Home-delivered Meals Research Articles

Health outcomes reported by healthcare providers and clients of a community-based medically tailored meal program

BackgroundMedically tailored meal (MTM) programs provide home-delivered meals to people living with serious illness and poor nutritional status. Client outcome studies have found evidence of decreased healthcare utilization and cost savings associated with MTM program participation, and inconclusive evidence of change in health measures. The purpose of this study was to use a novel observational framework to describe the client profile and change in health outcomes using routinely collected health and program data from a community-based MTM program at MANNA (Philadelphia, PA).MethodsClients reported their self-rated health and experiences of food insecurity and malnutrition. Healthcare providers reported clients’ body mass index, systolic blood pressure, and hemoglobin A1C. These health outcomes, measured at program intake and 3–6 months later, were linked with administrative data for 1,959 clients who completed at least two months of MTM services in 2020, 2021, and 2022.ResultsClients exhibited substantial heterogeneity in demographics and health status at intake. Self-reported malnutrition risk decreased significantly over program duration (p < .001). Nearly one-third of clients with poor health reported improvement over time. Over 60% of clients with obesity experienced stable BMI. Clients with hypertension experienced significant improvements in systolic blood pressure (p < .001). Clients with diabetes and available data (n = 45) demonstrated significant reduction in hemoglobin A1C (p = .005).ConclusionWe found evidence that participation in MANNA’s MTM program was associated with favorable health outcomes for clients with serious illness and nutritional risk. Community-based organizations can maximize the completeness of their data by focusing on routinely collected internal data like validated health screeners and surveys.

A public health/hospital partnership to improve Emergency Department transitions of care for vulnerable older adults.

Community-dwelling older adults are at high risk for unmet social service needs. We describe a novel partnership embedding county services case managers in the Emergency Department (ED) to connect older adults to community services alongside their medical care. Setting: A medium-sized urban ED with 55,000 patient visits a year. Case managers from the Franklin County, Ohio Office on Aging (OA) were embedded within the ED. The OA team worked with the ED social work team to identify community-dwelling older patients, perform an in-person intake assessment, and initiate needed community services (including home-delivered meals, emergency response systems, house repairs, and transportation). Program logic model and development are reported in detail. From June to December 2023, there were 7284 ED visits for adults ≥60 years old. Referrals to the OA case manager ranged from 1 to 13 per day. The OA case managers performed 252 full intake assessments on unique patients. The population was 51% men. Only 11% (n = 28) were currently connected to OA services, and of those already connected 29% (n = 8) needed increased services. Of the remaining unconnected patients (n = 224), 8% (n = 20) were not county residents and the OA team connected them with other county OAs. Half 53% (n = 120) were accepting of services and had services from the OA or other community health programs initiated during the ED visit. The OA team made three new Adult Protective Services referrals and one referral to the long-term care ombudsman. The program did not increase ED length of stay or hospital admission rates. Embedding county service enrollment within a community ED is a cost neutral intervention that reached a population without previous services. Future plans include expansion of the program and evaluation of the program's ability to detect elder mistreatment and self-neglect.

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

Patients at risk for malnutrition and their perceptions on a home-delivered meal service

Patients at risk for malnutrition and their perceptions on a home-delivered meal service

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.

"It Made Me Feel Like a Person Again": Benefits of Meals on Wheels-Based Social Connection Programs.

Social isolation and loneliness are associated with negative health outcomes, and these outcomes are exacerbated among older adults who are homebound. To address this issue, Meals on Wheels programs increasingly provide social connection services to clients in addition to home-delivered meals. This descriptive qualitative study examines the impact of three types of social connection programs on the well-being of homebound older adult clients, as well as on the volunteers and staff members who deliver the programs. Thematic analysis of semi-structured interviews conducted with 117 clients, volunteers, and staff in six Meals on Wheels social connection programs across the United States indicated that program participation was associated with substantial benefits. Benefits included the development of supportive friendships, reduced feelings of loneliness, and an improved overall sense of well-being. Insights from this study may inform the development, expansion, and sustainability of social connection programs provided by community-based organizations.

Experiences accessing nutritious foods and perceptions of nutritional support needs among pregnant and post-partum mothers with low income in the United States.

Access to nutritious foods, a social determinant of health, contributes to disparities in maternal and infant health outcomes such as mental health, breastfeeding intensityand cardiometabolic risk. This study explored perceived nutrition access and intake among pregnant or post-partum women eligible for Medicaid. Qualitative, semistructured interviews were conducted with 18 women who were either currently pregnant (n = 4) or up to 12 months post-partum (n = 14) in 2021-2022. Mothers spoke English (n = 11) or Spanish (n = 7) and lived in the Texas Panhandle. Interviews were audio-recorded, transcribed, translated (Spanish to English)and verified. Two or more researchers coded each interview until consensus was reached using thematic analysis with ATLAS.ti software. The study revealed five drivers for nutrition access. (1) Social factors influenced nutrition; those with less support expressed limited ability to eat healthfully. (2) The Women, Infantsand Children program was perceived as a helpful resource for some, while others faced challenges obtaining it. (3) Stress was bidirectionally related to unhealthy food choices, with food sometimes used as a coping mechanism. (4) Mothers prioritized their babies and others and had limited ability and time to prepare healthy meals. (5) Most participants felt they received inadequate nutrition guidance from their healthcare providers. Participants provided positive responses to a proposed nutritious home-delivered meal intervention. Low-income women may experience nutritional challenges specific to this life stage. Interventions that reduce stressand burden of household tasks (e.g. cooking)and improve education and access to nutritious foods may improve mothers' ability to consume nutritious foods.

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.

Participant Assessment of an Alternative Flexible Congregate Nutrition Meal Program for Older Adults

Congregate Nutrition Services have long been a pillar of public health assistance, championing the independence and community engagement of older Americans. The advent of COVID-19, however, restricted access to these services due to the closure of physical locations. In response, Lanakila Meals on Wheels initiated a virtual congregate meal program, Kūpuna U, in collaboration with community partners in Honolulu County. The program combined grab-and-go or home-delivered meals with virtual and in-person classes to improve both nutrition and socialization for older adults. This study aimed to capture participant feedback to assess and enhance the Kūpuna U program, developing it as a flexible and scalable congregate meal solution applicable nationwide. Five focus group discussions were conducted with program participants (n = 34). The majority of participants were female (74%), Asian (73%), and living alone (56%). Participants found the program beneficial, enhancing their nutrition, social engagement, and learning experiences on various topics tailored for older adults. Supportive staff played a crucial role in motivating participants to stay engaged. Participants also identified potential enhancements to the program, including more activities and courses, expanded hours, additional in-person options at various locations, and culturally tailored meals.

A protocol for stakeholder engagement in deliver-EE: A pragmatic randomized comparative effectiveness trial evaluating effects of meal delivery on the ability of homebound older adults to remain in the community

BackgroundFew clinical trials include a detailed protocol for stakeholder engagement in the design and execution of the clinical trial. Deliver-EE is a pragmatic clinical trial to assess how different types of home-delivered meals can affect older adults' health and well-being. We present the protocol for stakeholder engagement in this national, multi-site trial and initial findings from our efforts. MethodsTwenty-nine participants were recruited to two stakeholder advisory panels. The “Lived Experience Perspectives” panel is defined as the clients, caregivers, and meal delivery drivers with first-hand knowledge and lived experiences with meal delivery. The “System Perspectives” panel is defined as representatives from the larger financial, clinical, regulatory, and operational environments in which meal delivery to homebound older adults operate. Together, these two groups holistically represent interested parties that coordinate the interdependent elements of meal delivery to homebound older adults in order to: 1) inform our understanding of what matters most to older adults, their families, and the larger health and social care systems; 2) provide strategies to overcome challenges conducting the study; 3) enhance dissemination and uptake of study findings; and 4) identify opportunities for future research. ResultsAlthough stakeholder partners share a common goal of using home-delivered meals as a method to improve outcomes for homebound older adults, individuals have different goals for participating as advisors in this research. ConclusionsUnderstanding what individual stakeholders hope to gain from their participation is critical in designing an effective engagement protocol and critical for meaningful and rigorous stakeholder engagement in clinical trials.

Socioeconomic factors associated with uptake and satisfaction with a post-hospitalization meals benefit in Medicare Advantage.

Kaiser Permanente Southern California began offering a 4-week supplemental benefit of home-delivered meals to Medicare Advantage members after discharge from a hospitalization for heart failure and other medical conditions in 2021. The purpose of this study is to explore the associations between socioeconomic disadvantage and food insecurity with patient uptake of and satisfaction with the meals. Data for this cross-sectional study were drawn from survey and electronic medical record data for members referred for the meals benefit (n = 6169) and linked to a hospitalization encounter (n = 2254) between January and December 2021. Uptake was assessed using vendor records; measures of socioeconomic status included the neighborhood deprivation index (NDI) and prior receipt of medical financial assistance (MFA) from the health system. Patients were invited to complete an email or phone survey about their satisfaction with the meals and food insecurity. Multivariable log-binomial regression models were used to examine the association between socioeconomic disadvantage and food insecurity with meals uptake and satisfaction. Sixty-two percent of patients referred for the benefit accepted the meals (mean age: 79 ± 9, 59% people of color). While there was no significant relationship between NDI and meals uptake (RR: 0.99, 95% CI: 0.92-1.07, p = 0.77), patients who received prior MFA were more likely to accept the meals (RR: 1.09, 95% CI: 1.02-1.16, p < 0.01). Sixty-nine percent of patients who completed the survey (23% response rate) reported that meals were very or extremely helpful. Patients with food insecurity (29% of survey respondents) were more likely to report that the meals were helpful for their recovery compared to food secure patients (RR: 1.21, 95% CI: 1.09-1.35, p < 0.01). The home-delivered meals appeared to be particularly utilized by and helpful to patients with greater financial strain and/or food insecurity, suggesting that supplemental benefits could be more targeted toward addressing unmet needs of vulnerable adults.

Testing a Prioritization Tool to Identify Older Adults in Need of Home-Delivered Meals and Nutrition-Related Services

The Expanded Food Security Screener (FSS-Exp) determines food insecurity risk based on physical, economic, and social access to food. It categorizes individuals into 5 priorities based on need for a home-delivered meal. Concurrent and construct validity were applied to the tool. For concurrent validity, partial correlations between FSS-Exp and health- and food-related measures were significant and ranged between 0.20 and 0.33. For construct validity, analysis of variance was used to examine scores of the health- and food-related tools by priority level. The 2 highest priority levels had significantly lower mean scores for all the health variables except for dietary intake. The FSS-Exp tool effectively identifies those most in need of meal services.

Suicide risk factors among older adults: Implications for counselors as Medicare providers

AbstractProfessional counselors will be eligible to serve Medicare beneficiaries as of January 1, 2024, and Medicare is the primary health insurance program for older adults in the United States. This population is rapidly increasing, and growth is accompanied by increased mental health concerns such as suicide. Older adults who receive home‐delivered meals (HDM) may be at risk due to isolation, especially throughout the coronavirus pandemic. Grounded in the interpersonal theory of suicide, we sought to understand the relationships between proximal (thwarted belongingness; TB, perceived burdensomeness; PB) and distal (chronic pain, loneliness, and perceived social support) risk factors among older adults who receive HDM. TB and PB were correlated with pain, loneliness, and perceived social support, and these variables predicted TB and PB. Understanding relationships between proximal and distal suicide risk factors may inform interventions for counselors to address loneliness, enhance social support, and identify suicide risk among older adults.

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.

Home-delivered meal boxes in a family setting: a qualitative study investigating reasons for use and perceived impact on meal practices

BackgroundCooking and consuming a homemade meal is associated with health benefits. Home-delivered meal boxes can support families in cooking this fresh meal. The current study aimed to gain a deeper understanding of the determinants of meal box use, and of the perceived impact on meal practices of parents with younger (i.e., aged 6–12 years) and older children (i.e., 13–18 years).MethodsFour focus groups were conducted (n = 19); two with parents of younger children, and two with parents of older children. A semi-structured interview guide was developed and interviews were recorded and transcribed. Reflexive thematic analysis was performed using NVivo 1.4.ResultsMost parents mentioned practical reasons like saving time and money, as well as inspiration, as reasons to choose a home-delivered meal box. Also, tastiness and menu variation were often mentioned as determining factors by both parent groups. However, a few parents stated to stop using the meal boxes because of returning menus or too small portion sizes. Meal box providers were chosen based on the price, the freshness and the quality of the products. Moreover, positive effects on parents’ perceived cooking skills and knowledge were reported. Also, some parents mentioned positively changed attitudes towards vegetarian dishes. Lastly, parents reported healthier eating due to more appropriate portion sizes and more vegetables. A prominent difference between parent groups was that older children played a role in continuing the use of meal boxes, and helped to prepare the meals (contrary to younger children).ConclusionsHome-delivered meal boxes might be promising to enhance families’ meal practices. This study could inform social marketeers and health promotors to adopt an optimal strategy to reach families.

SOCIAL CONNECTIONS AND SUICIDE DESIRE AMONG COMMUNITY-DWELLING OLDER ADULTS

Abstract As the population of older adults in the U.S. continues to increase, so will the prevalence of critical mental health concerns such as suicide (CDC, 2020). The Interpersonal Theory of Suicide posits desire for suicide develops from the simultaneous presence of thwarted belongingness and perceived burdensomeness (Joiner, 2005). Low social connection and perceptions of low social support can result in feelings of thwarted belongingness and perceived burdensomeness among older adults (Van Orden et al., 2012). The purpose of this study was to understand the relationship between social connections (frequency of contact with others, both synchronous or “real-time” and/or asynchronous) and suicide desire among community-dwelling older adults who received home-delivered meals (HDM) during Covid-19. This cross-sectional study was part of a grant-funded project by the Administration for Community Living. Among a sample of 320 older adults in a large southeast metropolitan area, we identified 25 participants who had no social connections of any type within the past week. These individuals had the highest levels of suicide desire and loneliness, and had the lowest levels of perceived social support. Implications for practice and future research include: a) recognition of the social connections HDM volunteers provide to older adults who may be lonely and at risk of suicide, b) an understanding of suicide desire among older adults during the Covid-19 pandemic, and c) opportunities for nutrition service providers to invest in equipping HDM volunteers to respond to suicide.

LONELINESS AND OLDER ADULTS: RESULTS FROM A COMMUNITY-BASED INTERVENTION

Abstract The number of older adults identifying themselves as lonely has increased during the last two years as they have struggled with the impact of the pandemic on their perceptions of relationships with others. Recent research has shown that the negative health implications of loneliness are similar to those found with smoking or obesity. Most current interventions continue with past practice by adding people to engage with the older adult, although research suggests that while this intervention addresses social isolation, it does not address loneliness directly. Information regarding the development and implementation of a loneliness intervention with older adults based on the Health Beliefs Model in one rural mid-west county will be presented. Participants were recipients of home-delivered meals and had volunteered for a project that provided peer-to-peer instruction to improve digital literacy. In addition to technology training sessions, participants received a weekly contact from a separate volunteer as a friendly ‘check-in.’ Beginning in the fourth week, brief 5-10 minute coaching sessions about loneliness were included in these weekly contacts. The presentation will include details of the loneliness content, and describe training and support provided to the volunteers. Interviews were conducted with participants at baseline, approximately three months, and at the end of contact with each participant. Results showed no statistically significant change in loneliness, but participants reported they saw potential usefulness for the content with family and friends and potentially themselves in the future. They also provided helpful suggestions for revision. Plans for revision will be presented.

APPLICATION OF A NEW TOOL FOR PLANNING IMPLEMENTATION EVALUATIONS IN CLINICAL TRIALS

Abstract The VA Cooperative Studies Program (CSP) study “Geriatric OUt-of-hospital Randomized MEal Trial in heart failure – Veterans Affairs” (GOURMET-VA) is a randomized, single-blind, multi-center, clinical trial investigating the effects of home-delivered meals in Veterans discharged from hospitalization for heart failure. GOURMET-VA is one of the first CSP studies to integrate implementation scientists during protocol planning. We describe how the three phases of the new Implementation Planning Assessment (IPA) Tool was used proactively to guide planning of the implementation evaluation for the trial, oriented towards future adoption and sustainment of the intervention. Phase 1 (“Planning, Framing, &amp; Aligning Interested Parties”): During early protocol development, the implementation team helped identify and facilitated meetings with relevant VA national leadership. These meetings resulted in plans for engagement throughout the trial and input on trial design. Phase 2 (“Implementation Process Data Collection”): Guided by IPA, the implementation evaluation uses mixed methods to understand the context into which the intervention is being implemented, experiences of Veterans and clinicians with the intervention, and barriers and facilitators to implementation at the patient, healthcare provider, and leadership levels. Phase 3 (“Planning for Sustainment of Effective Trials”): A preliminary dissemination and sustainability plan was drafted, including how the implementation evaluation data may be used to inform adaptations of the GOURMET-VA intervention to improve effectiveness and uptake. We found that the structured guides that comprise the IPA were valuable in helping the implementation scientists and the trial team to find common ground in terms of rationale, methods, and language.

Home-Delivered Meals and Nursing Home Placement Among People With Self-Reported Dementia

Home-delivered meals promote food security and independence among homebound older adults. However, it is unclear which of the 2 predominant modes of meal delivery, daily-delivered vs mailed (or drop-shipped) frozen meals, promotes community living for homebound older adults with dementia. To assess the risk of nursing home admission within 6 months between homebound individuals receiving daily-delivered vs drop-shipped frozen meals. This pilot, multisite, 2-arm, pragmatic clinical trial included older adults with self-reported dementia on waiting lists for meals at 3 Meals on Wheels (MOW) programs in Texas and Florida between April 7 and October 8, 2021, to assess time to nursing home placement. Participants were randomized to receive either meals delivered by an MOW driver or frozen meals that were mailed to participants' homes every 2 weeks. Participants received their assigned intervention for up to 6 months. The primary study outcome was days from randomization to a Minimum Data Set nursing home admission assessment within 6 months. Feasibility of conducting this type of study was examined by tracking enrollment, examining baseline characteristics, monitoring participants' intervention fidelity, measuring the proportion of participants linked with Centers for Medicare & Medicaid Services (CMS) data, and analyzing the primary study outcome. Among 325 eligible participants who were randomized, 243 enrolled in the study (mean [SD] age, 81 [8.0] years; 152 (62.6%) were female): 128 to the daily-delivered meals group and 115 to the drop-shipped frozen meals group; 119 participants (49.0%) lived alone. Among the total participants enrolled, 227 (93.4%) were linked deterministically to their CMS data; probabilistic methods were used to link the remaining 16 participants (6.6%). At 6 months from randomization, 160 participants (65.8%) were still receiving meals, and 25 (10.1%; 95% CI, 6.3%-14.0%) were admitted to a nursing home. After adjusting for sex, race and ethnicity, age, program, and living arrangement and the use of death as a censoring event, the adjusted log hazard ratio of nursing home placement between daily-delivered and drop-shipped frozen meals was -0.67 (95% CI, -1.52 to 0.19). This pilot randomized clinical trial demonstrated the feasibility of enrolling participants with self-reported dementia on waiting lists at MOW programs, linking their data, and evaluating outcomes. While this pilot study was not powered to detect meaningful, statistically significant differences in nursing home placement, its feasibility and initial results warrant exploration in a follow-on, adequately powered trial. ClinicalTrials.gov Identifier: NCT04850781.

Economic Evaluation of a Personalized Nutrition Plan Based on Omic Sciences Versus a General Nutrition Plan in Adults with Overweight and Obesity: A Modeling Study Based on Trial Data in Denmark.

Since there is no diet that is perfect for everyone, personalized nutrition approaches are gaining popularity to achieve goals such as the prevention of obesity-related diseases. However, appropriate choices about funding and encouraging personalized nutrition approaches should be based on sufficient evidence of their effectiveness and cost-effectiveness. In this study, we assessed whether a newly developed personalized plan (PP) could be cost-effective relative to a non-personalized plan in Denmark. Results of a 10-week randomized controlled trial were combined with a validated obesity economic model to estimate lifetime cost-effectiveness. In the trial, the intervention group (PP) received personalized home-delivered meals based on metabolic biomarkers and personalized behavioral change messages. In the control group these meals and messages were not personalized. Effects were measured in body mass index (BMI) and quality of life (EQ-5D-5L). Costs [euros (€), 2020] were considered from a societal perspective. Lifetime cost-effectiveness was assessed using a multi-state Markov model. Univariate, probabilistic sensitivity, and scenario analyses were performed. In the trial, no significant differences were found in the effectiveness of PP compared with control, but wide confidence intervals (CIs) were seen [e.g., BMI (-0.07, 95% CI -0.51, 0.38)]. Lifetime estimates showed that PP increased costs (€520,102 versus €518,366, difference: €1736) and quality-adjusted life years (QALYs) (15.117 versus 15.106, difference: 0.011); the incremental cost-utility ratio (ICUR) was therefore high (€158,798 to gain one QALY). However, a 20% decrease in intervention costs would reduce the ICUR (€23,668 per QALY gained) below an unofficial gross domestic product (GDP)-based willingness-to-pay threshold (€47,817 per QALY gained). On the basis of the willingness-to-pay threshold and the non-significant differences in short-term effectiveness, PP may not be cost-effective. However, scaling up the intervention would reduce the intervention costs. Future studies should be larger and/or longer to reduce uncertainty about short-term effectiveness. ClinicalTrials.gov registry (NCT04590989).