Intervention The HEP intervention is based on the conceptual model of disability formulated by Buchner and Wagner (1992) This model suggests that predictors of (ie, risk factors for) disability such as poor chronic disease control, physical inactivity, and social isolation can be modified in order to reduce susceptibility to functional decline. The HEP nurse conducts an initial assessment of each participant’s health and functional status and risk factors for disability and works with the participant to develop a “health action plan”. This personalized plan, tailored to each participant’s individual goals and preferences, addresses one or more disability risk factors identified by the nurse’s assessment. All participants are encouraged but not required to enroll in three core components of the intervention described previously (CDSM, LFP, HEP health mentor) (Davis et al 1998; Wallace et al 1998; Lorig et al 1999). Participants with psychosocial issues such as depression are encouraged to meet with the HEP social worker. Data collection Data collection focused on health and functional outcomes, adherence to the program (specifically, frequency of participation in core components of HEP), and hospitalization. Participants reported this information on written questionnaires at enrollment and again at 6 and 12 months after enrollment. The HEP nurse mailed the questionnaire to the participant in advance of the initial and follow-up assessments to allow the participant to complete it as his or her own pace. The participant then brought the questionnaire in for the assessment visit with the nurse. If the questionnaire was incomplete at the time of the visit, the nurse assisted the participant in completing it. The nurse next reviewed the participant’s responses for completeness and accuracy and then, with the participant present, transferred the questionnaire information into WellWare©, a secure, data-entry software program that has been internet-accessible since 1 January 2003. Sociodemographic information was also collected and entered at the initial visit. Once entered, data were stored in a database at SSSKC. Staff of SSSKC removed all personal identifiers and then transmitted these data to researchers at the University of Washington for analysis. The University of Washington’s institutional review board approved the data collection procedures. Clinical Interventions in Aging 2006:1(3) Five state HEP dissemination Risk factors We used well established scales to measure three modifiable risk factors for disability: (1) 15-item Geriatric Depression Scale (GDS) (Sheikh and Yesavage 1986), on which a score greater than five is suggestive of depression; (2) Physician- based Assessment and Counseling for Exercise (PACE) scale (Long et al 1996), on which a score of four or less (exercising only infrequently) corresponds to being physically inactive; and (3) Nutrition Screening Initiative (NSI) DETERMINE (Disease, Eating poorly, Tooth loss or mouth pain, Economic hardship, Reduced social contact, Multiple medications, Involuntary weight loss or gain, Need for assistance in self- care, Elderly) instrument (Posner et al 1993), on which a score of 4 or more indicates nutritional risk and a greater likelihood of poor health at baseline and functional disability a year later. Functional status and mobility We assessed functional status using the National Health Interview Survey (NHIS) bed disability days questions: “In the past 12 months, did you stay in bed because of illness or injury? If yes, how many days did you stay in bed?” Previous analyses have shown that this measure is able to detect (ie, it is responsive to) important changes in functional status in relatively healthy elderly populations over time (Wagner et al 1993). We also assessed functional status with two NHIS restricted-activity day questions analogous to the bed disability days questions (Scholes et al 1991). We assessed mobility with four yes/no questions: “Because of your health, do you have any difficulty climbing one flight of stairs? Several flights?” and “Because of your health, do you have any difficulty walking one block? Several blocks?” Functional assessment also included difficulty with basic activities of daily living (ADL) function, ie, bathing, dressing, toileting, transferring in and out of bed, and feeding (Katz et al 1963). Health status and hospitalization We used the Medical Outcomes Study (MOS) question on self-rated health as a measure of health status (Ware and Sherbourne 1992; McHorney et al 1993, 1994). The following questions provided information on hospitalization in the 12 months before and after enrollment by self-report: “In the past 12 months, were you ever in the hospital overnight for physical health problems? If yes, how many days were you in the hospital overnight?” Participants completed a checklist to indicate which of seven chronic medical conditions (heart problems, diabetes, hypertension, 269