More than a Meal Demonstrating Value- n4a 072317€¦ · More Than a Meal: More Than a Meal:...

Linda Netterville, MA, RD, LD, Meals on Wheels America

David Dosa, MD, MPH, Brown University

Brenda Schmitthenner, MPA, Gary and Mary West Foundation and West

Health Institute

More Than a Meal: More Than a Meal: More Than a Meal: More Than a Meal: Demonstrating Demonstrating Demonstrating Demonstrating

Value Through Enhanced Service Value Through Enhanced Service Value Through Enhanced Service Value Through Enhanced Service

Delivery and Outcomes DataDelivery and Outcomes DataDelivery and Outcomes DataDelivery and Outcomes Data

SESSION OBJECTIVES

• Identify opportunities for enhancing service delivery that

can be marketed to healthcare entities.

• Discuss how outcomes data can be utilized to build a

stronger value proposition with healthcare entities.

• Develop a strategy to identify and approach potential

healthcare partners.

Ongoing MTAM research supported by the Gary and Mary West Foundation and the Gary and Mary West Health Institute

POSITIONING FOR THE FUTURE

D R I V I N G T H E C H A N G E

• Federal and government funding cannot keep pace

• Increase in need for service/waiting lists

• Increased costs

• Competition with for-profits

• Opportunities with healthcare providers

• Research needed

• Improved client health outcomes of Meals-plus model

• Demonstrate healthcare savings

THE MORE THAN A MEAL JOURNEY

W H AT H E A LT H C A R E PAY O R S A R E S E E K I N G

THE MORE THAN A MEAL JOURNEY

W H AT H E A LT H C A R E PAY O R S A R E S E E K I N G

• Better Care

• Meet consumer needs

• Access to the consumer

• Quality metrics

• Healthier People

• Improved health outcomes

• Value-added services to manage health

• Smarter Spending

• Cost effectiveness

THE MORE THAN A MEAL

JOURNEYSay have helped them remain in their home

Say helped them eat healthier foods

Say improved their health

2017 Evaluation of the Effect of OAA Title III C Nutrition Services Program on Participants


JOURNEYSay fallen with injury during past 3 months

Say fear of falling

Say difficulty walking or climbing stairs

2017 Evaluation of the Effect of OAA Title III C Nutrition Services Program on Participants

Establishing Value for MOW:

The More Than a Meal Journey

Kali S. Thomas, PhD; Mingyang Shan, MS; Roee

Gutman, PhD; Pedro Gozalo, PhD; Jessica Ogarek, MS; &

David Dosa, MD, MPH


� MTAM Pilot Research Study (Phase 1)

� MTAM 2: Medicare Claims Analysis– What do MOW clients look like

– Pre/Post value of MOW

– Moving beyond Pre/Post

� MTAM 3– Qualitative interviews with drivers/MOW

administrators

– Developing an intervention

More Than a Meal Pilot Research Study

� Funded by AARP Foundation

� Conducted by Brown University’s Center of Gerontology and Healthcare Research and released March 2015

� 15-week Randomized Control Trial (RCT) of 600+ seniors on the waiting list for MOW or receiving meals

– In-person survey conducted at baseline

– 15-week follow up conducted by telephone

– Comparisons made against publicly available data from the National Health and Aging Trends Study (NHATS)

� Executive Summary, Report, Infographic

http://www.mealsonwheelsamerica.org/theissue/research/more-than-a-meal


� Findings in Brief

– A senior who requests meals is significantly more vulnerable than the average age matched citizen (NHATS).

– Daily-delivered meal recipients experienced greatest improvements in health and quality of life.

– Daily-delivered meals recipients reported greater benefitsfrom their home-delivered meal experience compared to those receiving weekly frozen meals.

– Those who lived alone and received daily-delivered meals were more likely to report improvements in feelings of worry, isolation and loneliness compared to the others.


MTAM 2: Medicare Claims Analysis� Funded by Gary and Mary West Foundation

� Conducted by Brown University’s Center of Gerontology and Healthcare Research in 2016

� Goals

– Describe the population of Medicare beneficiaries receiving services from MOW programs (Observational Aim)

– Describe healthcare utilization and associated costs in the pre and post MOW enrollment periods (Observational Aim)

– Compare healthcare utilization of clients receiving MOW compared to a matched population of those who did not receive MOW (Experimental Aim)

Motivation for Medicare Study

� Little is known about the health and healthcare utilization of MOW clients

� Critical challenge of observational studies with community health providers such as MOW is the lack of a direct identifiers to link client records to Medicare data (Social Security Numbers)

� Objective – Link MOW program data to Medicare data using deterministic and probabilistic matching techniques

MOW Program Data

� 13 Programs (CA, GA, NC, OK, RI, TX)

� Enrolled clients between 1/1/10 and 12/31/13

� Data included clients’ gender, race, DOB,

service dates, & 9-digit ZIP codes

� Inclusion Criteria

– 66 years or older at beginning of service

– Service start date after 1/1/2010

– Final Sample = 29,593

Linking MOW Data with Medicare

Enrollment Data

� Deterministic Matching

– Gender, DOB, 9-Digit ZIPs

� Probabilistic Matching

– Blocked on 5-digit ZIP and gender

– Estimated probability likelihood (6-9 ZIP code digits

and full DOB, DOB year and month, and DOB year)

� Exclusion Criteria

– Clients with Medicare Advantage (MA) coverage

– Clients less than 65 years of age

Examining Clients’ Health and

Healthcare Utilization

� MOW Clients with 1-1 Match

– Final Sample = 14,019

� Linked Matches to Utilization Data from Medicare

� Calculated inpatient, ED, and nursing home events in the year prior and 6-months following MOW enrollment

Who Receives MOW?

Descriptive Characteristics

Gender N %

Male 5199 37.1

Female 8820 62.9

Age Group

65-69 1742 12.4

70-74 2033 14.5

75-79 2323 16.6

80-84 2887 20.6

85-89 2972 21.2

90+ 2062 14.7

Race/Ethnicity

White 10343 73.8

Black 2622 18.7

Hispanic 455 3.3

Asian 354 2.5

Other 185 1.3

Native American 40 0.3

Unknown 20 0.1

Chronic Conditions

N %

Hypertension 12560 89.6

Hyperlipidemia 11041 78.8

Anemia 9792 69.9

Rheumatoid/Osteoarthritis 9378 66.9

Ischemic Heart Disease 8788 62.7

Heart Failure 6583 47.0

Diabetes 6574 46.9

Depression 6060 43.2

COPD 5431 38.7

Chronic Kidney Disease 5184 37.0

Osteoporosis 4190 29.9

Alzheimer's/Related or Senile Dementia 3995 28.5

Stroke/TIA 3445 24.6

Atrial Fibrillation 3025 21.6

Acute Myocardial Infarction 1074 7.7

Pre-Post Analysis

� MOW recipients’ healthcare costs also declined following enrollment compared to time periods pre-enrollment.

– Hospitalization-associated costs fell by an average of $362, $1,155, and $1,356 at the 30-, 90-, and 180-day time periods following enrollment.

– Nursing facility costs fell by $244, $652, and $363, over the same period, respectively.

– Modest reductions in ED/observation costs were noted over the same period of $22, $43, and $27 respectively.

Association versus Causation

A N E P I D E M I O LO G I C A L D I L E M M A

� Phase 2 shows reductions in healthcare utilization and Medicare costs post MOW

� Does not necessarily imply that MOW services are directly causing these reductions

� Two roads forward

– Developing a control group using secondary data sources and previously collected data

– Prospective data collection

Developing a Control Group

� Using Medicare claims data to identify a similar appearing regional control group to compare against those receiving MOW services

� Results to date show more modest improvements in healthcare utilization and cost

� Methodologically, unclear whether this is due to a “sicker control group” or factors that are not present in claims data– Prescribers choose MOW for people who are sicker

(Smell Test)

� Leaves us with the need to conduct blinded studies to prove value


More Than a Meal 3� Partners: Gary and Mary West Health Institute,

Brown University and Meals on Wheels America

� Two-year research project – March 2016-March 2018

� Goal:

Improve the health, safety, and well-being of seniors through an enhancement of Meals on Wheels (MOW) current meal-delivery service and wellness checks


More Than a Meal 3Specific Aims

� Identify the needs of the healthcare market related to daily client monitoring (Healthcare Exploration)

� Understand the workflow and capabilities of Meals on Wheels (MOW) programs (Phase 1)

� Pilot an enhanced meal-delivery service that includes a standardized wellness check (Phase 2)

MTAM 3 Healthcare Exploration

� Formed a healthcare exploration group consisting of select members of the collaborative research team representing each organization (MOWA, Brown University, WHI)

� Identified key informants to provide insight on:

– How a community-based organization, such as MOW, can create value to a healthcare payer or provider as part of the healthcare continuum of integrated care and population health

– The value of receiving information from MOW programs about their patient population as reported by MOW drivers

Data Collection and Analysis

� Conducted 10 interviews

– July 2016 – November 2016

� Key informants included

– 1 MCO Administration, 6 MCO CMOs, 3 Geriatricians

� Questions

– Demographics

– Current role, responsibilities

– Topical

• Value of community-based services

• What’s important to know about a MOW client from a health and

safety perspective?

� Summarized key findings and themes

Preliminary Themes

Concluding Thoughts

� Research to demonstrate value is important and key to negotiating in the healthcare marketplace

� More research in this area--particularly in identifying target high-risk groups is important

� Local entities are doing innovative things but need to share this with the greater community

� Does MOW need to expand to demonstrate value and survive?

CONFIDENTIAL – Do not reproduce or distribute

More Than a Meal 3

Gary and Mary West Health InstituteBrenda Schmitthenner, MPA, Andrea Morris, PhD, MPH and

Megan Holt, DrPH, MPH, RD


Phase 1

Aim: Understand the workflow and capabilities of MOW Programs

Research Questions:• Are MOW programs already checking on clients and are

drivers reporting any concerns/risks? • How are concerns/risks addressed and by whom?• Is there potential for standardization?


Phase 1 – Data Collection & Analysis

Conducted site visits at six MOW programs across the country and 84 interviews:

o July 2016 – October 2016

Key informants included:o 11 leadership members, 11 coordinators, 15 case

managers, 47 drivers

• Notes taken during ride-alongs• Interviews were recorded and transcribed• Preliminary themes identified across transcripts


Phase 1 – What We Learned

Relationships between MOW clients and drivers• More than a meal• Positive driver motivation• Meaningful to drivers and clients• Value of wellness checks

Existing practices• Driver reporting process• Use of technology• MOW program follow-up• Data collection and documentation


Phase 2

Aim: Pilot an enhanced meal-delivery service that includes a standardized wellness check

Information obtained through Phase 1 informed Phase 2 development and selection of two MOW pilot sites


Phase 2 – Pilot an Enhanced Meal-Delivery Service

Goals:• Enhance technology-enabled wellness tool

established by Meals on Wheels of Greater Pittsburgh• Develop and implement a care navigation model• Develop and implement study-related tools• Driver and staff training• Care navigation toolbox• Conduct driver focus groups• Track and analyze data• Engage a healthcare partner



Pilot site selection is an opportunity for learning from two very different MOW programs

Pilot Site 1 – Meals on Wheels San Diego County• Geography: covers large urban, suburban and

rural county• One paid driver route, over 3,000 volunteer drivers• Regional service centers and no case

management



Pre-Implementation Strategy• Collected health-related info on clients• Hired key project staff• Selected six test routes and adopted mobile

routing technology• Incorporated six wellness indicators in change

of condition tool• Trained drivers and staff on tools



Pilot Site 1 – Implementation Strategy • Currently testing the training, submission and receipt of wellness

alerts and care navigation response on three routes with 60 clients

Enhanced Meal-Delivery Service Protocol: 1) Driver uses mobile routing app on cell phone to deliver meal, and

electronically report when delivery has been completed 2) Upon verification of meal delivery, driver receives a prompt to

report changes or concerns within six wellness domains, and send electronic alert to a Care Navigator embedded in the MOW program

3) Care Navigator is trained to receive and respond to alerts



Learnings to date:• Readiness and organizational culture is important• Training volunteers is a challenge• Receptivity to technology varies• Tipping point between care management and care

navigation• Drivers are submitting alerts:

o 42 concerns/risks identified in 18 clients in six weeks

o 14 health-related alerts, 11 safety alerts, five social/community isolation alerts



Pilot Site 2 – Site selected and contracting in progress• Rural program with all paid drivers delivering meals

to clients’ homes in several counties• Operates senior center that provides congregate

meals• Transition from paper-based to technology-based

practices• Enthusiastic and engaged• Existing relationship with hospital to provide post-

discharge meals


Future Travel: More Than a Meal Journey

What’s Next for More Than a Meal 3?

Apply learnings from Pilot Sites to:• Demonstrate feasibility• Deport evidence via outcomes data • Disseminate standardized toolkit (process change,

training, technology, workflows, algorithms, metrics, ROI models)

• Scale a sustainable model to other nutrition providers


Broader Implications for Community-Based Programs

• Opportunity to leverage person-centered, sustainable, contemporary, and competitive services and supports that address the social determinants of health.

• Opportunity to collect and report data that positions your organization to be the community solution for population health management.

• Opportunity to engage with healthcare entities – aligning services to meet payor/provider needs.

• Opportunity to identify and advocate for changes in policies and regulations to support payment of health-related support services.

DISCUSSION QUESTION

45

• What are the opportunities you see for your program?

• What are the barriers for your program?

CONCLUSION


RESEARCH SERIES

• Rigorous research methods

• Hands-on stakeholder engagement to better understand the value and impact of Meals on

Wheels

• Support an advancement of partnerships between MOWs and healthcare entitles

CONTACTS:

Linda Netterville, MA, RD, Linda Netterville, MA, RD, Linda Netterville, MA, RD, Linda Netterville, MA, RD, LDLDLDLD

Meals on Wheels AmericaMeals on Wheels AmericaMeals on Wheels AmericaMeals on Wheels America

[email protected]@[email protected]@mealsonwheelsamerica.org

David David David David Dosa, MD, Dosa, MD, Dosa, MD, Dosa, MD, MPHMPHMPHMPH

Brown UniversityBrown UniversityBrown UniversityBrown University

[email protected][email protected][email protected][email protected]

Brenda Schmitthenner, MPA Brenda Schmitthenner, MPA Brenda Schmitthenner, MPA Brenda Schmitthenner, MPA

Gary Gary Gary Gary and Mary West Foundation and and Mary West Foundation and and Mary West Foundation and and Mary West Foundation and West West West West Health Health Health Health InstituteInstituteInstituteInstitute

[email protected]@[email protected]@gmwf.org

Thank You!Thank You!Thank You!Thank You!

More than a Meal Demonstrating Value- n4a 072317€¦ · More Than a Meal: More Than a Meal:...

Documents

Transcript of More than a Meal Demonstrating Value- n4a 072317€¦ · More Than a Meal: More Than a Meal:...