Developing a Volunteer Education Initiative for Older Adults’ Health

Abstract Older adults need sufficient information to make healthy decisions and be active participants in their healthcare. Yet there is often a lack of information available. The Bronx Health Corps (BHC) was created to meet this need by providing older adults with usable knowledge on managing health conditions and promoting healthy behaviors in community-based settings. The BHC trained 175 volunteers, educated 2,065 older adults, with a total attendance of >5,000. Steps of creating a volunteer education initiative will be presented with qualitative and quantitative data utilization in implementation of the program. Focus groups with older adults noted challenges in addressing community health needs and the importance of reaching outside of healthcare settings to address the health of the community. Focus groups with Spanish speaking older adults and caregivers expanded knowledge on their attitudes toward the 4Ms and their ability to use that knowledge in interacting with their providers.


Bronx Health Corps: Developing a Volunteer Education Initiative for Older Adults' Health
Improving the health and lives of older adults -particularly those with multiple chronic health conditions -is a goal shared by a wide range of health systems stakeholders. Each stakeholder has an important part to play in pursuing this goal, but the engagement and participation of older adults themselves and the community organizations that are part of their lives, is essential for achieving lasting change.
The Bronx Health Corps is a successful example of a community-based effort to engage older adults, community volunteers, community-based organizations, and health providers to educate and empower older adults to improve their health.
This guide provides a case study for community-based organizations interested in developing a volunteer-driven program to empower older adults to manage their health through community engagement and education. It provides an overview of how the Bronx Health Corps was planned, designed and implemented, and includes practical tips and strategies needed to replicate a similar effort.
A downloadable version of this guide can be found at: https://hign.org/research-academic-opportunities/community-programs/volunteer-health-corps

Background
The vision for the Bronx Health Corps was conceived by the Hartford Institute for Geriatric Nursing (HIGN) at NYU Meyers as a part of a federal grant it received in 2015 from the U.S. Department of Health and Human Services, Health Resources and Services Administration. The Geriatric Workforce Enhancement Program (GWEP) grants were awarded to 44 institutions across the country with a focus on improving healthcare for older adults and maximizing patient and family engagement. HIGN worked in partnership with Montefiore Health System, Regional Aid for Interim Needs (R.A.I.N.), NYU School of Medicine and NYU School of Social Work.
The project objectives were to: • Provide educational resources to increase knowledge of older adult healthcare needs and enhance the skills of professionals caring for older adults in primary care and community settings.
• Develop strategies to unite primary care providers and community-based networks to be partners in promoting health • Utilize community resources to educate and support older adults, to promote healthy aging and manage chronic diseases.

The Need
The U.S. population is rapidly aging, and many older adults live with chronic conditions including, heart disease, cancer, diabetes, and dementia. These conditions can lower quality of life for older adults and contribute to the leading causes of death among this population. And for many older adults living in poverty, and for racial and ethnic communities, the risks are even greater. These older adults struggle with rising housing and healthcare bills, inadequate nutrition, lack of access to transportation, diminished savings, and job loss. They can face numerous obstacles to accessing appropriate care and supports needed to maintain and even improve their health. Efforts to address these health inequities includes addressing health literacy, as there is a growing concern that many older adults do not have sufficient knowledgeor the skills to use that knowledge-to make healthy decisions and to be active participants in their healthcare. The Bronx Health Corps was established to meet this need by providing people with usable knowledge about how to manage certain health conditions and how their behavior affects their health.

Overview: Bronx Health Corps
The Bronx Health Corps was created to address gaps in healthcare by working with community stakeholders, and older adults to build an infrastructure to educate and empower individuals to take care of their health in community-based settings. A community-based setting provides the opportunity to educate older adults where they congregate while also reaching those disconnected or inconsistently engaged with healthcare, and connect them to care. With one main objective under this GWEP project to utilize community resources to educate and support older adults, the BHC was formed. Local volunteers were recruited to deliver trainings to older adults. The BHC focused on creating a series of health workshops intended to increase knowledge and activate behavior changes around a series of health issues that reflected the most pressing needs. Materials on health promotion, disease prevention and management of chronic diseases were developed as a way to supplement the information received from primary care providers, building networks within the community that support wellness, care coordination, patient and family-centered healthcare for older adults. The success of the BHC resulted in further funding from the New York Community Trust, expanding the program through a partnership with JASA, a community-based aging organization. As of November 2019, the Bronx Health Corps trained 175 volunteers, educated over 2,000 unique older adults, with a total attendance of over 5,000.

Developing the Bronx Health Corps
The following sections outline the steps that GWEP staff and partners took to develop this educational program.

STEP 1: Conducting a Needs Assessment
Before creating a volunteer education initiative, developing the educational workshops, or recruiting volunteers to be the trainers, we needed to determine the educational needs of our community. This means asking questions such as "What are the key health issues for older adults;" "What is already going on to address these needs;" and "Who may be doing related work?" There are several additional ways to assess needs, including data collection via reported sources, key informant interviews, gathering information from meetings with community organizations and providers; conducting focus groups and collecting new data via surveys.
For the Bronx Health Corps, we focused on the following strategies:

Organization Assessment
Regional Aid for Interim Needs (R.A.I.N.) was selected as our first community-based partner for the Bronx Health Corps. R.A.I.N. serves a large number of older adults at their 11 senior centers located throughout the Bronx. Additionally, R.A.I.N. has a large network of community-based organizations (CBOs) they collaborate with to provide services to older adults. As we expanded the program, we selected JASA, an aging services organization with fourteen locations in the Bronx, as our second community partner.
If you have not yet selected a partner, you should find organizations serving older adults in your community and then begin to assess their ability to participate in the following ways: • ORGANIZATIONAL STRUCTURE: Do you or the potential partner organizations have the internal capacity to host such a program?
• FUNDING: Are resources available or will funds need to be raised?
• STAFF TIME: Do you or your potential partner organization have the capacity to support the volunteer efforts including recruitment, education, administrative support and ongoing supervision?
• RELATIONSHIPS WITH OTHER COMMUNITY-BASED ORGANIZATIONS: Do you or your potential partner organization(s) have a network of community-based organizations that could expand the reach of the program?
If your assessment finds a lack of funding, the next step is to identify additional resources. If you have determined your organization has the capacity to run the program, the next steps are assessing the needs of the larger community and the target community.

Community Needs Assessment
The first step of the community needs assessment is obtaining data on health indictors and social determinants of health among older adults. This information is often available on local Department of Health websites or from community-based organizations with a public health or social services focus. Further, if you are partnering with a local health provider, they may have this information. For example, Montefiore Health System has served older adults and their families in the Bronx for decades and provided a good deal of data on health status and unmet needs.
Secondly, we compiled a list of available resources and their locations in the community including faith-based organizations, senior services, libraries and other agencies that serve older adults or places they congregate. While R.A.I.N.'s 11 senior centers were to serve as the primary hubs for the initial rollout, to encourage other partnerships and reach more older adults, we identified additional organizations that could serve as collaborators by participating in key stakeholder interviews and focus groups to learn more about needs of older adults in their communities. Community surveys, focus groups, and stakeholder's input will help your organization determine the health education needs of older adults and caregivers in the community.

Assessing the Needs of the Target Community
Surveys, focus groups and interviews are all means to capture data about the needs and preferences of the target population. The findings of the survey can provide an overall picture of the communities' needs and awareness of services. The community survey should include questions on the frequency of healthcare visits, self-efficacy in reading and understanding medical forms, barriers to care, availability of health-related trainings in their community, transportation barriers, and any chronic health condition.

WHEN RECRUITING OLDER ADULTS, ASK YOURSELF:
• Am I recruiting from the appropriate places? • Am I making an effort to recruit with a racial, ethnic and gender representation of the target community? • Am I making an effort to reach people inconsistently or not connected to healthcare?
WHEN SELECTING DATA COLLECTION SITES, CONSIDER: • The accessibility of the spaces you are holding the focus groups (elevator, large doorframes) • The acoustics of the space (i.e., will the space hinder the ability to hear)

Bronx Health Corps Provider
• Finding a private space that protects the Focus Groups One focus group of 10 providers was confidentiality of participants convened at R.A.I.N., to gain insight into barriers older adults and their providers face. Participants in the focus groups included executive directors, care coordinators, educational consultants, social workers, case managers, trainers, nurses, and clinical coordinators.
Providers noted that it was challenging to address the health needs of older adults in their community when many older adults do not access preventative health services, such as check-ups and screenings. Providers spoke to the importance of reaching outside of healthcare settings to address the health of the community. Many older adults are not aware of services that are available to them. Once an older adult was in the healthcare system, providers identified gaps in services as a barrier to care. For example, a doctor being unable to access case managers notes. Providers felt it was critical to empower the patient.

Older Adult Community Survey
A survey was developed to administer to older adults. The survey asked about the health conditions of the survey participant and their families and their health education and service needs. Ninety-one participants were recruited at R.A.I.N. senior centers through flyers and the survey was administered by R.A.I.N. Program Directors at 11 senior centers. Findings indicated the majority of those surveyed needed information on applying for senior services (63%) and completing advanced directives (54%). Over half of those surveyed have, or have a family member with diabetes. Almost a quarter of participants have or have a family member with Alzheimer's disease, 41% Asthma and 39% Heart Disease. The survey asked knowledge questions on health conditions and healthy behaviors. Less than half of participants were able to identify depressive symptoms or dietary guidelines. Findings of the survey confirmed the need for more education to improve health self-management.

Older Adult Focus Groups
Community survey responses were used to formulate focus group questions. Ten focus groups were conducted at 10 R.A.I.N. senior centers. Focus groups lasted between 60 and 90 minutes. The older adults expressed a strong interest in topics around dementia and living healthier. Although over half of those surveyed were impacted by diabetes, focus group participants said diabetes courses were frequently offered in the senior centers they attended. To learn how to live healthier, the older adults requested more information on exercise, stress, nutrition and sexual health. Finally, focus group participants wanted more information on symptoms of chronic conditions, when to seek medical attention, and how best to communicate their concerns with their primary care provider. Participants also offered feedback on delivery of the trainings. The most cited suggestions included: " When you go to the doctor, you don't always get all the information you need" -BHC Volunteer STEP 2: Creating an Advisory Committee An advisory committee is an asset when establishing a large volunteer community health initiative. An advisory committee can be set up to fulfill a range of roles and capacities. For the Bronx Health Corps, staff was seeking support with the development of the volunteer program and evaluation of the programs' outcomes. A board can be structured in many different ways; for the BHC we included staff from partner organizations, other organizations serving older adults, and older adults that attend senior centers. Once the BHC was up and running, two volunteer health educators joined the advisory committee. The BHC advisory committee helped prioritize education topics, assisted with volunteer recruitment, and helped identify potential community-based settings for the education and outreach. Through this process, we learned that clarity on roles and how that may change over time helps keep members engaged.

Bronx Health Corps Advisory Committee
Program partners accessed their professional networks to recruit potential advisory committee members. The Bronx Health Corps recruited representatives from the following:

STEP 3: Development of Education Workshops
After completing a needs assessment and prioritizing educational topics, project staff -for the BHC we utilized a nurse practitionerdeveloped a series of 1-hour health workshops for older adults and their caregivers. Each workshop consists of a presentation, participant handouts, and an accompanying instructor manual (for the volunteer trainers). The

ADVISORY COMMITTEE TIPS • Hold meetings at a time that will attract the most board members • Assign members defined roles • Provide a scope of work for their role as advisory board members • Identify ways that various advisory board members can contribute to the mission • Select members that represent the diversity of the community HEALTH LITERACY PRINCIPLES: • Provide the important information first • Use non-technical language whenever possible • Provide information at an appropriate reading level • Use large font • Include pictures and graphics • Reiterate important information
accompanying instructor manual contains additional information for the volunteer trainer including icebreakers, points of emphasize, and prompts to guide the conversation. Handouts for older adult workshop participants include fact sheets, health related graphics and activity sheets. Each workshop focused on a particular health topic, offering tips for improving health, and included activities that promote positive health behaviors. The workshops were translated into Spanish to reflect the demographic needs of the community.

Developing a Volunteer Education Initiative
One of the project goals was to involve community residents, including older adults, as trainers for the health education workshops. The Bronx Health Corps uses a train-the-trainer model. The train-thetrainer model provides for the opportunity to include community members, provide community-based trainings and support peer learning. Each health workshop focused on a different topic ranging from healthy diet, exercise, stress management; living with Alzheimer's disease and related dementias, and enhanced knowledge on skills to manage heart failure and asthma. Training of the volunteers was conducted by a social worker from our community-based partner R.A.I.N., or a nurse practitioner from the Hartford Institute for Geriatric Nursing.

BRONX HEALTH CORPS WORKSHOPS
Based on the needs assessments, the Bronx Health Corps developed the following workshops:

STEP 4: Recruitment and Training of Volunteers
Recruitment and training of volunteers to teach these workshops depends on the structure of your organization and collaborators. Some collaborations divide responsibility for volunteer recruitment among all agencies participating in the workshop. Others assign volunteer recruitment and training to one organization, while assigning other tasks (outreach to older adults, space procurement, etc.) to the remaining partners. These responsibilities must be clearly outlined when starting the project.
In the case of The Bronx Health Corps, R.A.I.N. was in charge of volunteer recruitment. The NYU Project Coordinator primarily facilitated training with support and logistical assistance by R.A.I.N. and other partners.

Volunteer Qualifications
Ideal volunteers for this program are interested in health and health education, are committed to working with others, and have a passion for working with older adults. If possible, they should be comfortable with speaking to small and large groups, possess some classroom/group management skills, and depending on the community, possess competency of another language. Individuals who are residents from the local community can be a good fit for the project, as they are familiar with the social environment of those living in and around the senior centers. Given the commitment they are asked to make, seeking volunteers who are reliable and themselves eager to learn is important.

Starting the Recruitment Process
Use multiple venues to recruit volunteers. When recruiting volunteers, it is important to demonstrate why the project is important to the community, to older adults, and what the goals of this project are.
TARGET AUDIENCE: Consider conducting outreach to the older adults you intend to reach with the health workshops. Members from the target audience may be better positioned to effect change within the group.
ONLINE POSTINGS: Many volunteers seek out opportunities via the Internet. Consider posting on specific volunteer websites such as Volunteermatch.com. Some cities have dedicated agencies that assist in recruiting volunteers online. In addition, reach out to local colleges and job boards. Reach older adult volunteers through AARP and Retired Persons Volunteer Program (RSVP).

FLYERS:
Create eye-catching flyers with a brief tag line and contact information. These can be distributed at a variety of locations, and at community events.

HEALTH/COMMUNITY FAIRS: Recruit volunteers from individuals who attend fairs.
VOLUNTEERS: Encourage volunteers to recruit other volunteers to join the program.

COLLABORATIONS:
Leverage your organizational contacts to recruit volunteers from like-minded organizations whose mission aligns with yours.

INTERNS:
Interns can be a valuable source of volunteers. Interns receiving school credit stay with an organization for a semester, a year, or more. This consistency provides stability and a strong base for the program to build upon. Interns can be recruited from university programs, AmeriCorps, or other programs, and through standard volunteer recruitment efforts.

Volunteer Training
Part 1: Orientation (Day 1, 2 hours) Providing an overall orientation to the volunteers is essential. This will not only provide context to the effort, but serve to reinforce the projects' goals and hopefully establish their "buy-in" to the program. The BHC orientation includes: • Overview of the initiative • Background of the Community-based organization partners • Overview of agency policies for example: -Define volunteer -Agencies policies on confidentiality, background checks, safety, record keeping, conflictof-interest, dress codes, supervision and evaluations

Part 2: Workshop Training (Day 2, half-day)
During the workshop training, it is important to provide enough time for volunteers to gain a thorough understanding of the topic, and an opportunity for the volunteers to ask any questions.
Steps in the BHC volunteer training include: • Assessing volunteer knowledge of the topic by a multiple choice pre-test • A health professional training the volunteers on the workshop • A health professional answering any questions the volunteer has about the topic • Knowledge is reassessed with a multiple choice post-test • Volunteers must score 80% to move forward in the orientation process Part 3: Teach-backs (Day 3, half-day) Teach-backs is a method used to assess if the volunteer educator has adequate knowledge of the health topic they were trained on by repeating the information back to the instructors to ensure that the information was retained. Teach-backs also provide an opportunity to evaluate presentation skills and is a helpful way for trainers to learn if their training methods are working and if anything needs to be modified.
Bronx Health Corps Workshop teach-backs: • Scheduled a week after the workshop training so that volunteers have time to review the materials.
• The volunteers teach 15 minutes of the workshop they were trained on.
• The presentations are evaluated by agency staff using an oral presentation rubric.
• The rubric assesses the volunteer on a scale from 1-4, on five dimensions, eye contact, enthusiasm, clarity of speech, preparedness and organization, and responding to audience challenges.
Once the volunteers meet the standards of the rubric, they will receive a certificate of completion and they will be ready to train older adults.

Engaging with the Volunteers
Clear, consistent communication with new and recurring volunteers helps engagement and keeps the organization informed of their availability and changes. Once a volunteer has accepted a workshop to facilitate, it is the agency's responsibility to make sure the volunteer is aware of all the requirements of the workshop.
Keeping track of volunteer information, and communication with volunteers, is critical for program planning and evaluation. Some of the strategies used by the BHC included: • Creating a database with volunteer contact information, availability and language skills.
• Periodically reaching out to volunteers to ensure their schedule and contact information remains the same.
• After volunteers are scheduled to teach a workshop, sending them a calendar invite and give them a call and an email a couple days before the training as a reminder.

Volunteer Support and Appreciation
It is extremely important to recognize the effort of volunteers to show appreciation for their efforts. It recognizes their contributions, demonstrates how valuable their work is, and helps build comradery and improve volunteer retention. A few of the ways that the BHC recognized volunteers included: • CERTIFICATES OF COMPLETION/SERVICE: Detailing the courses passed and trainings completed.
• T-SHIRTS: Designed to give the volunteers a sense of community and belonging. Volunteers are encouraged to wear these when completing any volunteer activities in connection with the project.
" The training gave me the confidence level to teach" -BHC Volunteer " They (workshop attendees) have the courage to ask questions that they fear asking their primary care providers" -BHC Volunteer Follow-up can be difficult -it helps to engage program directors at the site of the training to assist with following up with the attendees.

Volunteer Focus Group
Holding a focus group of volunteers provides the opportunity for the volunteers to share what they liked best about the program and challenges they experience. Findings can be used to improve the program and help retain volunteers. Questions we asked of the BHC volunteers included motivation for volunteering, satisfaction with training received, successes and challenges of training older adults and what helped them stay engaged as a volunteer.

Achievements and Sustainability
Thus far, the Bronx Health Corps has taught over 300 workshops, trained over 2,500 unique older adults with over 5,000 workshop attendees. Attendees reported a high level of satisfaction with the program, and positive health behavior changes as the result of participation. Workshop attendees appreciated the BHC bringing health education into their community. Providing trainings in places older adults congregate creates an environment for participants to feel comfortable asking questions, and provides them with the confidence to initiate conversations with their primary care providers and share information with friends and family. Through the success of this initial effort, additional funding was secured and the project expanded to more areas of the Bronx through the inclusion of a second community-based organization, JASA.
As the population ages, it is critical that services are tailored to the needs of older adults. The Institute for Healthcare Improvement (IHI) describes an Age-Friendly Health Systems (AFHS) as one that incorporates the 4Ms: WHAT MATTERS: Aligning care with each older adult's specific health outcome goals and care preferences.