in Excess Mortality Associated with COVID-19 — United States, 2020. MMWR Morb Mortal Wkly Rep 2021;70:1114–1119.

8 Kaiser Family Foundation. 2020. https://www.kff.org/coronavirus-covid-19/press-release/8-in-10-people-who-have-died-of-covid-19-were-age-65-or-older-but-the-share-varies-by-state/ 

9 https://acl.gov/programs/strengthening-aging-and-disability-networks/diversity-and-cultural-competency   





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