Delivering More Than A Meal: Impact of Home-Delivered

Delivering More Than A Meal: Impact of Home-Delivered

Delivering More Than A Meal: Impact of Home-Delivered Meal Service Models on Clients Health Kali S. Thomas, PhD Assistant Professor (Research), Department of Health Services, Policy and Practice, Brown University and Research Health Scientist, Providence VAMC March 23, 2016 Background Much evidence suggests benefits of home-delivered meals (HDMs) Research needed Quantify improvement in quality of life Determine effectiveness of the daily check in and social contact

Motivation for Study Funding cuts and increased costs = fewer seniors served, fewer meals delivered, increase in waiting lists New lower cost model of frozen, once-weekly meal delivery More Than A Meal Study Pilot funded by AARP Foundation Study Aims Aim 1. Characterize seniors on waiting lists for HDM Aim 2. Evaluate the impact of HDMs Aim 3. Evaluate the comparative effectiveness of meal delivery method Secondary Goals

Practicality of conducting RCT with this population Refine methods for larger scale evaluation Design Three-arm randomized controlled trial Frozen, once-weekly delivered meals Daily-delivered meals Remain on waiting list 8 sites 626 participants Baseline survey (in person) and 15week follow-up (via telephone) Initial Interview Follow-Up Interview

Data Analysis Demographic Characteristics Marital Status Married Widowed Age <65 Age 85+ Education Less than high school High school diploma or GED Some college or higher Race and Ethnicity White Black Hispanic or Latino

Medicaid 23% 45% 15% 25% 28% 40% 32% 60% 33% 12% 31% Help with Personal Care Needs Do you sometimes need the help of another person with personal care ne...

58% Do you have someone to help you over a long period of time with personal care activit... 61% 0% 10% 20% 30% 40% 50% 60% 70% Social Support How often do you have contact with friends or family? Is there a family member, friend, or neighbor that you feel you can call on for help if you need it?

8.27% 13.02% 10.08% 22.98% 58.68% 86.98% Daily or almost daily Once or twice a week Once or twice a month Less than once a month Yes

No Comparing Participants to the Population of Seniors Nationally Nationally Representative Survey 2013 National Health and Aging Trends Survey (NHATS) Self-Rated Health Anxiety & Depression Fear of Falling Difficulty Shopping and Cooking

Observations Inside and Outside the Home Analyses Chi-square to test differences between groups Ref. Thomas, K.S., Smego, R., Akobundu, U., and Dosa, D. (2015). Journal of Applied Gerontology Participants Have Worse SelfRated Health than Seniors Nationally 41% 30% 29% 25% 22%

19% 11% 7% 5% 1% Excellent Very good Good MTAM Seniors Seniors Nationally Fair

Groups significantly different at the p<.001 level Ref. Thomas, K.S., Smego, R., Akobundu, U., and Dosa, D. (2015). Journal of Applied Gerontology Poor Participants More Likely to Have Depression and Anxiety than Seniors Nationally 31% 28% 16% 14% Depression MTAM Seniors

Anxiety Seniors Nationally Depression measured using PHQ-2 and Anxiety measured using the GAD-2; Groups significantly different at the p<0.001 level. Ref. Thomas, K.S., Smego, R., Akobundu, U., and Dosa, D. (2015). Journal of Applied Gerontology Participants More Likely to Have Fallen and Have the Fear of Falling Limit Activities than Seniors Nationally MTAM Seniors 27% 56% 79%

Fallen Worried about falling Fear limited activities Seniors Nationally 10% 27% 42% Groups significantly different at the p<0.001 level Ref. Thomas, K.S., Smego, R., Akobundu, U., and Dosa, D. (2015). Journal of Applied Gerontology Participants More Likely to Need Help

Shopping for Groceries and Preparing Food than Seniors Nationally MTAM Seniors 87% 69% Shop for groceries Prepare or heat up food Seniors Nationally 23% 20%

Groups significantly different at the p<0.001 level MTAM Participants Have More Exterior Hazards Than Seniors Nationally 15% Uneven Walking Surfaces Roof Problems 5% 11% 8% Missing Bricks, Siding, or Other Outside Materials MTAM Seniors

13% 6% Broken or Boarded Windows 0% 13% 7% Crumbling Foundation or Open Holes 5% 25%

10% 10% 15% 20% Seniors Nationally Q: Standing in front of the respondent's home/building, did it have Groups significantly different at the p<0.001 level. 25% MTAM Participants Have More Hazards Inside the Home Than Seniors Nationally

11% Tripping Hazards 5% Flooring in Need of Repair Broken Furniture or Lamps Evidence of Pests Peeling or Flaking Paint 0% 24% 16% 3% 16%

2% 10% 4% 5% 17% 10% 15% 20% 25% MTAM Seniors Seniors Nationally

Q: Inside the respondent's home/apartment/unit, did you observe Groups significant different at the p<0.001 level Aim 1 Conclusions American older adults on Meals on Wheels waiting lists need a variety of supports Need additional help beyond meals Important to assess these needs Referral to other services Opportunities for collaboration Study Aims 2 & 3 Evaluate the impact of home-delivered meals Evaluate the comparative effectiveness of meal delivery method

Primary Outcomes of Interest Mental health, self-rated health, social isolation/loneliness, feelings of security and safety Secondary Outcomes of Interest Hospitalization, falls, satisfaction Demographic Characteristics Note. N=626. Measures did not differ significantly by group, or by site Retention and Reasons for Attrition Average retention rate across all sites was 74% (n=459) Varied from 68% to

87% No differences between groups, within site Reasons for Attrition 14.00% 22.00% 18.99% 8.86% 26.01% 10.13% Moved/NH No Longer Wanted/Needed Meals

Died Hospital Could Not Contact Other Improvement in Mental & Self-Rated Health Anxiety Depression Self-Rated Health n Control

99 115 449 44% 51% 23% Daily Weekly, Frozen 54% 57% 61% 71% 29%+ 24%+

Note: Depression measured using PHQ-2 and anxiety measured using the GAD-2; + = p<.10 Decreasing Worry about Staying Home ** 80% ns + 70%

67% ns 60% 57% 51% 50% 40% Control 41% 36% 35%

30% 20% 10% 0% Full Sample (n=242) + = p<.10; ** = p<.01; ns = not significant Live Alone (n=112) Daily Frozen, Once Weekly Improvement in Loneliness^

** ns 70% ns ns 60% 55% 51% 50% 46%

46% Control 40% 38% 32% 30% Daily Frozen, Once Weekly 20% 10%

0% Full Sample (n=292) Live Alone (n=148) ^Adjusted analyses published: Thomas, Akobundu, Dosa (2015) J Geron Soc Scie ** = p<.01; ns = not significant Self-Reported Improvement in Loneliness^ 100% 90% 80% 70% 60% 50%

40% 30% 20% 10% 0% * 77% 65% Daily Frozen, Once Weekly ^Adjusted analyses published: Thomas, Akobundu, Dosa (2015) J Geron Soc Scie * = p<.05

Feelings of Safety 100% 90% 80% 70% 60% 50% 40% 30% 20% 10% 0% * = p<.05 * 80%

70% Daily Frozen, Once Weekly Hospitalization and Falls^ * 60% 54% * 50% 41%

40% Control + 30% 20% Daily ns 20% 14% 21% 13%

10% 0% + = p<.10; * = p<.05; ns = not significant Frozen, Once Weekly Satisfaction 99% of participants in both groups would recommend program to others Reasons for recommendation vary Daily: Help or Driver Frozen, once-weekly: Meal Conclusions: Aims 2 and 3

Home-delivered meals have many benefits in addition to improved nutrition Significant improvements in security and loneliness among individuals living alone Marginally significant difference in hospitalization rate Significant difference in rate of falls Benefits from daily-delivered meals greater than once-weekly delivered, frozen meals Significant improvements in loneliness, self-rated health, feelings of safety Significant difference in rate of falls Limitations Sample size (power) Once-weekly delivery in this study by Meals on Wheels programs were not

comparable to the competitor model that drop-ships frozen meals Randomization and data collection by sites Findings are based on self-report More Than A Meal: Phase 2 Ongoing Funded by Gary and Mary West Foundation (GMWF) Linking client records to Medicare Claims to examine differences in healthcare utilization and costs Hospitalization (all-cause and preventable) Emergency Department visits Nursing home placement

Design 15 programs across the country Client rosters 2010-2013 (38,000+ clients) Compare outcomes between daily and limited meal delivery Compare outcomes between meal recipients and propensity-matched controls Results To Be Continued Acknowledgements Co-Investigators

David Dosa, MD, MPH Pedro Gozalo, PhD Roee Gutman, PhD Vince Mor, PhD Students Aderonke Ilegbusi Mingyang Shan Raul Smego

Jinru Tao Project Staff Rajesh Makenini Cindy Williams Funders AARP Foundation Gary and Mary West Foundation Community Partners

Meals on Wheels America Meals on Wheels America Members Aging, Disability & Transit Services of Rockingham County, Reidsville, NC Athens Community Council on Aging, Athens, GA Broward Meals on Wheels, Plantation, FL Community Meals, Houston, TX Interfaith Ministries for Greater Houston, Houston, TX Meals on Wheels of Ocean County, Lakewood, NJ Meals on Wheels of Rhode Island, Providence, RI Putnam County Senior Citizens Center, Unionville, MD Meals on Wheels of Tarrant County , Fort Worth, TX The Heritage Area Agency on Aging, Cedar Rapids, IA VNA Meals on Wheels, Dallas, TX Open Hand, Atlanta, GA Guernsey County Senior Citizens Center, Inc. Cambridge, OH

Western South Dakota Senior Services, Inc. Rapid City, SD Meals on Wheels of Lancaster, Inc. Lancaster, PA Chapel Hill-Carrboro Meals on Wheels, Chapel Hill, NC Meals on Wheels of Greater San Diego, Inc., San Diego, CA Riversiide MOW, Riverside, CA Doc Services, Inc., Miami, OK Meals on Wheels of Shawnee and Jefferson Counties, Inc. Topeka, KS THANK YOU! [email protected] WAITING LISTS: PRACTICE AND POLICY IMPLICATIONS Uche Akobundu, PhD, RD March 23, 2016

02/16/2020 37 WAITING LISTS: POLICY & PRACTICE IMPLICATIONS Some Frequently Asked Questions What is a waiting list? Why are there waiting lists? Who is placed on a waiting list? How many programs have waiting lists? 02/16/2020 38 WHY ARE THERE WAITING LISTS? Thousands of seniors are currently waiting to receive Meals on Wheels nationwide.

Declining federal funding through the Older Americans Act, cuts in state and local grants, stagnant private funding and rising food, transportation and operational costs all have led to a growing gap between those served and those in need. With the senior population set to double by 2050, Meals on Wheels America felt is was important to act now to shine a light on this issue. 02/16/2020 39 WAITING LISTS: POLICY & PRACTICE IMPLICATIONS Practice Implications Challenges:

Inability to provide timely, preventive nutrition services to those in need Waiting list management assessment, prioritization Opportunities: Advocacy #SeniorsCantWait Campaign Research MTAM & Randomized Controlled Trial design Service Expansion Stakeholder & payor partnerships 02/16/2020 40 ADVOCACY: #SENIORSCANTWAIT November 2015, Meals on Wheels America

launched the #SeniorsCantWait campaign We heard from Members in 32 states Members participating in this Campaign received a #SeniorsCantWait Toolkit comprised of: Two customized images for Facebook and Twitter Template Press Release Elected Officials Social Media Contact Information Social Media Best Practices Template Social Media Tweets and Posts 02/16/2020 41 #SENIORSCANTWAIT CAMPAIGN 02/16/2020 42

#SENIORSCANTWAIT CAMPAIGN: SOCIAL IMAGES 02/16/2020 43 #SENIORSCANTWAIT CAMPAIGN: SAMPLE TWEETS 02/16/2020 44 #SENIORSCANTWAIT CAMPAIGN: RESULTS We heard from Members in 32 states 100 Members reported having more than 20,000 seniors on waiting lists across the country

o Meals on Wheels America has 1,100 Members o Findings reflect a small subset - likely undercounts the severity, but illustrates a real problem >50% of Members said their program's waiting list is bigger than it was a year ago 02/16/2020 45 LEARN MORE 02/16/2020 46 SERVICE EXPANSION: ADTS ROCKINGHAM CO. Help Advocate for People We Serve Raise money

Raise awareness Change the Conversation Capture meaningful data Shift from outputs to outcomes 02/16/2020 47 VOLUNTEER & COMMUNITY ENGAGEMENT 02/16/2020 48 WAITING LISTS: POLICY & PRACTICE IMPLICATIONS Policy Implications

Targeting of nutrition services to those in greatest health and social need vs serving all those in need Sufficient funding needed to meet growing need This week we mark the 44th anniversary of the creation of the Older Americans Act Nutrition Programs & celebrate the advancement of the Older Americans Act through the legislature Both strong legislation and robust appropriations are needed to stem the rising need, and provide costeffective and impactful nutrition services to millions of seniors 02/16/2020 49 STAY TUNED 02/16/2020

50 THANK YOU! UCHE AKOBUNDU, PHD, RD [email protected] 02/16/2020 51

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