Phelan et al reported any days of restricted activity, and hospitalization did not increase during the year of program participation. The findings from this five-state dissemination of HEP mirror those from the randomized (efficacy) trial (Leveille et al 1998) in some respects and those from the local dissemination (effectiveness) (Phelan, Williams, Leveille, et al 2002) in other respects. Improvement in three disability risk factors varied among the present and previous dissemination and the randomized trial. Physical activity and exercise readiness (PACE scores) improved significantly in all three studies. Depression improved significantly in both the five-state and the local dissemination, but not in the randomized trial. Nutritional risk improved significantly in the five-state dissemination, but not in either the local dissemination or randomized trial. Perceived health improved in all three studies, significantly only in the local dissemination, marginally in the five-state dissemination, and non-significantly in the randomized trial. Functional decline was prevented or reduced in all three studies, although the bed days measure was significant only in the randomized trial and the restricted activity days measure was marginally significant only in the two dissemination studies. Finally, the percentage of HEP participants hospitalized declined significantly in the efficacy trial (from 21% in the baseline year to 13% at follow-up) but was unchanged in the two dissemination studies. As described previously (Phelan, Williams, Leveille, et al 2002), differing methods have been used over time to ascertain hospitalizations (administrative data for the efficacy trial versus self-report for the present and the local dissemination, the latter of which has been shown by others [Roberts et al 1996; Wallihan et al 1999] to have limited reliability), and thus the present results regarding hospitalizations should be interpreted cautiously. Two papers describe a program very similar to HEP, called Health Matters, implemented by a California long- term care insurance company in consultation with original HEP staff (Holland et al 2003, 2005; Tidwell et al 2004). A comparison of the Health Matters program and HEP has been published previously (Leveille et al 2004). Similar programs are being tested in other locales with somewhat different populations (Hughes SL and Boult C, personal communication), and SSSKC is currently in negotiations with Carle Hospital Foundation to include HEP as part of a Medicare demonstration project. These developments all indicate HEP’s robust potential for obtaining, for example, capitated funding from Medicare, similar to the Program of All-Inclusive Care for the Elderly for frail elders meeting 272 nursing home certifiability criteria (Gross et al 2004), or contracts with healthcare insurers whose older members enroll in HEP. Limitations of the present evaluation include its before– after design, which means that observed results may not be due to the HEP intervention. The other major limitation is that, of 224 participants enrolled, only 115 (51%) completed a 12-month follow-up questionnaire, and thus there was power to detect only large changes on our health and functional outcomes of interest. Such low participation is not unusual for senior center programs in general and is more likely with programs such as HEP, wherein a follow- up questionnaire is requested and no incentive is offered. We observed a similarly high non-completion rate in the local dissemination, which may bias our results. However, our comparison of those who did and did not complete the 12-month questionnaire showed that these groups differed in such a way that effects might have been greater than those observed had the non-completers actually participated in the 12-month follow-up. That is, HEP participants who did not complete the 12-month questionnaire had more ADL difficulty, more mobility difficulty, and greater severity of two of the three disability risk factors at time of enrollment in the program. Based on these differences, one would predict that non-completers would have benefited more than completers had they continued with the intervention, which may have led to greater mean improvement. In light of the difficulty encountered with retaining participants for one year, and data from the local dissemination suggesting that, among who experience improvement in their disability risk factors, most improvement occurs in the first six months (Phelan, Williams, Wagner, et al 2002), it was decided to change the duration of the program to six, rather than twelve months, with an option for participants to extend for a full twelve months if they desire. This change has been in effect since 2004. In spite of bias due to dropout, several strengths merit mention. First, the program continued to reach its target population (older adults with chronic conditions at risk for functional decline). Second, the five state dissemination attracted participants who were more diverse than those in the local dissemination (25% vs 11.5% nonwhite, respectively) from a variety of community centers in urban and rural regions of the US. Third, the five state dissemination achieved this enrollment through the cooperative efforts of newly created community-based networks of social service providers, academics, primary Clinical Interventions in Aging 2006:1(3)