Kali Thomas, Assistant Professor at the Brown University School of Public Health and a Research Health Scientist at the U.S. Department of Veterans Affairs (VA), opened her presentation by noting that she has a longstanding interest in assessing the impact of programs to enable older adults to remain at home. Previous work has included studies on spending on home-delivered meals and low-care nursing home residents and a follow-up analysis of state savings related to increasing home-delivered meals capacity. This analysis showed that by spending more and expanding home delivery of meals, states could have saved $109 million in 2009 (Thomas and Mor, 2013). In addition, 26 states would have immediately realized savings based on these results and 22 others were projected to have savings in the future. She noted that she also completed a project with Meals on Wheels America with funding from an AARP Foundation grant to profile older adults on waiting lists for home-delivered meals, and to study the effectiveness of different meal delivery modalities on clients’ outcomes. Currently, she noted that she is leading a study to evaluate the role of home-delivered meals and use of health care.
A Logic Model to Assess Program Impact
Thomas then shared a logic model that provides a way to assess the impact of the programs’ performance. The model is a feedback loop in
which each component (inputs, process, outputs, and outcomes) informs the other. Because of current reporting requirements, Thomas noted that programs do well on tracking information in the first three elements of the model. They can explain their funding and resources that they use, as well as their missions and the legislation that enables them to provide services. They can describe the cost and their infrastructure, their staffing, and the vendors and food preparation facilities they contract with. They can report on the number of volunteers they are able to recruit and retain and the numbers of people receiving meals. They can report on the number of unduplicated meals that older adults receive and provide some information on client satisfaction.
However, when it comes to outcomes, Thomas emphasized that information is lacking. Several avenues to find current measures of these programs exist. The National Survey of Older Americans Act (OAA) Participants is a telephone survey with approximately 6,000 clients of OAA programs. About 1,000 of these older adults receive home-delivered meals and 900 receive congregate meals. Participants are asked about how often they receive a given service, how they feel the service affected their lives, and whether it met their physical, social, and emotional needs. The Performance Outcome Measurement Project was developed by the U.S. Administration on Aging (AoA) in collaboration with State Units on Aging1 and Area Agencies on Aging2 and a number of universities. This project developed a publicly available toolkit, which is a combination of the grantee development efforts and provides step-by-step instructions on how programs can go about measuring outcomes. A third source of information about outcomes is scholarly research and the grey literature. A wide spectrum of published papers and reports about program outcomes has been published.
Even with all this information, Thomas stated that some limitations to current evidence exist. The National Survey of OAA Participants is cross-sectional so it measures participants’ feelings at only one point in time. It is self-reported data and includes no adequate comparison and control groups
1 State Units on Aging are agencies of state and territorial governments established under the OAA in 1965 and designated by governors and state legislatures to administer, manage, design, and advocate for benefits, programs, and services for older adults and their families and, in many states, for adults with physical disabilities. The term “state unit on aging” is a general term, and the specific title and organization of the governmental unit will vary from state to state. For more information, visit http://www.eldercare.gov/Eldercare.NET/Public/About/Aging_Network/SUA.aspx (accessed May 9, 2016).
2 Area Agencies on Aging (AAAs) were established under the OAA in 1973 to respond to the needs of Americans ages 60 and older in every local community. AAAs provide a range of options that allow older adults to choose the home and community-based services and living arrangements that suit them best, making it possible for older adults to “age in place” in their homes and communities. For more information, visit http://www.n4a.org/files/LocalLeadersAAA.pdf (accessed May 9, 2016).
to shed light on the reported improvements. The Performance Outcomes Measurement Project data are not collected in every state. The scholarly literature is primarily descriptive, contains mostly self-reported nutrition status information, and lacks scientific rigor to produce generalizable findings.
Assessing the Importance of Outcomes Measurement
Stepping back, Thomas asked the question, “Why is outcomes measurement, in fact, important?” Having information about outcomes informs improvements in the rest of the service delivery system. It also provides the evidence base needed to guide decision making at all levels. Policy makers at all levels of government, from Congress to state and local governments, rely on outcomes information to make budget decisions. Increasingly, funding for health and social programs is based on outcomes. Third, Thomas pointed out that outcomes research is needed to ensure the sustainability of nutrition programs for older adults because it can make the case that these programs matter.
As important as it is to measure outcomes, it is a difficult endeavor. This is because it can be challenging to determine who is ultimately responsible for documenting outcomes—the programs? The contracting Area Agency on Aging? The State Unit on Aging? Researchers and academia? Resources—financial, time, work load—also make documenting outcomes a particular challenge. Another challenge is the issue of uniformity across programs. Programs vary dramatically from site to site with respect to the information they collect and the software they use.
As a result, Thomas said that a big question remains, “What outcomes should we measure?” Ideally, Thomas stated, researchers should be measuring what OAA programs were designed to achieve and seek to answer the questions: Are they reducing hunger and food insecurity among older adults? Are they promoting socialization and the health and well-being of older adults? Are they delaying adverse health conditions?
It is critical, noted Thomas, to consider not only what the programs were designed to achieve, but also the outcomes of importance to different stakeholders, including policy makers and payers, caregivers, and clients (see Box 6-1).
Thomas then described a variety of ways in which these data could be collected. Many validated survey instruments are available, so she stressed the importance of not reinventing the wheel. Ideas for potential surveys that were offered include surveys of all recipients as well as surveys of families or family caregivers. It also is possible to capture program data at regular intervals. One example she highlighted was North Carolina’s Aging and Disability Transit Service, which interviews clients on a regular basis: upon requesting service, beginning service, and annually thereafter. Clients are
asked a variety of questions related to health, quality of life, depression, social isolation, and food insecurity. Another possibility is to link client data to medical records. Thomas noted that she and her colleagues are about to embark on a project to do that retrospectively. Finally, another possible option is to conduct a large programmatic trial. The pilot that Thomas conducted with Meals on Wheels America and funded by AARP Foundation showed that such a trial is possible.
In conclusion, Thomas reiterated that outcomes measurement is important. Measuring and documenting outcomes will shed light on the unmet needs of older adults who receive these services and improve understanding of the people who are not receiving these services but perhaps could be. Thomas noted that outcomes measurement also provides a better understanding of what types of models work better and for whom. Outcomes measurement also can assist in subgroup analyses to identify older adults who may benefit most from these services as well as prioritize those on waiting lists. Finally, outcomes measurement can be valuable for cost-
effectiveness and cost-benefit analyses. When all is said and done, however, Thomas emphasized that all of this work is dependent on robust, diverse funding and resources at all levels, from the local level to the federal level.
The final session of the workshop covered findings, questions, and unmet needs3 emerging from the presentations as summarized by Elaine Waxman. Waxman is a Senior Fellow in the Income and Benefits Policy Center at The Urban Institute (see Box 6-2).
Following the Session 6 presentations, the floor was opened for questions and general discussion. The first question dealt with whether it is possible to retrospectively analyze National Health and Nutrition Examination Survey (NHANES) data on participation in meals programs. Thomas responded that her understanding was the sample sizes for participation in home-delivered meals programs was small and she did not know about data on other programs. She emphasized, though, that the questions on NHANES are good, validated questions and noted that one of the benefits of the senior nutrition programs is socialization and that NHANES does not have data on this. A workshop participant added that NHANES is useful for examining data on the Supplemental Nutrition Assistance Program (SNAP) and the Special Supplemental Nutrition Program for Women, Infants, and Children (WIC) but is very limited for home-delivered meals program data.
A participant congratulated Waxman on her summary of the workshop and suggested two additional items for consideration: (1) multigenerational households and the challenges for older adults who have grandchildren in the home, and (2) mobility issues and the difficulties they pose for older adults in accessing food even if food sources are nearby.
3 A demographic group that was briefly addressed in the workshop, but that may be sometimes overlooked is older people living in rural areas. Nearly 23 percent of the U.S. population ages 60 and older lives in rural areas (U.S. Census 2010; http://www.agid.acl.gov/StateProfiles/Profile/Pre/?id=109&topic=1&years=2011 [accessed May 9, 2016]). Some states such as Mississippi, North Dakota, and West Virginia have a significantly higher portion of their older population living in rural areas than is true for other states. Compared to urban and suburban areas, residents of rural areas face unique challenges and concerns. Rural residents often do not have access to public transportation (cabs, buses, trains) or Internet connection in the home. Without Internet connections, residents also do not have the ability to access transportation services such as Uber, or to order online meals or other services.
Another participant noted the importance of better defining a population under consideration. Older adults from age 50 to 110 vary considerably, so precision in description is needed. In addition, care needs to be taken with the language used to describe older adults. This participant suggested that “older adults” should be used in place of “elders” and “seniors.” Nancy Wellman, moderator of this workshop session, agreed with
this latter observation. She added that her research shows that older adults are among the most likely group to change their eating habits if they are given good reasons for it and have the knowledge to do so. Older adults are very receptive to new information about healthy eating because they want to retain their independence and do not want to leave their homes.
Lloyd, formerly a national nutritionist with the AoA, commented on
sources of available data and studies that participants might be interested in. She noted that a national evaluation is under way of OAA nutrition programs, including process and cost evaluations. These evaluations will be posted on the AoA website4 sometime in November 2015. She also reminded participants about the AoA’s September 2015 Research Brief on OAA Nutrition Programs. Another part of the national evaluation is currently in the field. It is looking longitudinally at individual outcomes, including food insecurity, social connectedness, chronic conditions, medications, health care utilization, and is matching these data with Medicare data on hospital and emergency room admissions. These data will be available in 2017. Both components of the national evaluation are being conducted by Mathematica Policy Research.
A representative of Mom’s Meals commented that their organization now serves many populations in addition to older adults, including the physically disabled. Including all the populations they serve can strengthen efforts to bring attention to the issue of ensuring adequate nutrition for vulnerable populations. He stated that funding is often an issue and that there are long waiting lists for individuals who could greatly benefit from meals programs, especially those who are physically disabled.
Wellman responded that, similar to school populations that participate in free, reduced price, and full price programs, there are adult populations who are willing and able to pay full price for nutritious delivered meals. Delivering meals to them is a way to broaden the population of older adults who can retain their independence and stay at home.
A participant who works with minority and migrant populations in California noted that accessibility to programs is often limited for these populations because of language and cultural issues. This issue should be considered when developing information for older adults.
A participant asked Thomas to comment about available data on people who are on waiting lists for programs. Thomas responded that she did not know about any national data. However, she has done a study that surveyed eight programs around the country that had waiting lists of more than 3 months. The study found significant needs, such as many respondents who did not have money to buy food and 12 percent who reported having no one they could call on for help. Great needs exist but nothing was available to meet those needs. Wellman added that some information is available about people on waiting lists who are readmitted to the hospital or who die before services become available. So, prioritization and targeting are important issues, she noted.
The final comment concerned the role of the built environment and
4 See http://www.aoa.acl.gov/Program_Results/Program_Evaluation.aspx (accessed May 9, 2016).
how it plays a critical role in whether older adults have mobility and access to food. Departments of Transportation and of Building should be integrated into efforts to ensure improved mobility for older adults. Wellman agreed, noting that transportation is one of the most highly demanded services and that many people do not go to their local community or senior centers because they cannot get there.
Thomas, K. S., and V. Mor. 2013. Providing more home-delivered meals is one way to keep older adults with low care needs out of nursing homes. Health Affairs (Millwood) 32(10):1796-1802.
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