1

2018 Grantee

Increasing Use of 

Community-Based 

Resources by Food-Insecure 

Seniors in Illinois

Summary: 

To decrease the prevalence of food insecurity, Age Options 

designed their Closed Loop Referral System project. The project 

aimed to increase the likelihood that patients experiencing food 

insecurity and/or at nutrition risk would receive and act upon 

referrals to community-based resources.
2 

Table of Contents

Health Care Professional Engagement Flyer ........................... 3

Health Fair Recruitment Handout ................................................... 4

Informed Consent....................................................................................... 5

Participant Recruitment Brochure .................................................. 6

Post-Intervention Questions ................................................................ 7

Post-Intervention Referral Survey ................................................... 8

Pre-Intervention Questions .................................................................. 9
3 

Health Care Professional 

Engagement Flyer

Handout for health care professionals encouraging 

patient referral to nutrition programs. 
FOOD INSECURITY IMPACTS HEAL TH 

Are your patients 60 years of age or older . 

- Skipping meals?

- Concerned about their next meal?

- Running out of food before they have money to buy more?

- Eating the right foods for their health condition(s)?

Did you know? 

- Older adults who are food insecure have higher rates of chronic

conditions, higher prevalence of depression and diminished capacity. . . (Berkowitz, S., et al., 1993) 

- Providing short-term home delivered meals as part of a hospital discharge

showed a 6.3% reduction of 30 day readmissions. (Martin, S., eta/. 2018)

As part of your overall screening of a patient's health, protocols are 

in place to screen for Social Determinants of Health, one of which is 

food insecurity. 

OPPORTUNITIES FOR FOOD INSECURE PATIENTS 

o Members of your health care team can address food insecurity by referring patients aged 60+ to

AgeOptions, the Area Agency on Aging of suburban Cook County. By using NowPow, an on-line

referral and resource system, referred patients may be eligible for home delivered meals where

special medically tailored options are available. Patients will be connected to other appropriate

food resources as needed.

o Locate the designated NowPow user on your health care team to document the referral in the

patient's medical record. AgeOptions will inform you via NowPow if the referred patient is

receiving the home delivered meals and/or participating in any other food programs. AgeOptions

will close the referral loop.

AGE0PTIONS

nutrition.innovations(

i

L ageoptions.org, 

(708) 383-0258 (800) 699-9043

This flyer was prepared and printed In part with federal Older Americans Act, Administration for Community Living, State of Illinois General Revenue and AgeOptions funds. The Illinois 

Department on Aging and U.S. Administration on Aging are recognized for their support of AgeOptlons. Neither Is responsible for the content of this flyer. 
4 

Health Fair Recruitment 

Handout

Flyer used to encourage health care professional 

participation in the study. 
AgeOptions is looking for referral partners 

who use Aunt Bertha's or NowPow's on-line 

resource, referral and closed-loop referral 

platforms. 

In 2018, AgeOptions was awarded an Administration for Community 

Living Nutrition Innovations grant. The grant has the following 

objectives: 

 Implement a closed-loop referral system between healthcare 

providers and nutrition services 

 Increase referrals to nutrition programs 

 Increase consumer access and the utilization of nutrition programs, 

government benefits programs and various evidence based health and 

wellness programs. 

If you make use of Aunt Bertha's or NowPow and utilize their closedloop referral processes, we are interested in having a conversation with 

you! 

Contact information: 

Paul H. Bennett 

Manager of Community Initiatives 

paul.bennett@ageoptions.org 

(708) 383-0258 

Connecting Older Adults with Community-based Resources and Options 

The Area Agency on Aging in Suburban Cook County, since 1974 

AgeOptions 

1048 Lake Street, Suite 300 

Oak Park, Illinois 60301-1102 

Phone(800)699-9043 

(708) 383-0258 

Fax (708) 524-0870 

www.ageoptions.org
AgeOptions 

www.ageoptions.org 

1048 Lake Street, Suite 300 

Oak Park, Illinois 60301- 1102 

phone (800)699-9043 

(708) 38 3-0 258 

fax (708)524-0870 

TTY (708)524-1653 
5 

Informed Consent

Provides information about the study for potential 

participants to review and consider before agreeing to 

participate.
EXHIBIT A- INFORMED CONSENT -

Nutrition Innovations Research Study (#19020802) 

Site principal Investigator: 

Department: 

Address: 

Protocol Title: 

Sponsor(s) 

Paul H. Bennett, PhD, MSW and 

Karen Mayer, PhD, RN 

ROPH - Professional Nursing Practice 

AgeOptions, 1048 Lake Street, #300, 

Oak Park, IL 60301 

708-383-0258; 800-699-9043 

paul.bennett@ageoptions.org 

Nutrition Innovations Research Study 

(#19020802) 

AgeOptions 

Key Information 

You are being invited to participate in the research study of a program evaluation. Research studies answer important 

questions that might help change or improve the way we do things in the future. 

It is hoped that the information we are about to share will tell you about the study and to help you decide whether you 

want to participate. We will be reading this consent to you; please ask any questions you have before telling us that you 

agree to be in the study. 

Receiving help from AgeOptions is voluntary, as well as your participation in the research. You do not have to 

participate in this study portion of this program to receive our help. If you decide not to participate in this study today 

or in the future, again your ability to receive any assistance from AgeOptions or from your healthcare provider which 

could be Rush University Medical Center or Oak Street Health will not change or be affected. 

Purpose of Study 

The purpose of this study is to explore the value of what is called a closed loop referral system and the benefit of 

services provided to you. A closed-loop referral system is one where nurses, social workers and doctors who make 

referrals for programs for you such as meals will know if you received the food or actually went to a dining site. Wealso 

want to find-out if the services provided to you were helpful. 

Funding of this Study 

The study is funded by a grant from the United States Administration on Community Living. 

Cost and Benefit 

There is no cost to participate in this study and you will not receive anything from us regarding your participation in this 

study other than possibly services. However, while the help you may receive is free, you may be asked to donate 

towards the cost of some of the food services. Here again, contributions are voluntary. 

Potential Risks 

Wehave not identified any risks to you in answering our questions. However if at any time you feel uncomfortable 

answering a question, you can decide not to answer the question or just tell us to stop asking our questions. In addition, 

there is always a risk of loss of confidentiality or information about your identity. AgeOptions is taking precautions to 

secure your identity and will not be disclosing this information to anyone beyond the researchers at AgeOptions. 
What you are Being Asked to Do 

As a participant in the study portion of this program, you will be asked some questions now about your health and wellbeing and then we will contact you again in about eight (8) weeks to ask you many of the same and a few additional 

questions. Answering these questions may take between 10 to 15 minutes of your time. These questions will pertain to 

what you think about your health and well-being and your satisfaction with the services you may receive. 

What about confidentiality of your medical information? 

This authorization is voluntary. Rush University Medical Center and its affiliates ("Rush") will not withhold or refuse your 

treatment, payment, enrollment, or eligibility for benefits if you sign this authorization. You do not have to sign this 

authorization, but that means that you cannot be in the study or receive study-related treatment. 

By signing this document, you voluntarily authorize (give permission to) Paul H. Bennett, PhD, Karen Mayer PhD and 

their study team, and other Rush personnel involved with the conduct and review of this study (which may include offsite personnel) to use or disclose (release) health information that identifies you for the study described in this 

document. 

During the study, Paul H. Bennett, PhD, Karen Mayer PhD and their study team, will collect Protected Health Information 

(PHI) about you for the purposes of this research. PHI is your health information that includes your medical history and 

new information obtained as a result of this study. Some of this information will come from your medical record. The 

health information that Rush may use or disclose for this research includes: Name, Address, Gender, Contact 

information including Telephone Number and/Email Address and Age. 

Paul H. Bennett, PhD, Karen Mayer PhD and their study team may share your health information and the results of your 

study-related procedures and tests with people outside of Rush who assist with the conduct and review of this study. 

The persons who receive your health information may not be required by Federal privacy laws to protect it and may 

share your information with others without your permission, but only if permitted by the laws governing them. Your 

health information described above may be used or disclosed to: 

• To the Researcher, Paul H. Bennett, PhD at AgeOptions and Oak Street Health 

• The study Sponsor, United States Administration on Community Living 

• Monitoring agencies such as the Food and Drug Administration (FDA), the National Institutes of Health and the 

Rush Institutional Review Board (IRB). 

While you participate in the study you will have access to your medical record, but Paul H. Bennett, PhD, and Karen 

Mayer PhD are not required to release your study information that is not part of your medical record. Rush is required 

by law to protect your health information, and study records that identify you will be kept confidential. The results of 

study tests/procedures performed as part of this study may become part of your medical record. Any study information 

in your medical record will be kept indefinitely. Your identity will not be revealed on any report, publication, or at 

scientific meetings. 

You have a right to inspect and copy the information to be disclosed with this authorization and you may obtain a copy 

of the information by contacting the office listed above. 

If you no longer want to be in the study and do not want your future health information to be used, you may change 

your mind and revoke (take back} this authorization at any time by writing to Paul H. Bennett, PhD at AgeOptions, 1048 

Lake Street, #300, Oak Park, IL 60301. If the authorization is revoked, you will no longer be allowed to participate in the 

study and previously authorized individuals/entities may still use or disclose health information that they have already 

obtained about you as necessary to maintain the integrity or reliability of the current study. 

This authorization is valid for the entirety of this research study. It will expire upon completion of the study or if you 

revoke (take back) the authorization. 
If you withdraw from this study, the data already collected from you may not be removed from the study records. The 

study doctors and/or study team may ask you whether they can continue to collect follow-up data on you. If follow-up 

information will be requested, you will be asked to sign a separate, consent form before this information can be 

collected. 

Records of participation in this study will be maintained and kept confidential as required by law. You will be assigned a 

participant identifier. A password and encrypted document will be maintained with your name and assigned identifier. 

In a separate password and encrypted document will be your responses to questionnaires. Both of these documents will 

be stored in password and encrypted protected files in Microsoft Office 365 which maintains the files in the Cloud 

Sharing of Results of the Study 

AgeOptions intends to publish the results of our study findings. However, it is important that you know, that no 

personal information about you will ever be shared regarding your participation in this study. 

Questions 

Do you have any questions? Can you tell me in your own words, what you are agreeing to do? 

If you have any questions in the future, you can reach the Manager of this program and coordinator of this project, Paul 

Bennett at 800-699-9043. In addition, we will be happy to send you a copy of what I am reading to you. 

Consent 

Do you agree to participate in this study by answering some questions now and that we may contact you again in 

approximately eight weeks from now? 

If yes, the name of individual and NowPow Identifier number will be recorded in an Excel Spreadsheet with the columns 

to record the following: 

• Name: _______________ 

• Date: _______ NowPow Identifier#; ________ 

If yes, would you like us to send you a copy of the statement which we just read to you? If yes, a column in the same 

Excel Spreadsheet will record that a copy was sent to the individual 

• Enter date only if request is made for a copy: __________ 

For those that give consent, a column in the same Excel Spreadsheet will record the name of the AgeOptions staff who 

obtained consent and the date of consent. 

I have received consent from this individual to participate in the Nutrition Innovations Research Study (#19020802). 

• Name of AgeOptions Staff Who Obtained Consent: _______________ 

• Date Consent was obtained: _______ 
6 

Participant Recruitment 

Brochure

Pamphlet to let people know they may be eligible for 

nutrition programs and services. 
Programs funded by Area Agencies on Aging 

such as AgeOptions are paid for using Older 

Americans Act funds, plus state and local 

monies and donations. Your health care 

team can send a referral to AgeOptions 

which will promptly call you to discuss 

your opportunities. 

If you do not have a health care professional 

you can talk to, call us directly: 

Call AgeOptions at: 

(800) 699-9043 or

(708) 383-0258

This brochure is prepared and printed in part with federal Older Americans Act, 

Administration for Community Living, State of Illinois General Revenue and AgeOptions 

funds. The Illinois Department on Aging and U.S. Administration on Aging are recognized 

for their support of AgeOptions. Neither is responsible for the content of this brochure. 

Food & Your Health 

Did you know that what 

you eat or not eat can 

impact your health? 

Talk to Your Health Care Team 

Your health care team may not always 

ask you about food. But, help may be 

available to you. 

You should ask them about nutritional 

services in your community. Your health 

care team can make a referral to 

AgeOptions to help you get the food you 

need. 

Connecting Older Adults with Community-based Resources and Options 

The ATea Agency on Aging ofSuhuTban Cu<.1k County 
 

- Are you skipping meals? - Concerned about your next

meal?

- Worried your food will run out

before you have money to buy

more?

- Are you eating the right foods

for your health condition(s)?

If you are 60 or older and answered 

"yes" to any of these questions, talk 

to your doctor, nurse, social worker, 

care coordinator or other member of 

your health care team. They can tell 

you about community programs to 

help you get the nutrition you need to 

stay healthy! Other resources are 

available too. 

AGE0PTIONS. 

Connecting Older Adults with Cnmmunity-based Resources and Options

The Area Agency on Aging of Suburban Cook County 

Programs & Services 

There are programs and services to help 

everyone, but especially for persons 60 

years of age and over. Many of these 

programs are right in the community 

where you live. 

AgeOptions or your local Area Agency 

on Aging can link you with community 

resources aimed at food. They can also 

help you obtain other government 

programs, benefits and health 

education. 

I Possible Options for Food & Information 

• Meals near where you live and where you can

also talk with neighbors and learn about nutrition • Meals delivered to your home • Local food pantries in your neighborhood • Farmer's markets • Groceries delivered to your home • Education & wellness programs • SNAP (Supplemental Nutrition Assistance

Program - Food Stamps)
7 

Post-Intervention 

Questions

Survey given to participants at the end of the study. 
 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

1 

EXHIBIT D: POST INTERVENTION QUESTIONS 

IDENTIFIERS 

1. Code Name #: _______________ 

2. Interviewer: ________________ 

3. Date of Post Interview/Decision to Close: __mm/dd/yyyy_________ 

4. Study Participant? 

1☐ Yes 0☐ No 2☐ Unable to locate 

Hello, I am from AgeOptions, the Suburban Area Agency on Aging. As you may 

remember about eight (8) weeks ago, you agreed to answer some follow-up 

questions regarding food. Is this a good time for us to ask you these questions? 

Many of these questions may sound familiar to you, but we would like to ask 

them again. 

At this time, 

(Food Insecurity Trigger Questions) 

1. Are you worried that your food will run out before you have money to buy more? 

1☐ Yes 0 ☐ No 2☐ Declined to Answer 

2. In the last 2 months, have you run out of food that you bought, and didn't have money 

to get more? 

1☐ Yes 0 ☐ No 2☐ Declined to Answer 

3. I am not always physically able to: 

1. Shop 3 Cook 4 Feed Myself 5

2. 0

☐ ☐ ☐

☐ No difficulty with these ADL/IADLs 

3. 2☐ Declined to Answer 
 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

_________________________ 

2 

4. Do you have enough money to pay for food each month? 

1☐ Yes 0 ☐ No 

5. Thinking about what money you have for food, what applies? 

1☐

☐

☐

☐

☐

I ask family for food 

2 I ask friends for food 

3 I ask strangers for money for food 

4 I go to the food pantry for food 

5 Other, please specify: ______________________________________* 

6. Have you eaten today or last evening in the last 12 hours? 

1☐ Yes 0☐ No 

6a. If No, how many hours is it since you last ate? ____# hours 

6b. If Yes or No? 

Where did you obtain food for you most recent meal? 

1 ☐

☐

☐

☐

☐

☐

☐

☐

I bought it at a grocery 

2 I bought it at a convenience store 

3 I was given this food at a food pantry 

4 My family provided me with food 

5 A friend provided me with food 

6 I attended a group congregate meal site 

7 I receive home delivered meals 

8 Other, Please Specify_________________________________________* 

6d. If No, how many hours is it since you last ate? ____ hours 

6e. Where did you obtain food for your most recent meal? 
 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

3 

7. If food obtained in grocery or convenience or food pantry, did someone help you? 

1☐ Yes 0☐ No – I was able to get it myself 

7a. If yes, who helped you? ______________________________ 

8. Regarding the food that you do eat, which of the following statements is most true: 

1.___ I can eat whatever I want, I am not on any special kind of diet 

2.___ My doctor has told me that there are things that I should not eat and I am able to 

keep the diet that my doctor wants me to be on 

3.___ My doctor has told me that there are things that I should not eat, but I am unable 

to be keep the diet that my doctor wants me to be on. 

4.___ I do not know what I should or should not eat 

9. As to shopping for food, which of the following statements is most true: 

1.___ I am able to go to the store or food pantry and obtain my food 

2.___ Sometimes, I can go to the store or food pantry and other times, I must rely on 

others 

to shop for my food 

3.___ I am not able to go to the store or food pantry and obtain my food and must rely 

on others to shop for my food 

10. As to cooking food, which of the following statements is most true: 

1.___ I am able to cook food 

2.___ Sometimes, I am able to cook food and other times, I must rely on others 

to cook my food 

3.___ I am not able to cook food and must rely on others to cook my food 
 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

4 

11. When we last spoke to help determine what types of food programs you might be 

eligible to participate or receive, we needed to know about your living situation. Has 

there been a change in the last six to eight weeks in your living situation? 

1___Yes 0___No 

Ask only if (YES) there has been a change, 

12. Since there has been a change, please tell me which of the following describes where 

you live. 

1___I live in a home or apartment 

2___I live in an apartment in a senior building 

3___I live in a supportive or assisted living residence 

4___I live with friends 

5___ I stay with friends 

6___ I live with family 

7___ I do not have a permanent place to stay 

8___ I am homeless 

9___ Other, specify: ______________________* 

These next set of questions focus on your feelings about your health. 

(Questions taken from the PROMIS Global Health Tool) 

13. In general, would you say your health is: 

5___Excellent 4___Very Good 3____Good 2___Fair 1 ___Poor 

14. In general, how would you rate your physical health? 

5___Excellent 4___Very Good 3____Good 2___Fair 1 ___Poor 

15. In general, how would you rate your mood and your ability to think? 

5___Excellent 4___Very Good 3____Good 2___Fair 1 ___Poor 

(Question from the UCLA Loneliness Scale (R-UCLA) – Three Item Loneliness Scale) 

16. How often do you feel that you lack companionship? 

1___Hardly ever 2___Some of the Time 3___Often 

17. How often do you feel left out? 

1___Hardly ever 2___Some of the Time 3 ___Often 
 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

5 

18. How often do you feel isolated from others? 

1___Hardly ever 2 ___Some of the Time 3___Often 

(N-4-A Questions) 

19. On a weekly basis do you participate in social activities or attend organized groups, such 

as choirs, support groups, cultural performances, group meals, exercise classes? 

1___Yes 0___No 2____Declined to answer 

19a. If Yes, what activity (ies) do you participate? _________________________ 

20. Would you say that you often feel that a lack of companionship? 

0___Yes 1___No 2____Declined to answer 

21. Is it difficult or impossible for you to leave your home without assistance? 

0___Yes 1___No 2____Declined to answer 

22. Do you see or talk to friends at least once a week? 

1___Yes 0___No 2____Declined to answer 

(Question from the Diener Satisfaction with Life Scale) 

For these next three (3) statements, think about a scale of one (1) to seven (7), 

with one (1) being that you strongly agree and seven (7) being that you strongly 

disagree with the statement. I will now read each of these statements and tell me 

a number between one (1) to seven (7). 

23. The conditions of my life are excellent 

What number would you give it? ____ 

1_____Strongly Agree 2_____ Somewhat Strongly Agree 3_____Agree 4____Neither Agree or Disagree 

5_____Disagree 6______Somewhat Strongly Disagree 7____ Strongly Disagree 

24. I am satisfied with my life 

What number would you give it? ____ 

1_____Strongly Agree 2_____ Somewhat Strongly Agree 3_____Agree 4____Neither Agree 

or Disagree 

5_____Disagree 6______Somewhat Strongly Disagree 7____ Strongly Disagree 
 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

6 

25. So far, I have gotten the important things I want in life 

What number would you give it? ____ 

1_____Strongly Agree 2_____ Somewhat Strongly Agree 3_____Agree 4____Neither Agree 

or Disagree 

5_____Disagree 6______Somewhat Strongly Disagree 7____ Strongly Disagree 

26. Approximately eight (8) weeks ago, we asked you how many appointments you had 

scheduled with your primary care physician or doctor, clinic or with a specialist or with a 

physical or occupational therapist or for counseling. At that time, you stated that you 

had #_________ appointments scheduled. (Interviewer: Look to pre-test question #25 

for # of appointments.) 

 How many of those appointments did you attend? #_____ 

27. Of the appointment(s) you were unable to attend, what were the reasons for not 

attending your appointment(s)? 

1___ I was a patient in the hospital 

2___ I was a patient the Emergency Room or urgent care center 

3___ I was unable to obtain a ride to go to my appointment 

4___ I was not feeling well enough to go to go to my appointment 

5___ I needed to take care of someone else, so I could not go 

6___ Other, please specify: __________________________________________* 

28. If you were in a patient in the hospital or an Emergency Room or urgent care center, what 

did the doctor tell you what was wrong with you? Please Specify:____________________ 
 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

7 

In checking our records, AgeOptions referred or provided you with information. 

Depending upon what services or programs, ask one or more of the following questions. 

(Interviewer: See pre-test question #26 to determine type(s) of referral received. Ask only 

about those referrals.) 

29. Did you visit the food pantry? 

1___Yes 2___No 

29a. If No, why not? 

1___ I no longer need help with obtaining food 

2___ I no longer need help with cooking food 

3___ I was in the hospital 

4___ I was unable to obtain a ride 

5___ I was not feeling well enough to go 

6___ I needed to take care of someone else, so I could not go to the appointment 

7___ Other, please specify: _____________________________________________* 

30. Are you attending a group congregate dining site? 

1___Yes 0___No 

30a. If No, why not? 

1___ I no longer need help with obtaining food 

2___ I no longer need help with cooking food 

3___ I was in the hospital 

4___ I was unable to obtain a ride 

5___ I was not feeling well enough to go 

6___ I needed to take care of someone else, so I could not go to the appointment 

7___ Other: _____________________________________________________* 

31. Did you receive or are you currently receiving home delivered meals? 

1___Yes 0___No 

31a. If No, why not? 

1___ Not found eligible 

2___ No longer need home delivered meals 

3___ Did not like the food 

4___ Other, please specify: _____________________________________________* 
 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

___________________________________________________________________ 

8 

32. Have you participated in MatherLifeWays Telephone Topics where you call-in and listen 

to a conversation on the telephone? 

1___Yes 0___No 

32a. If yes, how satisfied were you with the information you received? Would you say 

you were: 

5___Highly Satisfied 4___Satisfied 3___Neither Satisfied or Not 

Satisfied 

2___Not Satisfied 1___Highly Unsatisfied 

32b. If you were less than satisfied, can you tell us why? Please be specific: 

33. Similarly, when we last spoke, to determine if you were eligible for various programs 

from AgeOptions. Have you participated in any programs from AgeOptions? 

1 ___Yes 0___No 

Ask only if a participant responses with a “yes”

33a. Of the following, what programs or services did you receive from AgeOptions? 

1___ Accessing Information and Resources 

2___ Caring Together, Living Better 

3___ Illinois Financial Abuse 

4___ Make Medicare Work 

5___ Senior Medicare Patrol 

6___ Take Charge of your Health 

7___ Other, please specify: ______________________________________* 

34. Have you applied for any government programs besides a program helping you with 

food? 

1___Yes 0___No 

34a. If yes, of the following, what programs or services did you apply? 

1___ LHEAP 

2___ Medicaid 

3___ Medicare 

4___ SNAP, Food Stamps 

5___ Other, please specify: _______________________________________* 

Thank you very much. Please do not hesitate to give us a call here at 

AgeOptions at 800-699-9043 if you have any questions. 
8 

Post-Intervention 

Referral Survey

Survey given to health care professionals at the end 

of the study. 
NowPow Nutrition Post-Intervention Referral 

Survey 

Q1w 

Tell us your role: 

ANSWER CHOICES 

Primary Care Physician 

Physician's Assistant 

Primary Nurse Practitioner 

Nurse 

Social Worker 

Unit Clerk 

Q2w 

If you are not the professional who identified food insecurity, 

tell us who asks or asked you to make referrals for patients 

who are food insecure? 

% 

ANSWER CHOICES 

 

Primary Care Physician 

Physician's Assistant 

Primary Nurse Practitioner 

Nurse 

Social Worker 

Unit Clerk 

12 
Q3w 

Tell us the primary setting in which you see your patients and 

make referrals for patients who are food insecure. 

ANSWER CHOICES 

Inpatient hospital setting 

Outpatient clinic or primary care office 

Emergency Room 

In-home Health Risk Assessment 

Q4w 

How do you decide if a patient might benefit from a referral to 

address their food insecurity? 

ANSWER CHOICES 

A conversation with the patient 

The result of a screening tool 

Both a conversation and use of a screening tool 

Q5w 

Thinking about the past month, what percent of time do you 

refer older adult patients who present with food insecurity to 

community based resources? 

ANSWER CHOICES 

Zero Percent 

One Percent to 30 Percent 

31 Percent to 60 Percent 

61 Percent to 90 Percent 4 
91 Percent or more 

Q6w 

Thinking again about the past month, when you refer a patient 

for community-based resources for food insecurity, what 

percent of the time do you know if your older adult patients 

obtain or follow-up on these referrals? 

ANSWER CHOICES 

Zero Percent 

One Percent to 30 Percent 

31 Percent to 60 Percent 

61 Percent to 90 Percent 

 

91 Percent or more 

TOTAL 

Q7w 

When the older adult patient has connected with a communitybased resource for food insecurity, how do you find out that 

this occurred? (Check all that apply) 

ANSWER CHOICES 

Patient or Significant Other tells me 

Patient or Significant Other tells another professional at my office who tells 

me 

Information is included in my patient’s Electronic Medical Record (EHR)

Information is identified directly from NowPow 

Thinking back in time before referral information was available 

directly from NowPow or found in the Electronic Health 
Record, what percent of the time did you know if your older 

adult patients followed-up with community-based resources? 

ANSWER CHOICES 

Zero Percent 

One Percent to 30 Percent 

31 Percent to 90 Percent 

 

91 Percent or more 

Q9w 

Now that information is available from NowPow or found in the 

Electronic Health Record what percent of the time do you 

know if your older adult patients followed-up with communitybased resources? 

ANSWER CHOICES 

Zero Percent 

One Percent to 30 Percent 

31 Percent to 90 Percent 

91 Percent or more 

Q10w 

Which statements are true regarding your Electronic Health 

Record? (Check all that apply) 

ANSWER CHOICES 

I routinely check on the status of referrals for home and community-based resources 

addressing food insecurity in the Electronic Health Record 

I am more apt to refer my patients for community-based resources addressing food 

insecurity because information is available in the Electronic Health Record 
I do not routinely check on the status of referrals for home and community-based 

resources in the Electronic Health Record 

 

 

I did not know that status of whether or not a patient who was referred for food 

insecurity could be found in the Electronic Health Record 

Total Respondents: 15 

Q11w 

Which statements are true regarding NowPow? (Check all that 

apply) 

ANSWER CHOICES 

I routinely check on the status of referrals for home and community-based resources 

including food insecurity in NowPow 

I am more apt to refer my patients for community-based resources addressing food 

insecurity because information is available in the NowPow 

I do not routinely check on the status of referrals for home and community-based 

resources addressing food insecurity in NowPow 

I did not know that status of whether or not a patient who was referred for food 

insecurity could be found in NowPow 

Q12w 

How helpful is the closed loop system between your 

healthcare organization and AgeOptions in letting you know 

the outcome that your patient followed-up with the referral for 

community-based resources for food insecurity? 

ANSWER CHOICES 

Highly Helpful 

Moderately Helpful 

Neither Helpful or Unhelpful 

Moderately Unhelpful 

Highly Unhelpful
TOTAL 15 

Q13w 

What benefits have you observed in your patients who 

received a referral for community-based resources to mitigate 

their food insecurity? (Check all that apply) 

ANSWER CHOICES 

 

Improved health status 

Improved emotional or mental health status 

More stable health 

No change 

Responses 

Other (please specify) 

Q14w 

Since NowPow has been available to you, how likely are you 

to refer your patients to community-based resources for food 

insecurity? 

ANSWER CHOICES 

Highly Likely 

Moderately Likely 

Neither Likely or Unlikely 

Moderately Unlikely 

Highly Unlikely 

Q15w 

Since NowPow has been available to you, how connected do 

you feel to community-based resources for food insecurity as 

a treatment option for your older adult patient’s non-medical 

needs? 
ANSWER CHOICES 

Highly Connected 

Moderately Connected 

Neither Connected or Not Connected 

Moderately Not Connected 

 

Highly Not Connected 

Q16w 

How satisfied are you with NowPow and/or the information 

that you find in your Electronic Health Record pertaining to 

being informed of the outcome of your referral for your 

patients identified as food insecure. 

ANSWER CHOICES 

Highly Satisfied 

Moderately Satisfied 

Neither Satisfied or Not Satisfied 

Moderately Not Satisfied 

Highly Not Satisfied 

Q17w 

Are there any changes/ improvements, in the system or the 

information that would be helpful in communicating the result 

of a community-based resource referral addressing food 

insecurity? 
 

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9 

Pre-Intervention 

Questions

Health and wellness questions participants were 

asked at the beginning of the study. 
1 

EXHIBIT C: PRE-INTERVENTION QUESTIONS (HEALTH AND WELLNESS) 

1. Coded Name of Patient #___________________

2. Interviewer: ____________________________ 

3. Date of Pre-Intervention Interview: ___mm/dd/yyyy___________ 

4. Read Informed Consent 

1☐ Yes 0☐ No

5. Agreed to Informed Consent 

1☐ Yes 0☐ No

6. Study Participant 

1☐ Yes 0☐ No

Thank you for agreeing to answer these questions. It is likely that you were asked these first 

three questions before, but we would like to ask them to you again. 

(Food Insecurity Trigger Questions) 

1. Are you worried that your food will run out before you have money to buy more? 

1☐ Yes 0☐ No 2☐ Declined to Answer 

2. In the last 2 months, have you run out of food that you bought, and didn't have money to get 

more? 

1☐ Yes 0☐ No 2☐ Declined to Answer 

3. I am not always physically able to: 

1. Shop 3☐ Cook 4☐ Feed Myself 5☐

2. 0☐ No difficulty with these ADL/IADLs 

3. 2☐ Declined to Answer 

4. Thinking about money for food, do you have enough money to pay for food each month? 

 1☐ Yes 0☐ No

5. Thinking about what money you have for food, what applies? 

1☐

☐

☐

☐

☐

 I ask family for food 

2 I ask friends for food 

3 I ask strangers for money for food 

4 I go to the food pantry for food 

5 Other, please specify: ______________________________________* 
2 

6. Have you eaten today or last evening in the last 12 hours? 

1☐ Yes 0☐ No 

6a. If No, how many hours is it since you last ate? ____# hours 

6b. If Yes or No? 

Where did you obtain food for you most recent meal? 

1 ☐

☐

☐

☐

☐

☐

☐

☐

 I bought it at a grocery 

 2 I bought it at a convenience store 

 3 I was given this food at a food pantry 

 4 My family provided me with food 

 5 A friend provided me with food 

 6 I attended a group congregate meal site 

 7 I receive home delivered meals 

 8 Other, Please specify_______________________________________________________* 

7. If food obtained in grocery or convenience or food pantry, did someone help you? 

1☐ Yes 0☐ No – I was able to get it myself 

7a. If yes, who helped you? ______________________________ 

8. Regarding the food that you do eat, which of the following statements is most true: 

1___

__

__

__

I can eat whatever I want, I am not on any special kind of diet 

2_ My doctor has told me that there are things that I should not eat and I am able to keep 

the diet that my doctor wants me to be on 

 3_ My doctor has told me that there are things that I should not eat, but I am unable to be 

keep the diet that my doctor wants me to be on. 

4_ I do not know what I should or should not eat 

9. As to shopping for food, which of the following statements is most true: 

1___

__

I am able to go to the store or food pantry and obtain my food 

2_ Sometimes, I can go to the store or food pantry and other times, I must rely on others 

 to shop for my food 

 3___ I am not able to go to the store or food pantry and obtain my food and must rely on 

 others to shop for my food 

10. As to cooking food, which of the following statements is most true: 

1___ I am able to cook food 

2___ Sometimes, I am able to cook food and other times, I must rely on others 

 to cook my food 

3___ I am not able to cook food and must rely on others to cook my food 
3 

11. I would like to ask you about where you live, please tell me which of the following describes where 

you live. 

1___I live in a home or apartment 

2___I live in an apartment in a senior building 

3___I live in a supportive or assisted living residence 

4___I live with friends 

5___ I stay with friends 

6___ I live with family 

7___ I do not have a permanent place to stay 

8___ I am homeless 

9___ Other, specify: ______________________* 

These next set of questions focus on your feelings about your health. 

(Questions taken from the PROMIS Global Health Tool) 

12. In general, would you say your health is: 

5___Excellent 4___Very Good 3____Good 2___Fair 1 ___Poor 

13. In general, how would you rate your physical health? 

 5___Excellent 4___Very Good 3____Good 2___Fair 1 ___Poor 

14. In general, how would you rate your mood and your ability to think?

 5___Excellent 4___Very Good 3____Good 2___Fair 1 ___Poor 

 (Question from the UCLA Loneliness Scale (R-UCLA) – Three Item Loneliness Scale) 

15. How often do you feel that you lack companionship? 

1___Hardly ever 2___Some of the Time 3___Often 

16. How often do you feel left out? 

1___Hardly ever 2___Some of the Time 3 ___Often 

17. How often do you feel isolated from others? 

1___Hardly ever 2 ___Some of the Time 3___Often 

(N-4-A Questions) 

18. On a weekly basis do you participate in social activities or attend organized groups, such as choirs, 

support groups, cultural performances, group meals, exercise classes? 

1___Yes 0___No 2____Declined to answer 

18a. If Yes, what activity (ies) do you participate? _________________________ 

19. Would you say that you often feel that a lack of companionship? 

0___Yes 1___No 2____Declined to answer 
4 

20. Is it difficult or impossible for you to leave your home without assistance? 

0___Yes 1___No 2____Declined to answer 

21. Do you see or talk to friends at least once a week? 

1___Yes 0___No 2____Declined to answer 

(Question from the Diener Satisfaction with Life Scale) 

For these next three (3) statements, think about a scale of one (1) to seven (7), with one (1) 

being that you strongly agree and seven (7) being that you strongly disagree with the 

statement. 

22. The conditions of my life are excellent 

What number would you give it? ____

23. I am satisfied with my life 

What number would you give it? ____ 

1_____Strongly Agree 2_____ Somewhat Strongly Agree 3_____Agree 4____Neither Agree or Disagree 

5_____Disagree 6______Somewhat Strongly Disagree 7____ Strongly Disagree 

24. So far, I have gotten the important things I want in life 

What number would you give it? ____ 

1_____Strongly Agree 2_____ Somewhat Strongly Agree 3_____Agree 4____Neither Agree or Disagree 

5_____Disagree 6______Somewhat Strongly Disagree 7____ Strongly Disagree

Now for my last question today . . . . 

25. Within the next six (6) weeks, how many appointments do you have scheduled with either your 

primary care physician, doctor or clinic or with a specialist or for physical or occupational therapy or 

counseling? Enter number of appointments: #______

Thank you very much. We will be calling you soon to find-out what programs and services you are receiving. 

We will also be calling you again in about eight (8) weeks to ask you some very similar questions as part of 

this study. Please do not hesitate to give us here at AgeOptions a call at 800-699-9043 if you have any 

questions. 

Interviewer: Indicate below where this participant was referred. This information will be part of the postintervention survey. 

26. Where was the participant referred for nutrition related services (check all that apply): 

1☐ Food Pantry 2☐ Congregate Dining Site 3☐ Home Delivered Meals 

4☐ Mather Lifeways Telephone Topics 5☐ AgeOptions Program 6☐ Government Programs

1_____Strongly Agree 2_____ Somewhat Strongly Agree 3_____Agree 4____Neither Agree or Disagree 

5_____Disagree 6______Somewhat Strongly Disagree 7____ Strongly Disagree