Att C

Older Adult Mobility
Assessment Tool Plan:
Phase 1 Report
Presented to:
Dr. Ann Dellinger
CDC MVIP Team Leader
14 March 2011

Presented by:
Moshe Engelberg, PhD, MPH
Joe Smyser, MPH

Older Adult Mobility Assessment Tool Plan:
Phase 1 Report

Executive Summary
This report encompasses Phase 1 of a three-phase project to develop an older adult safe mobility
assessment. Phase 1 involved collecting actionable research to determine the need and approach
for such a tool and to shape subsequent phases. Phases 2 and 3 involve the actual creation and
dissemination of the tool.
The conclusion of the first phase of research is this: We do not know nearly enough about the safe
mobility experience of older adults in the United States. While information about falls, driving,
social networks, home safety, community walkability and other silos of research are out there, no
one has linked all these silos together. We cannot paint a picture of what adults age 65 and older
experience when they try to get where they want to go. There are anecdotes, compelling data
from assessments focused on certain aspects of older adult safe mobility, glimpses provided by
national surveys, but when it comes to a holistic nationwide understanding of the trends and
patterns in older adult safe mobility, we are driving blind.
Our policies do not reflect what we do know about the needs and wants of older adults, in part
because it's hard to find the right data to tell the right story. There is no single national
organization with a mandate to collect these data and tell this story, so at the moment the field is
open and broad, and reflects the missions and viewpoints of a myriad of actors in older adult safe
mobility. Compounding this opportunity is the need: In the next decade some 17% of Americans
will be 65 and older, and that percentage will continue to increase, with 10,000 Americans reaching
65 every day for the next 20 years.
Leaders in the field of older adult safe mobility contend that as it stands today our research does
not adequately capture a holistic view of the safe mobility experience of older adults, our policies
are shaped in an uncoordinated and often uninformed manner and our best practices, the
information that could help older adults make better decisions for themselves, are not reaching the
public.
The time is ripe for CDC leadership on this issue, leadership that offers a tangible first step on the
road to fully understanding and meeting the safe mobility needs and wants of older adults. An older
adult safe mobility assessment makes sense, linking the domains of older adult safe mobility
together and empowering the individual with a way to improve their mobility. This first phase of
research strongly supports the creation of just such a tool, led and managed by the CDC, in
collaboration with its partners across the country.

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Introduction
I. BACKG ROU ND
As part of an overarching effort to (1) Improve injury prevention to make older adults safer; (2)
Improve the visibility of motor vehicle injury prevention (MVIP) and the team through a high
impact product; and (3) Make the MVIP team’s good work more relevant and useful, we were
engaged to conduct the first phase of research toward the development of an Older Adult Safe
Mobility Assessment Tool.
The U.S. is just experiencing the beginning of a "silver tsunami," with those 65 years and older
comprising approximately 17% of the population by 2020. At present 10,000 Americans reach 65
every day, and this will continue for the next 20 years. The motivation to better understand the
mobility experience of older adults comes from a recognition that public health and other
authorities are ill-prepared to service the needs of this demographic. With most adults aging in
place, rather than in retirement or nursing homes, it is absolutely critical to better prepare the field
for what is on the horizon.
There is widespread agreement that older adults in the U.S. do not adequately plan for their future
mobility needs, nor are most aware of existing mobility resources in their communities. Thus,
when an individual’s mobility becomes impaired they are ill prepared to adapt their lifestyle to their
changing needs. Once at this stage, an individual’s ability to access resources may be
compromised, because their mobility is compromised. This calls for a tool to help people
understand their mobility situation and plan accordingly.
In this paper, "older adult" refers to persons age 65 or older. "Safe mobility" is conceptualized
simply as people getting to where they need to go without injury. The risk reduction safety aspect
is what ties this project to public health and injury prevention. We conceived of older adult safe
mobility within the Social Ecological Model, which recognizes the interconnectedness between the
individual, their environment, and other influences on behavior. This holistic view of mobility
encompasses an individual's physical and mental health, their social network, the state of their
home, their neighborhood, their city, county, state and finally the overall mobility situation of older
adults in the nation as a whole.

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II. PU RPOSE & G OALS
The purpose of this phase of the project was to 1) establish whether or not there is a need for an
older adult safe mobility tool, 2) determine whether the CDC is best placed to lead the creation of
this tool, and 3) develop recommendations on how best to move forward with its creation.
Objectives & methodologies included:
1. Conducting an environmental scan to identify best practices and tools and to insure CDC’s
effort in this arena is complementary and non-duplicative of existing efforts.
2. Conducting internal interviews to tap into existing knowledge and resources at CDC on older
adult mobility and driving safety, and to gather input on who should be a part of the expert
panel, best practices, and partnership efforts.
3. Creating and convening an expert panel to establish scientific and implementation
parameters. Expert panelists were individually interviewed on multiple occasions, followed by
two rounds of small group conference calls, and a final debrief call.
4. Identifying and establishing key partnerships necessary to achieving the development of a
Tool that will meet the needs of older adults and ensure wide dissemination and use.
5. Determining design, implementation, and evaluation plan.
This foundational scientific work was necessary to move forward with the development of an
assessment product that is informed by current science and a wide range of experts and partners.

III. E XPE RT PANE L
Lynda A. Anderson
Director, Healthy Aging Program
Division of Adult and Community Health
CDC National Center for Chronic Disease Prevention and Health Promotion
Chris Kochtitzky
Associate Director for Policy Planning and Evaluation
CDC Office of the Director Div. of Emergency and Environmental Health Services
Gloria Krahn
Division Director, Division of Human Development and Disability
CDC National Center on Birth Defects and Developmental Disabilities
Dee Merriam
Community Planner
CDC National Center for Environmental Health
Katie Sobush
Transportation Planner
CDC Buildings and Facilities Office
Basia Belza
Lead, Coordinating Center, CDC-Healthy Aging Research Network
Aljoya Endowed Professor in Aging
University of Washington

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Doug Farquhar
Program Director for Environmental Health
National Conference of State Legislatures
Elinor Ginzler
Sr. Vice President, Livable Communities Strategies
Office of Social Impact
AARP
Kimberley Hodgson
Manager, Planning and Community Health Research Center
American Planning Association
Kathryn Lawler
Program Director
Aging Atlanta
Atlanta Regional Commission
Mary Leary
Senior Director
Easter Seals Project ACTION
National Center on Senior Transportation & other Transportation Initiatives
Barbara McCann
Executive Director
National Complete Streets Coalition
Sandra Rosenbloom
Professor of Planning
Adjunct Professor of Civil Engineering
University of Arizona
Jim Rimmer
Professor, Department of Disability and Human Development
Director, Center on Health Promotion Research for Persons with Disabilities
Director, National Center on Physical Activity and Disability
University of Illinois at Chicago
Jon Sanford
Director of the Center for Assistive Technology and Environmental Access
Associate Professor of Architecture
Georgia Tech
Bill Satariano
Professor of Epidemiology and Community Health
School of Public Health
UC Berkeley
Note: Additional potential expert panel advisors include Dr. Jim Sallis (SDSU and RWJF), Kathy
Sykes (EPA), and David Shotwell (Senior Director of Liveable Communities at AARP) as a
replacement for Elinor Ginzler, who moved to a different position within AARP.

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Part 1: Assessing the Need
I. KNOWLE D G E G APS IN OLDE R ADU LT SAFE MOBILIT Y
R ES EAR CH
A holistic picture, taking into account the major areas of research that interact to understand the
mobility experience of older adults in the U.S., does not exist. Though various aspects of mobility
among older adults are studied (falls, home safety, physical and mental health, neighborhood
walkability, driving), there is little interaction or collaboration by researchers across these research
silos. Nor is there a single tool (assessment, HRA, etc.) that links these research silos together.
There is also little understanding of what could be termed "patterns of mobility." Where older
adults go and do not go, why they go there, how they get there, and how often they go is not well
understood either at the national or local level. In addition, there is little knowledge of best
practices when it comes to communicating health messages about safe mobility to older adults.

POLICY
There have been two main barriers cited as creating gaps in policy regarding older adult mobility.
1) Policy makers do not consider the mobility-related needs and wants of older adults. Older adult
safe mobility topics require foresight, long-term planning and by their nature pertain to multiple
policy arenas (building codes, community planning, public transportation, traffic safety, developers,
engineers, local and state elected officials, healthcare). Older adult mobility is therefore a
challenging topic to address, which leads to more manageable topics taking precedent. 2) When
policy makers seek to address topics of older adult mobility, they do not know where to get the
information they need. The issue is broad and the actors are fragmented. There are no ready data
on patterns or trends on community or national levels. When data are available, they are usually
not presented in a policy friendly format. Policy makers have indicated that personal stories, or
case studies, are helpful in framing these issues, but these too are hard to come by.
The gap between what we do know about the mobility wants and needs of older adults, and the
related policies that are actually implemented by authorities, is of universal concern to experts
across older adult mobility disciplines. As a result of this disconnect, there is frustration that the
communities being built and maintained across the U.S. do not reflect the mobility realities of an
aging population.
Compounding this, there is no single entity in the U.S. that is responsible for advocating on behalf
of older adult safe mobility. This, added to the separate silos of mobility research, has led to a
fractured, uneven and predominately reactionary response to the mobility needs of an aging
population.

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EDUCATION
Similarly, educational campaigns either do not exist or are propriety and administered by
organizations whose coverage does not extend to the entire country, or who focus on a particular
aspect of mobility (for example, safe driving) rather than the whole range of the older adult
mobility experience.

DR IVING
There is evidence about the importance of driving, and consequently recommendations by public
health, transportation and other authorities, that older adults should continue to drive as long as is
safely possible. With a lack of public transportation options, and a cultural belief that driving is
equated with self-worth, self-reliance, and independence, most Americans do drive for as long as
they feel able. Motor vehicle use is therefore a tremendous part of an older adult's mobility
experience.
However, there is not a strong understanding of how driving - and not driving - fits into the overall
mobility experience. Where, how often, how comfortable, and how safe people feel when driving,
as well as how they evaluate alternatives, needs more attention, particularly within the holistic
context of older adult safe mobility.

FALLS
Just as safe driving is a main factor in an individual's mobility, so to is the issue of falls. Research
shows that most American's homes are ill equipped for the needs of older adults, which contributes
to falls inside the home. Once an individual has fallen, their mobility is often impaired, both within
and outside the home.
There is a gap in falls research as to the characterization of falls in the community outside a
person's home. It is assumed that most falls occur in the home, but this is an assumption based
on little community-level data. Additionally, reasons for falls outside the home are little
understood, as are the reasons older adults give for feeling comfortable or fearful when navigating
through their neighborhood or community at large, either by foot, assistive device (walker,
wheelchair) or vehicle.

S UICIDE
When an older adult's mobility is impaired, so often is their sense of self-worth. Older adults have
reported the loss of their license as one of the most traumatic experiences of their lives, and family
members, such as adult children, have echoed this sentiment. Unaware of community resources,
cut off from services and, often, separated from social networks, older adults in the U.S. can quite
easily fall into isolation. The resulting depression has been linked to a loss in quality of life as well
as suicide. Adults age 65 and over have a higher rate of suicide than any other age group.
The social support network of the individual appears critical in lessening suicide risk in this
population. Significantly more work needs to be done in order to understand the effect of social
networks on older adult's mobility experience, and vice versa, and thus provide

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appropriate interventions/programming. More research is also needed into how mobility
alternatives can be more accessible and appealing to decrease suicide risk.

CONCLUS ION
At present there is a fragmented approach to older adult safe mobility in the U.S. With siloed
research and siloed practice, there is poor understanding of trends and patterns in overall older
adult safe mobility in this country. The lack of comprehensive, compelling, easily understood data
present a challenge to crafting policy that reflects best practice. Finally, best practices are not
effectively shared with older adults or translated into behavior change because there is no single
national authority on older adult safe mobility. One highly credible organization needs to adopt a
mandate to bring together the disparate research and practice silos under a coherent theme, and
then to disseminate that information. Experts felt strongly that CDC, and particularly the MVIP
team is the right sponsor of this kind of activity.

II. SU MMARY OF RE LE VANT ASSE SSME NT S
Assessments that directly cover mobility issues fall into two categories: Those that measure
community and/or environmental indicators, and those focused on safe driving ability. We also
reviewed several traditional health risk appraisals (HRAs) and national surveys. While they do not
cover older adult safe mobility in any comprehensive way, they were explored as potential models
for a creating a new assessment tool or serving as distribution partners. Several examples of each
are described below. The list in the Appendix offers a more representative and annotated listing of
some of the better-known tools.
Tools that measure community or environmental factors include the Home and Community
Environment (HACE) Instrument, which measures home and community mobility, AARP's Livable
Communities survey?, which measures a variety of community-wide indicators important to older
adults, as well as assessments like the Lubben Social Network Scale (LSNS), which measures social
isolation in older adults. The most well known driving assessments are available from the AAA
Foundation, which focus on safe driving and recognition of driving deficiencies, and then AARP.
HRAs can be disease or condition specific, such as the American Diabetes Association's HRA for
diabetes, or more inclusive wellness assessments such as the Mayo Clinic's HRA. The CDC is
currently in the process of developing guidelines for a new broad HRA with the Centers for
Medicare and Medicaid Services (CMS), in accordance with the Affordable Care Act (ACA). Many
HRAs are developed for employer health and wellness programs. HRAs were included to inform the
type of safe mobility assessment tool that should be developed.
Relevant popular national surveys only peripherally related to older adult safe mobility include
HealthStyles, managed by Porter Novelli, which collects health attitudes and practices of a sample
of the adult U.S. population, and the Medicare Current Beneficiary Survey (MCBS), which collects a
wide array of indicators from a rotating panel of Medicare beneficiaries. They were included early
on as the most likely surveys to which an older adult safe mobility assessment could possibly be
piggybacked.

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THE NEED FOR INTEGR ATION
Each existing assessment, survey, HRA and report captures only a part of the whole of older adult
safe mobility. Community and environmental assessments such as AARP’s Livable Communities
does an excellent job capturing aspects of what makes a community attractive to many older
adults, but does not capture individual-level enablers and barriers to mobility within that
community, the state of a person’s home, or indicators of physical/mental health.
Tools such as the Home and Community Environment (HACE) instrument records the physical
environment of an older adult, such as the number of stairs in the home, the condition of sidewalks
and use of mobility devices, but leaves out the where and why of how people move as well as
personal physical/mental health indicators. Assessments such as
the Lubben Social Network Scale (LSNS) captures social networks and thus indicators of mental
health, but not the physical environment.
Furthermore, each of these existing tools is managed by a different organization, under its own
directive. There is no unifying purpose or overarching directive to collaborate or to combine
datasets.

CONCLUS ION
At present there are numerous mobility assessments actively used throughout the U.S. Most are
designed to collect information from only one particular mobility silo, such as assessments that
focus on falls prevention. None of these existing tools cut across mobility silos while focusing on
older adults. None create a national picture of older adult safe mobility that captures an individual's
physical and mental health, their social network, the state of their home, their neighborhood, their
city, and beyond. And none provide the comprehensive data needed to paint a picture of the overall
safe mobility situation of older adults in the nation as a whole.

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Part 2: CDC's Role
CDC's National Center for Injury Prevention & Control (NCIPC) is charged with preventing injuries
and reducing their consequences. Under the Center's purview are motor vehicle injury prevention
and response, home safety, and violence prevention, among other topics.
Older adult safe mobility encompasses several aspects of NCIPC's charge, specifically motor vehicle
injury prevention (MVIP), falls prevention, and suicide prevention. Safe mobility is therefore a key
public health issue ideally fit to CDC’s Injury Center.
Motor vehicle safety is particularly important to older adult safe mobility as there are over 31
million licensed drivers age 65 and older (with many more on the horizon) and the risk of motor
vehicle-related injury or death increases with age. Older adults will rely on their automobile as
their main source of transportation until such time as they are unfit to drive. Motor vehicle injury
prevention provides a strong starting point from which to address safe mobility more holistically.
CDC is not an advocacy organization, and cannot take on that role. However, it can provide timely,
relevant data that strongly support the advocacy efforts of individuals and other organizations.
NCIPC is seen as well positioned within the CDC to address safe mobility on a national scale.
Moreover, of all organizations mentioned by experts as relevant to older adult safe mobility, CDC is
the only agency mandated with protecting the welfare of the American public.

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Part 3: Framework for Development
I. WHAT ARE WE ASSE SSING ?
We are assessing if, how, and under what conditions older adults safely get to where they need to
go. "People getting to where they need to go safely" may be a simple description of safe mobility,
but it is a helpful way of conceptualizing such a broad and inclusive theme. Older adults need to
move through their home, their neighborhood and their community. There are enablers and
barriers to that movement, and that movement has an impact on many areas of health and wellbeing. An assessment tool should collect data regarding where, how, why and when a person is
and is not mobile, and in the process assess the corresponding barriers and enablers.
The assessment will include both factual and evaluative items, which is uncommon, as per the
recommendation of our additional advisor, Dr. Jim Sallis. An example of a factual item is "Can you
walk to a food store in 10 minutes?" or "Does your neighborhood have sidewalks?" An evaluative
item is "Are you confident with the safety of your route to the nearest food store?"
The need to empower individuals through actionable feedback was echoed by many expert
panelists. Information can lead to empowerment by enabling older adult users to be aware of
deficiencies and strengths in their own mobility situations. It may also engender more successful
advocacy on the part of older adults themselves, who are known to be a highly politically active
group.

R ECOMMENDED S COPE
Experts in specific silos of older adult mobility research and practice are inclined toward
assessments that mirror their experience (i.e. a researcher of falls can give specific
recommendations for a newer and better fall assessment). However, when such experts are asked
to consider gaps in knowledge of older adult safe mobility more generally, there is universal
agreement that there is great need for a tool that captures "patterns of older adult mobility" on a
large scale.
Based on CDC’s internal preferences, the first goal is to provide individuals with an understanding
of how to improve their own safe mobility, and second to paint a portrait of the current older adult
safe mobility experience, in order to make it better.
The data collected by this assessment will be the first step in highlighting the safe mobility realities
of older adults in the country, and should pave the way for incorporating such a tool into a large,
scientifically robust longitudinal examination of older adults and safe mobility.

DOMAINS OF MOBILITY & TOPICS
Domains include an individual's physical and mental health, their social network, the state of their
home, their transportation options, and their environment (neighborhood, city, county, state).
When appropriately aggregated, these domains may provide a snapshot of the overall mobility
situation of older adults in the nation as a whole.

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Research indicates older adults in the U.S. "age in place" and, though far more mobile than
previous generations, adults toward the older end of the spectrum tend to operate within what
some experts refer to as the "last mile," or approximately a mile radius from their home. The
experience of many users of this assessment will reflect this dynamic, and their engagement with
the various domains of older adult mobility will be particularly valuable to examine. Based on
expert panel input, we recommend primarily focusing on safe mobility within the home,
neighborhood and community, and particularly the “last mile.”
Within the domains of mobility listed above there are individual topics. These topics represent the
priority topics of organizations whose work is relevant to safe mobility, and to the work of particular
researchers and research groups. For example, there are researchers and organizations primarily
focused on falls (a topic) that occur within the home (a domain of mobility). While there is not a
one-to-one correspondence between domains and topics, the topics discussed most often by the
expert panel can be grouped into domains as follows.
Tier 1 Topic Silos
 Physical and mental health: Falls, disease states, healthcare utilization, home care, nursing,
aging process, suicide, and social networks related to dementia and depression
 Home & environment: Universal design, accessibility, disability, physical environment,
walkability, healthier cities/neighborhoods
 Transportation: Driving, licensure, public transport, para-transit, cycling/bicycling, planning
 City planning: Policies, urban and rural studies, codes and standards such as ADA guidelines,
engineering, contractors and developers
The particular topics that the safe mobility assessment will address depends on how the
assessment tool will be used, as well as the priorities of CDC and key partners. Regardless, it is
critical to recognize these spheres of influence if we are to capture an accurate picture of older
adult safe mobility. Each domain and topic act upon the others; they are not mutually exclusive.
Assessments that do not take this into account fail to acknowledge the complex, interwoven
exchange that older adults have with their environment.

UNIT OF ANALYS IS
The recommended unit of analysis is the individual, as the fundamental purpose of this tool should
be to give people the information they need to understand and improve their mobility. The
assessment will help people make better-informed decisions about their mobility by raising
awareness of personal barriers and enablers to safe mobility. Adults 65 and older will be better
able to prepare for and meet their safe mobility needs.
The individual unit of analysis does not preclude gathering valuable information about safe mobility
on a community or national level. This information would be valuable to any organization engaged
in any of the domains or silos of older adult safe mobility as there currently is no tool that links
these domains. The results would also help to fulfill an existing need to understand older adult
safe mobility on a more scientific, rather than anecdotal or purely subjective level.

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Because there is a strong need for policy makers and advocates to have better information on
patterns in older adult safe mobility, individual level data can be aggregated and geographically
linked in order to paint a picture of older adult mobility at a more macro level. Policy makers also
need a face or story to represent patterns and trends in a manner people can relate to. Even
without ideal sampling techniques or assessing specific communities per se (at least initially), the
findings will add to a more complete picture of the safe mobility experience of older adults in the
U.S. We believe a well-designed assessment will produce cost savings and inform policy within
three years from initial fielding of the final tool.

II. SCIE NT IFIC ISSU E S SPE CIFIC T O MOBILIT Y
GATHER ING VALID DATA ACR OS S DOMAINS OF MOBILITY
Current assessments are typically designed to examine either a single aspect of safe mobility, for
instance falls, or a single environment, like in-home. Assessing these domains holistically will
require significant conceptual clarity as to the different domains of safe mobility and their
interrelationships, as well as attention toward corresponding measurement issues. Attempting to
incorporate each of the relevant domains of older adult safe mobility will be challenging in terms of
survey length as well. A potential solution would be to employ a computerized adaptive test (CAT).
Fully/partially adaptive tests rely on item response theory (IRT) to present questions from a
question bank, based on information the user has provided at the outset, such as their age and
gender, as well as throughout the assessment. The result is a more tailored assessment experience
for the user, and more relevant feedback. This approach however assumes computer-based
administration.

PR EDICTIVENES S , PR ECIS ION, AND S CALING
Experts agree that there is not sufficient knowledge in place to create a formal risk appraisal that
quantifies risk and predicts the value of risk abatement behaviors with precision. This speaks to
creating an older adult safe mobility assessment that has an ordinal scale and shows what will
improve or worsen the situation, but without quantification of effect size.

MINIMIZ ING BIAS
Self-report assessments have the advantage of easier administration. They also have the
disadvantage of social desirability bias - participants answering questions to paint themselves in
the best light possible. Given the emotions often connected with one’s mobility, a social desirability
response bias should be anticipated.
When participants can choose to take an assessment or not it could introduce a self-selection bias,
leading to a biased sample. However, given the early stage of holistically assessing safe mobility,
we feel the convenience and practicality of a self-report assessment tool and a convenience
sample (stratified by age and/or other variables to approximate the older adult population in the
U.S.) deserves priority, with attention given to minimizing all forms of potential bias.

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III. IMPLE ME NT AT ION ISSU E S
In terms of implementation, we recommend employing an approach similar to what Porter Novelli’s
HealthStyles uses, given the credibility of HealthStyles within CDC, its longevity, and its widespread
use. The key idea is to partner with a broader data collection effort in a way that maintains the
independence of the Older Adult Safe Mobility Assessment. For example, HealthStyles originally
drew its sample of about 3,000 from DDB Needham’s much larger Lifestyle Survey, supplemented
with an additional sample of underrepresented populations (they switched from DDB Needham to
their in-house ConsumerStyles several years ago). The sample is weighted on selected
demographic variables, including age, in order to be representative of the U.S. population. We
recommend aiming for an annual sample size of 1,200 and maximum of 5,000, depending on what
CDC can support.
The key benefit is being able to link with a much richer dataset in order to better understand safe
mobility. There are partner options within the private sector, such as the two mentioned above,
Neilson, Maritz, and others; nonprofits such as AARP; universities like University of Michigan’s
Survey Research Center, and government agencies such as CMS or the U.S. Census Bureau, which
conducts the National Health Interview Survey for CDC. Key decision criteria include how easy the
partner is to work with, making sure CDC maintains real and perceived leadership, costs, and other
management and scientific issues. The partner implementation agency would be selected in Phase
2.

METHOD OF ADMINIS TR ATION
Phone surveys, computer-based surveys, in-person surveys and mailed surveys each have their
pros and cons and must be evaluated based on the particular population being studied, balanced
by the available resources of the implementing organization. Dissemination of this assessment
would be easier if it could be delivered through the internet, but this may leave out a significant
group of older adults. According to the Pew Internet and American Life Project, 42% of adults 65
and over use the internet and 26% of older Americans have a broadband connection. Of older
adults who do not use the internet, 6 in 10 would need assistance getting online. This speaks to a
two-pronged approach for the older adult safe mobility assessment.


The “push” strategy: First start with a mailed or phone assessment in conjunction with a
larger consumer survey as described above, which should overcome the potential internet
bias and assure a more representative sample. The resultant dataset would be the primary
one for validation and extrapolation of findings.



The “pull” strategy: Supplement the mailed assessment with an online version that could be
distributed on the web by your many partners. Each partner could offer solutions for the
domain or silo they represent as well. Data could be coded by source, that is where the
respondent filled it out. This makes the assessment available to a much broader
constituency more quickly.

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MAKING IT MEANINGFUL TO CUS TOMER S
The first objective is helping older adults understand and improve their safe mobility. Achieving this
objective requires both objective and subjective questions that get at practical everyday concerns
and experiences, perhaps supplemented by individualized feedback with personal stories of
challenges overcome and successes.

GETTING PAR TNER S ON BOAR D
Bringing together researchers and practitioners from each relevant silo of older adult safe mobility
takes time and persistence. Furthermore, balancing the expectations of each of these actors
requires tact and an eye toward creating a tool that is scientifically sound across domains and silos
of older adult mobility, though perhaps not as in depth in each particular silo as each partner would
prefer.
Incorporating every one of the actors in older adult safe mobility would be challenging, reflecting
the challenges inherent in conceptualizing an issue this broad. The following are organizations that
were recommended as partners for this project by expert panelists, though the list does not
necessarily include every possible organization that should or could be partnered with. Partners
are divided into categories of activity, from the built environment, to disability, driving,
government, healthcare/public health, livable communities, older adult advocacy, research and
transportation.
Built Environment, Professional Organization
American Institute of Architects
Institute of Transportation Engineers
Disability Specific
U.S. Access Board
Easter Seals
National Council on Disability
Driving
AAA
AAA Foundation
Government Officials
International City/County Management Association (ICMA)
The National Association of County and City Health Officials (NACCHO)
National Association of Regional Councils (NARC)
National Council of State Legislators (NCSL)
National League of Cities (NLC)
The United States Conference of Mayors (USCM)

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Healthcare / Public Health
Administration on Aging (AOA)
American Association for Occupational Therapy (AAOT)
American Diabetes Association
American Medical Association (AMA)
American Public Health Association (APHA) (several sections pertain to older adult health)
Arthritis Foundation
Centers for Medicare & Medicaid Services (CMS)
State Aging and Disability departments (exists for each state)
U.S. EPA
Liveable Communities
American Planning Association
Atlanta Regional Commission (ARC)
The Center for Community Change
Complete Streets Coalition
Congress for the New Urbanism (CNU)
Funders Network for Smart Growth and Livable Communities
ICLEI (International Council for Local Environmental Initiatives)
The National Center for Bicycling & Walking
The National Neighborhood Coalition
Partners for Liveable Communities
Smart Growth America
The Urban Land Institute
Walkscore
Older Adult Advocacy
AARP
N4A (National Association of Area Agencies on Aging)
National Council on Aging (NCOA)
NORC (Naturally Occurring Retirement Communities) Aging in Place Initiative
Research
Gerontological Society of America
Healthy Aging Research Network (HAN)
National Institute on Aging (NIA)
The Robert Wood Johnson Foundation
Transportation Research Board
University Transportation Centers
Transportation Specific
AASHTO
American Public Transportation Association (APTA)
Association of Pedestrian and Bicycle Professionals (APBP)
Association of Metropolitan Planning Organizations (AMPO)
Coordinating Council on Access and Mobility (CCAM)
Federal Transit Administration (FTA) (liveability initiative)

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U.S. Department of Transportation (USDOT)
Transportation Equity Network (TEN)
Transportation for America (T4 America)
National Center on Senior Transportation
Experts in older adult safe mobility, regardless of which research or practice silo their work reflects,
understand the need for a holistic tool on older adult safe mobility. There is strong buy-in for this
idea, so strong that expectations for the first tool of this kind run high. In order to recruit
partners, both individual and organizational, it is important to put the project into perspective and
manage expectations. Emphasis should be placed on the reality of limited resources, the
commitment to a step-by-step approach, and that this is the first foray into older adult safe
mobility assessment, to be hopefully followed by a more rigorous, larger-scale scientific study.

IV. LOOK AND FE E L OF T HE T OOL
The MVIP Brand Identity guidelines will help shape the look and feel of the assessment. Also,
experts do have recommendations on the look and feel of an assessment tailored for older adults,
typically based more on their own experiences creating tools for this audience than on a significant
literature base on the topic. The following are a few suggestions compiled from the expert panel.
It is important to note that these are informed opinions, and may or may not be reflected in the
preferences of older adults; that information will need to gathered during the development of the
tool itself.

NAR R ATIVE FLOW
Most older adults in the U.S. have some experience being assessed by a healthcare professional.
As the healthcare system in the country is designed to allow only a few minutes with each patient,
many older adults have come to equate assessments with an overly clinical and impersonal
approach. Some experts have recommended that a tool seeking to collect data on an individual's
safe mobility experience be organized in a somewhat colloquial manner. A narrative format,
guiding the user through each module in a familiar way, almost in a story-like fashion, could
engender more buy-in from older adult users. This approach will have to be tested in the tool
development phase.

ONLINE GUIDANCE
Because older adults are traditionally more responsive to a peer-to-peer approach with
assessments, another possible tactic to increase buy-in would be the creation of a "digital guide"
who mirrored the characteristics of the older adult using the tool in an online format. If a 68 year
old Latina logged on, an image of a woman reflecting the same traits could guide the user through
the narrative of the assessment. Each of these potential approaches will have to be tested.

VIS UALS
Photos were suggested to better illustrate environmental factors the assessment will address. For
instance, rather than a paragraph describing a type of traffic intersection,
pictures could depict the intersection in a much clearer and less subjective manner, thus making
responses more valid.

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AUDIO
Hearing loss is common among older adults, and any audio used in a tool should take this into
account. Relying on the user to distinguish between subtle sounds, for instance the sound of a
busy street vs. a calm street, should be avoided.
If a "digital guide" is employed, having that guide speak to the user, in essence reading out loud
the text presented on the user's screen, may further endear the user to the assessment process.
Hearing a fellow older adult's voice prompting them throughout the tool may have a positive effect.
Again, this should be verified through testing.

V. E VALU AT ION PLANS
Formative evaluation activities will be conducted as part of phase 2 to shape the development of
the tool. Process, impact and outcome evaluation plans will be developed within Phase 2 piloting
and will be completed during Phase 3.

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Next Steps for Assessment Development
I. PHASE 2
Phase 2 builds upon the actionable results of Phase 1 and involves building an older adult safe
mobility assessment and conducting validation research (for example, how feasible is a selfadministered tool, and how accepted is such a tool by its users). Phase 3 will involve the ongoing
implementation of the assessment via both a mail survey and an online survey. During both of
these phases significant attention will be given to testing the feasibility and validity of the tool with
the users of the tool themselves.
A key next step that can be greatly informed by this phase one project is gather the respective
organizations of the expert panelists into a cooperative network that lays out in broad strokes the
goal of the project and the roles of each organization.

DEVELOPMENT & DIS S EMINATION PAR TNER S
For development, the Healthy Aging Research Network, or HAN, stands out as a potential partner
for the development phase of this tool. HAN members include several top public health research
institutions, and its individual members have experience creating mobility assessments for older
adults. Additionally, HAN has an existing relationship with the CDC and is familiar with its work
process. Attention should also be given to AARP's Livable Communities initiative, with the Complete
Streets Coalition, Atlanta Regional Commission, Easter Seals and perhaps others vetting decisions
on tool design.
These same organizations will prove essential in the tool's dissemination, in addition to the National
Council of State Legislators (NCSL), and N4A (National Association of Area Agencies on Aging) due
to its national scope and numerous member organizations. AARP stands out as a potential partner
for distribution of this tool, thanks to its large older adult membership base. Because this tool
requires many users multiple partners should be included in the dissemination process, including
public health departments. Thankfully, each expert panelist involved in this project indicated they
would gladly involve their organization as well.
A potential rubric to assist in vetting potential partners follows:
Development Partners
 Good working relationship - prior experience working with CDC preferable
 Willingness to ensure real and perceived CDC leadership
 Expertise in specific mobility domains or topics
 Experience creating assessments - feasibility and validity testing
 Experience administering assessments - preferably with large sample sizes
 Experience analyzing assessment data - quantitative and qualitative
 Resources to commit – expertise, time, money, others

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Dissemination Partners
 Good working relationship - prior experience working with CDC preferable
 Willingness to ensure real and perceived CDC leadership
 Nationally focused organization
 Nationwide membership base of older adults
 Resources to commit – expertise, time, money, others
 Trusted, recognized leader in at least one older adult safe mobility topic

PHAS E 2 TAS KS
Phase 2 will consist of six main components, as follows, along with the optimal development
timeline.
Development of Primary Tool (Months 1-3)
1. Work with CDC MVIP Team to establish objectives, measures of success, and how CDC will use
the assessment.
2. Conduct qualitative consumer research to test concepts and shape the assessment and
feedback tool.
3. Get expert input as needed on key content and technical issues.
4. Develop draft of assessment and feedback tool based on consumer input and expert panel
feedback and resources already identified.
5. Design process, impact, and outcome evaluation plans.
Production for Pilot Testing (Months 3-5)
1. Create rough production plan for mail survey, as well as plans for distribution, data collection,
and analysis.
2. Formalize cooperative network to execute pilot study with experts and partners.
3. Convene and facilitate workshop with expert panel to guide refinement of assessment and
plans.
4. Pretest assessment and feedback tool in IDIs and/or focus groups, and with consumer panel.
5. Get expert panel and partner input via conference calls and refine as needed.
6. Finalize assessment and feedback tool for pilot testing.
Pilot Testing & Evaluation (Months 6-8)
1. Develop sampling frame and plan for pilot testing.
2. Field the mail survey (n=1200) to establish validation and identify refinements to the tool and
research process.
3. Conduct analysis per specifications.
4. Evaluate results and write up key findings to share with partners and for publication.
5. Recommend final content for mail assessment and feedback tool.
6. Finalize content, analytics and protocol.
Development of Online Tool (Months 6-8)
1. Identify objectives, target audiences, user requirements and use cases, and CDC guidelines.
2. Determine technical specifications and team requirements for online survey and feedback tool
for use by CDC and by partners, including integration of data from mail survey and web survey.
3. Create mock-ups and click paths of all pages and database.

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4. Create functional prototypes.
5. Conduct usability testing and prioritize modifications.
6. Formalize partnerships for co-hosting and dissemination.
Note: See “pull” strategy, page 13
Usability Testing of Online Tool (Months 8-9)
1. Prepare web-based assessment for online usability testing.
2. Conduct usability testing of online assessment and research process.
3. Conduct analysis per specifications.
4. Evaluate results and write up key findings.
5. Recommend final content and design for online assessment and feedback tool.
6. Finalize content, analytics and protocol.
Communications (Months 10-12)
1. Design look and feel and branding parameters.
2. Test and refine through qualitative focus group testing.
3. Establish communication guidelines for partners using the tool.
4. Get partner feedback, refine, and finalize guidelines.
5. Write up research and development process for publication.
6. Write up Phase 3 launch plan.

II. RE T U RN ON INVE ST ME NT
R EDUCING COS TS
Immediate savings
Older adult safe mobility encompasses many aspects of life for those 65 and older in the United
States. In the coming decade some 17% of Americans will be 65 and older, and that percentage
will continue to increase, with 10,000 Americans reaching 65 every day for the next 20 years,
according to the Pew Research Center. The older adult mobility assessment has as its first priority
helping older adults understand and improve their mobility situation. The financial costs of
preventable injuries that improved mobility could mitigate is staggering and well documented by
NCIPC. Even if the assessment only affects three topics - driving, falls and suicide - the cost
savings to society and the decrease in pain and suffering among individuals and families is
enormous. Many of the mobility-related protective actions, such as putting railings in the home to
prevent falls, can provide immediate impact and cost savings.
Efficiencies
In addition, the holistic older adult safe mobility assessment described in this report includes
measures that have traditionally been included in separate, individual assessments. These separate
assessments, each focused on their particular topic or domain of mobility, have their own
associated costs for development and dissemination. Funding the creation of one tool eliminates
redundant costs while delivering a better overall product.

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INFOR MING POLICY IN THE S HOR T TER M (3 TO 4 YEAR S )
Common ground
The expert panelists involved in the formation of this report represent several high profile, national
organizations with significant influence in policy circles. AARP stands as an obvious example. The
development and dissemination of this tool will involve close collaboration with these organizations
and others yet to be determined, all operating collaboratively under the leadership of CDC. This
older adult safe mobility assessment can be a highly effective rallying point for all players involved
in older adult safe mobility, providing common purpose from which to affect policy change. The
potential significance of this cannot be overstated. Buy-in for this project has been universal thus
far, and this is expected to continue to be the case. Leveraging the political and advocacy resources
of partnering organizations, and unifying them around the results of the holistic older adult safe
mobility assessment tool will be invaluable.
Fulfilling a need of policymakers
Policymakers throughout the country have indicated a difficulty in addressing the safe mobility
needs and wants of older adults due to a widespread lack of understanding of the patterns of older
adult safe mobility. This is precisely the data the older adult safe mobility assessment seeks to
collect. Once this data is available and disseminated through partner networks, policy makers will
finally have their first glimpse at a national, holistic picture of older adult safe mobility. This will
serve as a rational basis for policymaking decisions.

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APPENDIX
I. COMMU NIT Y/E NVIRONME NT AL ASSE SSME NT S
AARP Livable Communities
A volunteer-driven assessment of community transportation, walkability, safety and security,
shopping, housing, health services, recreation and social support.
http://assets.aarp.org/rgcenter/il/d18311_communities.pdf
CDC – Community Health Assessment and Group Evaluation (CHANGE) Tool
This is an evaluation and strategy tool to assess communities in five categories. All categories do
not directly apply to older adults (e.g., schools), but a useful example of a tool used to examine a
community and then build recommendations from the findings.
http://www.cdc.gov/healthycommunitiesprogram/tools/change.htm
COLLAGE Healthy Aging Assessments
Developed by a consortium of aging organizations and their members, Collage develops and
implements assessment tools to improve healthy aging. They also produce a wellness assessment
that focuses on 9 areas of wellness. They indicate it should be used in conjunction with the
Community Health Assessment.
http://collageaging.org/Site/Rpts/CommunityHealth.aspx
http://collageaging.org/Site/Rpts/Wellness.aspx
Craig Hospital Inventory of Environmental Factors (CHIEF)
The focus of the CHIEF is on the quantification of barriers experienced within five domains of
environmental factors (Policies; Physical and Structural; Work and School; Attitudes and Support;
Services and Assistance).
http://www.tbims.org/combi/chief/
Geriatric Resources for Assessment and Care of Elders (GRACE)
A model used by nurse practitioners and social workers to conduct a comprehensive geriatric
assessment.
http://medicine.iupui.edu/IUCAR/research/grace.asp

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Home and Community Environment (HACE) Instrument
Self-reported assessment evaluating home mobility, community mobility, basic mobility devices,
communication devices, transportation factors, and attitudes.
http://jrm.medicaljournals.se/files/pdf/37/1/37-44.pdf
Interpersonal Support Evaluation List (ISEL)
Self-reported indicators of social support.
http://www.psy.cmu.edu/~scohen/isel.html
Lubben Social Network Scale (LSNS)
Instrument designed to gauge social isolation primarily in older adults.
http://www.lubbensocialnetwork.org/
Measure of Quality of the Environment (MQE)
Evaluates the environments influence on a person's ability to perform daily activities.
http://www.ripph.qc.ca/?rub2=4&rub=18&lang=en
Social Support Survey (SSS)
A multidimensional self-report measure of social support.
http://www.rand.org/pubs/reprints/RP218.html
Senior Walking Environmental Assessment, Revised (SWEAT-R)
Instrument for measuring built environmental features associated with physical activity of older
adults.
http://www.ncbi.nlm.nih.gov/pubmed/19136025

II. DRIVING
AAA Foundation; SeniorDrivers.org, AAASeniors.com and AAAfoundation.org
The AAA Foundation houses several self-administered quizzes and assessment tools for senior
drivers. Most commonly used is the Roadwise Review (available online or via CD). They also house
a 15-question driving safety quiz (Driver 55).
AAA Foundation / PositScience
The AAA and PositScience partner to sell a “brain training” (Drive Sharp) program to help older
adult drivers. They also house a short vision/distraction test online:
http://www.positscience.com/testlets/cre/CRE_START.php

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University of Michigan Transportation Research Institute
Funded by the CDC, a battery of driving assessment instruments that have proven to be well
received.
Eby DW, Molnar LJ, Shope JT, Dellinger, AM. Development and pilot testing of an assessment
battery for older drivers. Journal of Safety Research 2007, Vol. 38(5):535-43

III. HRAS
American Diabetes Association HRA - Public
Tool that assists in determining risk for pre- or Type 2 diabetes.
http://www.diabetes.org/diabetes-basics/prevention/diabetes-risk-test/
American Heart Association Heart Attack Risk HRA – Public
Tool that assists in determining risk of heart attack or coronary heart disease.
http://www.heart.org/HEARTORG/Conditions/HeartAttack/HeartAttackToolsResources/Heart-AttackRisk-Assessment_UCM_303944_Article.jsp
Anthem Blue Cross HRA - Proprietary
Tool that assists in determining health status and health risks.
http://www.anthem.com/wps/portal/ca/footer?content_path=member/f0/s0/t0/pw_a119538.htm&l
abel=Take%20your%20Health%20Assessment
Cigna HRA (partnered with University of Michigan Trend Management System) Proprietary
Tool that assists in determining health status and health risks.
http://www.cigna.com/customer_care/broker/producer_communications/alerts/807879_CIGNA_HR
A_Fact_Sheet.pdf
Framingham Heart Study HRA - Public
Uses information from the Framingham Heart Study to predict a person’s chance of having a heart
attack in the next 10 years.
http://hp2010.nhlbihin.net/atpiii/calculator.asp
Mayo Clinic HRA. - Proprietary. Used by many other organizations.
Tool that assists in determining health status and health risks. Emphasis is on health education
and behavior change.
http://www.mayoclinichealthsolutions.com/products/Health-Assessment.cfm

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National Cancer Institute (Breast Cancer) HRA - Public
Designed for health professionals to assist in determining a woman's risk for invasive breast cancer.
http://www.cancer.gov/bcrisktool/
Navy/Marine Corps; Public Health Center HRA - Proprietary
Large-scale HRA for use by U.S. Navy and Marines. Not for use in the general population, however
common health themes apply.
http://www-nehc.med.navy.mil/Healthy_Living/General/healthriskassessment.aspx

IV. NAT IONAL SU RVE YS
HealthStyles (Porter Novelli, licensed by CDC) - Proprietary
Health attitudes and practices of a nationally representative sample of adults.
http://www.cdc.gov/healthmarketing/entertainment_education/healthstyles_survey.htm
Medicare Current Beneficiary Survey (MCBS) - Public
The only comprehensive source of information on the health status, health care use and
expenditures, health insurance coverage, and socioeconomic and demographic characteristics of
the entire spectrum of Medicare beneficiaries.
http://www.cms.gov/mcbs/

V. RE PORT S / RE PORT CARDS
Federal Interagency on Aging-Related Statistics - National Aging Statistics
The AgingStats.gov website has comprehensive statistics and reports about the state of older
Americans. They have recently published a report on the “Key Indicators” of well-being for older
Americans.
www.agingstats.gov/agingstatsdotnet/Main_Site/Data/2010_Documents/Docs/OA_2010.pdf
CDC – State of Aging and Health in America Report
National report card on 15 indicators of overall health for Americans 65 and over. The report is
from 2007 and based on primarily BRFSS data.
http://apps.nccd.cdc.gov/SAHA/Default/Default.aspx
CDC – State of Mental Health and Aging in America
Very similar to the above report. The focus is on mental health issues. Data is from 2006.
http://apps.nccd.cdc.gov/MAHA/MahaHome.aspx

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VI. ASSE SSME NT RE SOU RCE S
Aging Friendly.org
A conference series from the CDC Healthy Aging Research Network & Creating Aging-Friendly
Communities. Presentations and publications are available.
www.agingfriendly.org
American Geriatrics Society – Health in Aging - Aging In the Know
The AGS website has a comprehensive outline of what a health assessment for older adults entails.
Very good definitions and explanations for different categories/topics included in assessments
http://www.healthinaging.org/agingintheknow/chapters_ch_trial.asp?ch=8
Geridoc.net
A comprehensive list of online resources and older adult assessment tools in various categories.
Most of the links seem up to date and should provide us a good overview on what is available.
http://geridoc.net/assessmenttools.html
Clinical Toolbox for Geriatric Care
An online resource containing assessment tools and information. Primarily geared for Hospitalists to
quickly locate the best tool for any given clinical situation.
http://www.hospitalmedicine.org/geriresource/toolbox/howto.htm
My Life Stages – Sutter Health
A website with multiple health “quizzes” that span many health topics, including aging. Most
quizzes are more interactive than the normal multiple-choice quiz offered by other organizations.
https://mylifestages.org/MyLifeStages/community/Interactive+Health+Tools.page
University of Illinois at Chicago, Center for Health Promotion Research for Persons with
Disabilities
A collection of assessment tools is available online.
http://www.uic-chp.org/

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