Home-delivered Meal Programs Research Articles

Using Technology to Improve the Nutrition Care Process at a Medically Tailored, Home-delivered Meal Program

Using Technology to Improve the Nutrition Care Process at a Medically Tailored, Home-delivered Meal Program

Multiple imputation Procedure for Record Linkage and Causal Inference to Estimate the Effects of home-delivered meals

To assess the impact of home-delivered meals programs offered by Meals on Wheels (MOW) a dataset that includes enrollment into MOW and healthcare utilization is required. Because of confidentiality restrictions this data is dispersed over MOW programs internal systems and Medicare claims. In the absence of unique identifying identifiers, MOW beneficiaries are linked to Medicare beneficiaries using probabilistic linking algorithm. However, this procedure may erroneously link individuals across the two datasets, which may result in biased treatment effect estimates and suboptimal interval estimates. We propose a two-stage multiple imputation framework to estimate causal effects when the covariates and outcome information are stored in Medicare claims and the treatment assignment is MOW program data. In the first stage, we create multiple datasets in which MOW beneficiaries are linked to Medicare beneficiaries using a Bayesian record linkage technique. In the second stage, we match Medicare beneficiaries that were not enrolled in MOW programs to those that did. Using these matches we multiply imputed for each MOW beneficiary their unobserved healthcare utilization if they did not receive MOW. This procedure propagates the errors in the linking process and the matching process, and can be used to estimate effects of interventions in other linked datasets when there are no unique identifiers.

Evaluating the Implementation Fidelity of a Pilot Pragmatic Randomized Clinical Trial Comparing Daily-Delivered Meals to Mailed Frozen Meals.

In pragmatic clinical trials (PCTs), the intervention is carried out by participating sites instead of research staff. In this paper, we evaluate study sites' implementation adherence during a pilot PCT of home-delivered meals for older adults with dementia. Participants at three home-delivered meal programs were randomized to receive either (1) meals delivered daily or (2) frozen meals mailed every two weeks; participants' outcomes were tracked for six months. Using the adherence domains from the Framework for Implementation Fidelity, we identified six metrics to assess adherence, with a total possible adherence score ranging from 6 (low adherence) to 18 (high adherence); all three sites scored within the top quartile of adherence. Despite challenges to meal delivery during the COVID-19 pandemic, sites successfully implemented the intervention, justifying a follow-on PCT to test the comparative effectiveness of models of meal delivery on the time to nursing home placement for people living with dementia.

Meals On Wheels Clients: Measurable Differences In The Likelihood Of Aging In Place Or Being Hospitalized.

Little is known about how participation in home-delivered meal programs (known as Meals on Wheels), financed in part through the Older Americans Act, relates to the use of health services and the ability to age in place for elder Medicare beneficiaries. Using 2013-20 data from the National Health and Aging Trends Study, we evaluated the relationship between Meals on Wheels use and two outcomes-likelihood of continued community residence and risk for hospitalization-in the following year for Medicare beneficiaries ages sixty-five and older, overall and by gender, race, Medicaid enrollment, and frailty. Overall, Meals on Wheels users and nonusers were equally likely to still reside in the community one year later; however, continued community residence was more likely among users than nonusers who were Black, were enrolled in Medicaid, or were frail. Program use was marginally associated with increased likelihood of hospitalization in the following year overall, but more strongly so among frail users. Our findings are consistent with the heterogeneity of Medicare-age Meals on Wheels users nationwide and suggest that program benefits differ among specific populations.

‘We all have a stake in this’: a phenomenological inquiry into integrating suicide intervention in home-delivered meal service contexts

Objectives Late-life suicide is a public health concern, yet many older adults do not have access to traditional mental health services. The present study sought to explore how suicide intervention is integrated into home-delivered meal (HDM) contexts following volunteer training in an evidence-based suicide first responder program. Methods Using phenomenological inquiry, we examined the experiences of 20 HDM volunteers trained in ASIST. Results Three primary themes emerged: (a) Logistics influencing integration of Suicide Intervention into HDM Systems, describing HDM program logistics; (b) Intrapersonal Context, describing HDM volunteer characteristics influencing intervention utilization and HDM client concerns; and (c) Interpersonal Context, describing HDM relationship characteristics that influenced intervention utilization. Conclusion HDM and other nutrition services have potential for addressing late life suicide, particularly when volunteers best equipped to address risk receive training and HDM policies reflect the needs of their clients. Implications for HDM services, as well as the Aging Services Network, are discussed.

An Organizational Assessment of 34 Home Delivered Meals Programs that Engaged and Assisted Homebound Individuals With Obtaining the COVID-19 Vaccine During the Pandemic.

Vaccinating homebound individuals during the COVID-19 pandemic presented several challenges, including time and cost of engaging this group. In Los Angeles County, the departments of Public Health and Aging and Disabilities turned to home delivered meals programs (HDMs) for help with this public health priority. A mixed-method organizational assessment of 34 HDMs was conducted during March-April 2022 to describe these efforts. Most HDMs were nonprofit (67.6%) and had <25 staff (58.8%). Overall, they served a large catchment area before and during COVID-19, providing services to an estimated total of 24,995 clients/week and delivering 19,511 meals/day. A majority (82.4%) reported engaging their clients to facilitate COVID-19 vaccinations. As of early 2022, <6% of these HDMs' homebound clients were unvaccinated. These programs' efforts to assist older individuals who were homebound during the pandemic represent a potentially underutilized model of public-nonprofit/not-for-profit partnership for improving vaccine delivery and uptake in this hard-to-reach population.

HOME-DELIVERED MEAL DELIVERIES AND FEELINGS OF SAFETY FOR OLDER AMERICANS ACT PARTICIPANTS

Abstract Home-delivered meals supported by the Older Americans Act (OAA) serve a dual purpose of improving nutritional intake and providing regular social contact for older adults. This regular contact can increase feelings of safety experienced by meal recipients. The benefits of home-delivered meal services may vary between meal recipients based on sociodemographic characteristics. Variation in home-delivered meal clients’ reports of feeling safer at home because of regular meal delivery visits was examined to support ongoing efforts to increase social engagement and equity through the delivery of OAA services. Using data from the 2019 National Survey of Older Americans Act Participants (NSOAAP) home-delivered meal module, descriptive statistics and logistic regression were conducted to identify the characteristics associated with feeling safer at home because of meal delivery visits. The majority (85%) of meal recipients report feeling safer because of meal delivery visits, and rates were especially high for rural recipients (92%), those with a high school education or less (89%),racial/ethnic minorities (94%), and those with three or more ADL limitations (90%). Logistic regression found that rural residence (OR=3.3), lower educational attainment (OR=2.0), racial/ethnic minority status (OR=4.7), living alone (OR=1.6), and having 3+ ADLs (OR=1.9) were significantly associated with higher odds of feeling safer at home because of meal delivery visits; however, age, gender, and suburban residence were not significant. Findings suggest that benefits of home-delivered meal programs are supporting the needs of traditionally disadvantaged groups and broadly increasing meal recipients’ sense of safety in their homes.

Older Adults and the Food Security Infrastructure.

This project explores the correlates of state variation in food security using data from the 2008 to 2018 Current Population Survey's Food Security Supplements. The focus is on the relationship between state-level availability and accessibility of congregate and home-delivered meal programs, the Supplemental Nutrition Assistance Program (SNAP), the Senior Farmer's Market Nutrition Program (SFMNP) and the Commodity Supplemental Food Program (CSFP) on food security among lower-income households headed by older adults (ages 60 and up). Results show evidence that a senior-specific state level food security infrastructure plays a role in the food security status of households headed by older adults.

Moving the Needle on Outcome Measurement: A Longitudinal Analysis of Frailty Among Home-Delivered Meal Recipients

Frailty is a complex condition highly associated with malnutrition and can lead to the devastating loss of independence among older adults. Home-delivered meals (HDMs) aim to combat frailty and malnutrition and provide nutritional support to nearly 10 million older adults each year. Though self-reported metrics indicate that HDMs help older adults maintain their independence, few studies have systematically collected longitudinal data that objectively represent the health benefits of HDMs. The present study implemented two evidence-based instruments designed to measure frailty levels of HDM recipients (age 60 to 99 years) at two time points. HDM staff at one organization underwent multifaceted training to implement The Home Care Frailty Scale and the Clinical Frailty Scale with HDM recipients at the start of HDM enrollment and at three-month follow-up. Activity of daily living impairments (B = .46, p < .001) and instrumental activity of daily living impairments (B = .28, p < .001) were significant predictors of higher frailty levels at baseline (N = 245). Sixty-two recipients were analyzed at 3-month follow-up. Clinical Frailty Scale scores indicated stable frailty levels from baseline to follow-up (4.08 vs. 4.08). Home Care Frailty Scale scores indicated a slight increase in frailty levels (7.4 vs 7.63) though not statistically significant, t(61) = -.34, p = .74. These stable frailty metrics suggest that HDMs contribute to older adults’ ability to remain living in their own homes and communities and can support the importance of increased financial investments in HDM programs at the state and national levels.

Sustainability of the Aging Network's COVID-19 Responses: Isolated Impact or Transformative Change?

The COVID-19 pandemic mobilized individuals, organizations, and communities. Area Agencies and Aging (AAAs) and Title VI Native American Programs, core organizations of the network of community-based organizations (CBOs) that serve older adults and their families, pivoted their service delivery methods to provide life-sustaining services. Their long-standing expertise in community needs assessment, pre-existing cross-sectoral partnerships, and an infusion of emergency federal funding, enabled this rapid response. Recently concluded studies using key-informant interviews and national surveys of AAAs and Title VI programs highlight these service adaptations, from expansion of home-delivered meal programs to new partnerships in telehealth. These organizations also reported expansion of services offered and people served, and the emergence or strengthening of partnerships with other CBOs, businesses, and governmental organizations such as public health entities. For example, 78% of the respondents to the recent survey of AAAs reported that they have a role in vaccination outreach, scheduling support, or delivery. The papers in this symposium will use these new studies to describe the nature, origins, and potential sustainability of new and expanded services and partnerships. The Collective Impact Model for community change (introduced in the Stanford Social Innovation Review) will provide a framework for the discussion. Built on the importance of cross-sector coordination, the five pillars of success for collective rather than isolated impact are: a common agenda, mutually reinforcing activities, continuous communication, shared measurement, and a backbone organization. Each of these five pillars is relevant to the heightened community response during the pandemic, and to the likelihood of sustainability.

Terrie Fox Wetle Award (2020): The Role of Home-Delivered Meals Programs in Improving Health and Promoting Community Independence for Older Adults

Dr. Terrie “Fox” Wetle is internationally recognized as a leader who conducts and advocates for multi-disciplinary and multi-method investigations centered on aging, public health and health care with direct implications for shaping policy and practice. This award lecture, given in Dr. Wetle’s name, will be presented by the 2020 award recipient, Kali Thomas, PhD. Dr. Thomas will present a line of multi-disciplinary and multi-method research focused on the impact of home-delivered meals as it relates to the health outcomes of homebound, food insecure older adults. Findings will include results from observational and intervention studies conducted at both the local and national levels. Examples of how this evidence has influenced policy and practice, including greater integration with healthcare, will be provided. The lecture will conclude with discussion about future opportunities for collaboration with community partners to measure and understand the impact of these vital social services on the lives of older adults.

A Technology Training Program to Alleviate Social Isolation and Loneliness Among Homebound Older Adults: A Community Case Study.

Despite substantial evidence of the negative health consequences of social isolation and loneliness and the outsized impact on older adults, evidence on which interventions are most effective in alleviating social isolation and loneliness is inconclusive. Further complicating the translation of evidence into practice is the lack of studies assessing implementation and scalability considerations for socialization programs delivered by community-based organizations (CBOs). Our primary objective was to describe the implementation barriers, facilitators, and lessons learned from an information and communication technology (ICT) training program aimed at reducing social isolation and loneliness for homebound older adults in a home-delivered meals program. Participants received in-home, one-on-one ICT training lessons delivered by volunteers over a 14-week period with the goal of increasing social technology use. To assess implementation facilitators and barriers, 23 interviews were conducted with program staff (n = 2), volunteers (n = 3), and participants (n = 18). Transcripts were analyzed using thematic analysis. Aspects that facilitated implementation included the organization's existing relationship with clientele, an established infrastructure to deliver community-based interventions, alignment of intervention goals with broader organizational aims, and funding to support dedicated program staff. Challenges to implementation included significant program staff time and resources, coordinating data sharing efforts across multiple project partners, participant and volunteer recruitment, and interruptions due to COVID-19. Implications of these facilitators and barriers for scalability of community-based ICT training interventions for older adults are described. Lessons learned include identifying successful participant and volunteer recruitment strategies based on organizational capacity and existing recruitment avenues; using a targeted approach to identify potential participants; incorporating flexibility into intervention design when working with the homebound older adult population; and monitoring the participant-volunteer relationship through volunteer-completed reports to mitigate issues. Findings from this formative evaluation provide insight on strategies CBOs can employ to overcome challenges associated with implementing technology training programs to reduce social isolation and loneliness for older adults, and thus improve overall well-being for homebound older adults. Recommendations can be integrated into program design to facilitate implementation of ICT programs in the community setting.

P48 Preliminary Analysis from Statewide Stakeholder Interviews Around the Impact of Food Access During COVID-19

<h3>Background</h3> During the COVID-19 pandemic, nearly 24 million adults reported that their households sometimes or often lacked sufficient food in the last 7 days, with Black and Latino adults approximately 3 times as likely as White adults to report food insecurity. <h3>Objective</h3> The objective of this study was to assess the impact COVID-19 on food access in Rhode Island (RI), document challenges encountered, and identify promising practices and policy solutions by conducting individual, 1-hour key stakeholder interviews from September-November 2020. <h3>Study Design, Settings, Participants</h3> Virtual qualitative interviews (n = 25) were conducted with 33 key stakeholders from 25 community organizations located throughout RI. This includes state/city agencies (n = 9), nonprofit organizations (n = 5), Health Equity Zone representatives (n = 5), food pantries/food bank (n = 4), a home-delivered meal program (n = 1), and a FQHC (n = 1) that primarily serve low-income and racial/ethnic minority populations. <h3>Measurable Outcome/Analysis</h3> A structured interview guide was developed to capture scope of work, successes and challenges, and impact on health disparities including how organizations adjusted during COVID-19 to provide access to food safely. All interviews were recorded, transcribed, and thematically coded in NVivo with a priori codes to guide the analysis. An inductive and deductive approach was used to identify themes. <h3>Results</h3> Preliminary findings suggest that organizations struggled to meet food needs due to unemployment, lack of culturally relevant foods, insufficient resources (ie, funding, personal protective equipment, technology), and exacerbation of existing food access challenges connected to transportation and food storage needs. Despite these challenges, reported successes included enhanced collaboration between new and existing partnerships among stakeholders, increased effective communication among community stakeholders and the populations they serve, and increases in new initiatives to support food access needs. <h3>Conclusion</h3> Our findings highlight the need to ensure a coordinated response through strategic leadership that has a focus on vulnerable racial/ethnic populations to ensure access to culturally appropriate food during emergency situations.

One Year Impact on Social Connectedness for Homebound Older Adults: Randomized Controlled Trial of Tele-delivered Behavioral Activation Versus Tele-delivered Friendly Visits

ObjectivesLonely and socially isolated homebound older participants of a randomized trial comparing behavioral activation (BA) versus friendly visiting, both delivered by lay counselors using tele-videoconferencing, were reassessed at 1-year to determine whether benefits at 12 weeks were maintained over time. MethodsThe study reinterviewed 64/89 (71.9%) participants. ResultsThe positive 12-week impact of tailored BA on 3 indicators of social connectedness (loneliness, social interaction and satisfactions with social support) was maintained, albeit to a lesser degree, over 1 year. The positive impact on depressive symptoms and disability was also maintained. ConclusionsThe intervention's potential reach and scalability are suggested by several factors: participants were recruited by home delivered meals programs during routine assessments; the intervention was brief and delivered by lay counselors; care delivery by tele-videoconferencing is increasingly common. The 1 year outcomes indicate that brief BA delivered by tele-video conferencing can have an enduring impact on social connectedness.

Reasons for refusing referrals and challenges to effectual engagement in tele-treatment for depression among low-income homebound older adults

Objectives: To describe reasons for refusal to be referred to or enroll in a depression treatment study and post-enrollment challenges to treatment engagement and technology-related problems among low-income homebound individuals aged 50+ years with depression. Methods: Data came from a 3-arm randomized clinical trial that evaluated real-world effectiveness of lay counselor-delivered behavioral activation (BA) versus clinician-delivered problem-solving therapy (PST). Interventionists were embedded in a large home-delivered meals program and treatment sessions were videoconferenced; hence Tele-BA and Tele-PST. We described refusal reasons of those who refused initial case manager referrals (n = 279), telephone screening (n = 64), enrollment (n = 47), or post-enrollment baseline assessments (n = 18). We used inductive thematic analysis to explore challenges to effectual treatment engagement and tele-delivery-related problems among Tele-PST or Tele-BA participants (n = 183) from the interventionists’ tele-session process recordings. Results: More than a third of potentially eligible older adults refused their case managers’ referral, and a quarter of those who accepted referral refused further screening or enrollment. Three quarters of those who refused reported no interest or need or declined to talk about depression. Others refused given their busy schedule with medical appointments and caregiving. Nearly 80% of Tele-BA or Tele-PST participants had some challenges to effectual engagement in treatment sessions due to environmental and health-related conditions and other life stressors including financial distress. Though many tele-sessions had connectivity and other technology-related problems, these did not affect depression outcomes. Conclusion: Mental health service providers for low-income older adults need to be aware of these challenges when adopting best practice strategies for them.

Food Insecurity is Directly Associated with the Use of Health Services for Adverse Health Events among Older Adults

In 2018, 14.3 million US households experienced food insecurity, which has been linked to negative health outcomes such as depression and anxiety, diabetes, and hypertension. This connection is particularly important for older adults, who are at greater risk than younger adults for developing certain health conditions. We estimated the association between food insecurity and the use of health services for adverse health events over a 12-mo observation period following survey interview for a nationally representative group of older adults participating in the congregate meal (CM) and home-delivered meal (HDM) programs. We analyzed data from the Nutrition Services Program (NSP) Outcomes Survey matched to Medicare claims and enrollment data in 2015-2016 for a nationally representative sample of 626 CM or HDM recipients ages 67 y and older. We used logistic regression analysis controlling for demographic characteristics, prior health events, and geography to estimate the association between food insecurity and use of health services, including emergency department visits, inpatient stays, skilled nursing facility stays, and home healthcare episodes. We used ordinary least squares regression analysis to estimate the association between food insecurity and Medicare spending. Food insecurity was associated with an average increased likelihood of using health services for adverse health events of 16% (95% CI: 1%, 32%) for HDM participants. Food insecurity was associated with an average increased likelihood of emergency department visits of 24% (95% CI: 6%, 41%) for CM participants and 20% (95% CI: 5%, 36%) for HDM participants. There was no observed increase in likelihood of using the other health services. Food-insecure participants were less likely to have a skilled nursing facility stay. Food insecurity is associated with an increased likelihood of use of health services for adverse health events in older adult participants in meal service programs.

Serving Homebound Seniors: In-Home Senior Farmers’ Market Nutrition Program Enrollment and Fresh Fruit and Vegetable Home Delivery for Homebound Seniors in Central New Jersey

Low-income, homebound seniors may encounter affordability and accessibility-related barriers to consuming enough fresh fruits and vegetables (FV). This paper describes a two-stage pilot intervention to improve fresh FV affordability and access for home-delivered meal (HDM) program clients in Central New Jersey. The first stage of the intervention offered in-home Senior Farmers’ Market Nutrition Program (SFMNP) enrollment assistance to low-income HDM program clients, with 13 clients successfully enrolling in SFMNP. The second stage of the intervention offered fresh FV home deliveries to all 64 HDM program clients at no cost to clients. We sourced fresh FV from a farmers’ market run in partnership with a Cooperative Extension program affiliated with a large public research university. We carried out a post-intervention evaluation by conducting semi-structured interviews with 17 clients. Interviews addressed themes of farmers’ market access, SFMNP awareness, perceived changes to FV intake, and home delivery satisfaction. Evaluation results suggest that this short-term pilot intervention was well-received and effective in reducing barriers to FV access and affordability for a vulnerable senior population.

Making home-delivered meal programs relevant for today’s aging adult

The growing aging population increases the need for community food programs like home-delivered meals. This study explored factors influencing aging adults’ interest in home-delivered meal programs, like Meals on Wheels. Four focus groups were held with 31 primarily retired White females aged 65–84 years in a Midwest state. Focus groups were audio-recorded, transcribed, and analyzed. Participants also completed a 21-item sociodemographic questionnaire. Many were aware of Meals on Wheels but lacked awareness of other home-delivered meal programs. Meals on Wheels was associated with loss of independence, poor food quality, and companionship. Home-delivered meal programs participation motivators included affordable cost, choices/variety, nutritionist/dietitian involvement, and clientele testimonies. Home-delivered meal programs participation barriers were distrust of marketing claims, food safety concerns, and limited meal storage space. Preferred home-delivered meal programs attributes included convenience and quality menu options. Preferred home-delivered meal programs promotional strategies included brochures, in-person presentations, and product sampling. By addressing these motivators and preferred marketing strategies, home-delivered meal programs may be better able to appeal to today’s aging adult.

Improving Social Connectedness for Homebound Older Adults: Randomized Controlled Trial of Tele-Delivered Behavioral Activation Versus Tele-Delivered Friendly Visits

To test the acceptability and effectiveness of a lay-coach-facilitated, videoconferenced, short-term behavioral activation (Tele-BA) intervention for improving social connectedness among homebound older adults. We employed a two-site, participant-randomized controlled trial with 89 older adults (averaging 74 years old) who were recipients of, and initially screened by, home-delivered meals programs. All participants reported loneliness; many reported being socially isolated and/or dissatisfaction with social support. Participants received five weekly videoconference sessions of either Tele-BA or Tele-FV (friendly visits; active control). Three primary outcomes were social interaction (Duke Social Support Index [DSSI] Social Interaction Subscale), subjective loneliness (PROMIS Social Isolation Scale), and DSSI Satisfaction with Social Support Subscale. Depression severity (PHQ-9) and disability (WHODAS 2.0) were secondary outcomes. Mixed-effects regression models were fit to evaluate outcomes at 6- and 12-weeks follow-up. Compared to Tele-FV participants, Tele-BA participants had greater increase in social interaction (t [81] = 2.42, p = 0.018) and satisfaction with social support (t [82] = 2.00, p = 0.049) and decrease in loneliness (t [81] = -3.08, p = 0.003), depression (t [82] = -3.46, p = 0.001), and disability (t [81] = -2.29, p = 0.025). A short-term, lay-coach-facilitated Tele-BA is a promising intervention for the growing numbers of homebound older adults lacking social connectedness. The intervention holds promise for scalability in programs that already serve homebound older adults. More research is needed to solidify the clinical evidence base, cost-effectiveness and sustainability of Tele-BA delivered by lay coaches for homebound and other older adults.

Characterizing Intervention Opportunities among Home-Delivered Meals Program Participants: Results from the 2017 National Survey of Older Americans Act Participants and a New York City Survey.

The Home Delivered Meals Program (HDMP) serves a vulnerable population of adults aged 60 and older who may benefit from technological services to improve health and social connectedness. The objectives of this study are (a) to better understand the needs of HDMP participants, and (b) to characterize the technology-readiness and the utility of delivering information via the computer. We analyzed data from the 2017 NSOAAP to assess the health and functional status and demographic characteristics of HDMP participants. We also conducted a telephone survey to assess technology use and educational interests among NYC HDMP participants. Functional measures of the national sample included comorbidities, recent hospitalizations, and ADL/IADL limitations. Participants from our local NYC sample completed a modified version of the validated Computer Proficiency Questionnaire. Technology readiness was assessed by levels of technology use, desired methods for receiving health information, and interest in learning more about virtual senior centers. About one-third (32.4%) of national survey HDMP participants (n=902) reported insufficient resources to buy food and 17.1% chose between food or medications. Within the NYC HDMP participant survey sample (n=33), over half reported having access to the internet (54.5%), 48.5% used a desktop or laptop, and 30.3% used a tablet, iPad, or smartphone. The HDMP provides an opportunity to reach vulnerable older adults and offer additional resources that can enhance social support and improve nutrition and health outcomes. Research is warranted to compare technological readiness of HDMP participants across urban and rural areas in the United States.