Data Driven Decision Making 

Nutrition’s Role in the Changing 

Healthcare Environment 

www.nutritionandaging.org
Presenters: 

Linda Netterville, MA, RD, LD

Project Director, National Resource Center on Nutrition and Aging 

Sherry Simon, RD, LD

Vice President of Nutrition and Health Programs 

Meals On Wheels, Inc. of Tarrant County 

Alan Stevens, PhD 

Director, Center for Applied Health Research 

Scott and White Healthcare System 

Kali S. Thomas, PhD, MA

Assistant Professor, Center for Gerontology and Healthcare Research 

Brown University 

Research Health Science Specialist, Providence VA Medical Center 
Data Driven Decision Making 

Plan, manage, 

and administer 

Meet funder 

requirements 

Develop new 

programs 

Develop grant 

funded 

projects 

Develop 

program 

enhancements 

Justify budgets 
Sherry Simon, RDN/LD 

Vice President of Nutrition and Health Programs 

Meals On Wheels, Inc. of Tarrant County 
What Data Is Collected? 

How Is Data Collected? 

How Is Analysis Supported? 

How Are Results Used? 
Types of MOWI Programs / Data Collected 

 Meals Program including Choice Meals 

 Homeland Security Questions 

 Referrals 

 Accounting 

 Health, Medical, and Medication 

 Required Assessments and Evidenced-Based Screening Tools 

 Grant Projects: Diabetes, HomeMeds, PAM, Vision 

 Nutrition Diagnosis 

 “Healthy Days” Data
What Data 

Is 

Collected? 
• Demographic Information (name, address, route #) 

• Program(s) (Meals, RD Educ, HomeMeds, PAM, SAGE---with start 

and end dates) 

• Meals Detail (meal type, beverage type, food allergies, funding 

source) 

• Meal History (accounts for all the meals and how they were funded) 

• Medical Screen (major health concern, diagnosis, medical needs, 

PCP, Homeland Security Questions-emergency transportation, 

Hospitalizations and ER visits, Insurance type) 

• Medications (also includes herbs & vitamin/minerals, falls, 

dizziness, alcohol intake) 
• Health Screen (Height, Weight, other agencies involvement, health 

insurance details) 

• Documentation (free form writing with indication of type of note) 

• Assessments (DADS 2060, Nutrition Screen, Malnutrition Screen, 

Diabetes Screen, Emergent Care Screen, Healthy Days, EQ-5D) 

• Dietitian Notes (pretty an electronic medical record with BMI, diet 

recall, Nutrition Diagnosis) 

• Outcome Questions (facility specific questions, Healthy Days, 

questions taken from evidence based sources) 

• Client Contributions ( a record of the contributions made by 

or on behalf of the client) 

 

 1. Would you say that in general your health is excellent, very 

good, good, fair, or poor? 

 2. Now thinking about your physical health, which includes 

physical illness and injury, for how many days during the past 

30 days was your physical health not good? 

 3. Now thinking about your mental health, which includes 

stress, depression, and problems with emotions, for how many 

days during the past 30 days was your mental health not 

good? 

 4. During the past 30 days, for about how many days did poor 

physical or mental health keep you from doing your usual 

activities, such as self-care, work, or recreation? 

Note these are four questions (Core Module) out of a 14 question questionnaire—other 

questions are more specific---Activity Limitation Module and the Healthy Day Symptoms 

Module 
How Is 

Data 

Collected?
 Case Managers have Netbooks and use air cards to 

get onto the database and document while out in 

the field or in their homes 

At the same time, the staff in office are also updates 

and using the database 

We essentially built an electronic medical record 

for the HAIL, PAM, and HomeMeds where we can 

format into an actual medical personnel note 

We can build a report with any inputted data 

Examples----Fort Worth Emergency Management, 

Tarrant County Health Dept, EMS on the way to a 

clients home can print Medical HX and Meds 










How Is 

Analysis 

Supported? 
Office Staff dedicated daily to different 

aspects of the database 

IT Manager 

Technology Committee 

Every call/action documented in the 

database 
Database Programmer 

Evaluation Team 

Hosting of Server 

Interface with other Organizations 

Funders with specific needs 
How Are 

Results 

Used? 
 Pre and Post Data or Annual Data 

 Reports to Funders 

 Reports to Stakeholders 

 Adds validity 

 Benchmarking 

 Able to have measurement of what is being 

done

 Reproducible data 

 Share among like Agencies/Organizations 

 More that use these tools the stronger our 

message 

 Data=Results! 
Sherry Simon 

Vice President of Nutrition and Health 

Programs 

Meals On Wheels, Inc. of Tarrant County 

ssimon@mealsonwheels.org 

Office Number: 817-258-6427
Findings of MOWAA/Wal-Mart 

Expanding the Vision Grant 

Alan B. Stevens. PhD 

Director, Center for Applied Health 

Research 
MOWAA/Wal-Mart Expanding the 

Vision Grant 

• The goal of the grant is to expand MOWAA 

organization’s nutrition and meal services 

• Meals On Wheels, Inc. (MOWI) of Tarrant 

County was one funded agency 

– We were contracted to complete an evaluation of the 

MOWI project 

• Project period: March, 2013 ― March, 2014 
Meals On Wheels, Inc. (MOWI) of 

Tarrant County 

• Mission: 

– To promote the dignity and independence of 

older adults, persons with disabilities, and 

other homebound persons by delivering 

nutritious meals and providing or coordinating 

needed services. 
MOWI Programs/Services 

• Meals Program 

• Comprehensive Case Management 

• Client Services (e.g., fans/air conditioners, blankets, 

walkers, smoke detectors, minor home repairs) 

• Companion Pet Meals 

• Friend to Friend 

• HELLO (Help Eliminate Life’s Loneliness for Others)

• WOW (Words On Wheels) 

• Community Health Navigator 

• Diabetes/Nutrition Counseling 

• HomeMeds 

MOWI of Tarrant County Vision Grant 

• Collaborated with: 

– Area Agency on Aging of Tarrant County 

(AAA), 

– United Way of Tarrant County, and 

– John Peter Smith Hospital (JPS) 
Grant Goals: Outputs 

• Outputs: 

– Provide 18,000 meals to a minimum of 120 recently 

discharged hospital or emergency room patients 
Grant Goals: Outcomes 

• Outcomes: 

– 50% of clients served (60) will not have another 

hospital admission during the project period 

– 10% of clients served (12) will reduce their Emergent 

Care Assessment score upon ending the meal 

program 

– 50% of clients served participating in the HomeMeds 

program will have eliminated all medication alerts 

within 30 days 
Goal Achievement 

Goal: 18,000 meals to a minimum of 120 recently discharged hospital or 

emergency room patients 

A total of 18,010 meals provided during the funding period. 

A total of 121 patients received meal services during the funding period. 
Total Number of Meals Provided 

18,010

11,288

4,954

93 70 420 319 856

0

4,000

8,000

12,000

16,000

20,000

Meals

Provided

Noon Meals Breakfast

Meals

Shelf-stable

Meals

Frozen

Breakfast

Meals

Frozen Noon

Meals

Holiday Meals Weekend

Meals
Vision Clients Meal Information 

• Average number of meals: 131 meals 

• Average length on the program: 132 days 
Demographic Characteristics of 

Clients Served 

• Mean age: 71.51 years (42-94 years) 

• Female: 60% 

• White/non-Hispanic: 75% 

• Hispanic: 6% 

• Black/African American: 19% 
Hospitalizations at Intake 

• Among 121 reached clients, 105 clients had at 

least one recent hospitalization (average nights 

of hospitalization= 10.75) and 20 had a recent 

ER visit at intake. 

• Four clients had both a recent hospitalization 

and ER visit at intake. 
Outcome Achievement: 

Hospitalizations 

• 50% of clients (60) served will not have another 

hospital admission during the project period. 

– This outcome was achieved. 

75.3% (N=67)

80.4% (N=41)

24.7% (N=22)

19.6% (N=10)

0.0%

20.0%

40.0%

60.0%

80.0%

100.0%

3 months 6 months

No Hospitalization Hospitalization

Target Goal: 50%
Outcome Achievement: ER Visits 

• 50% of clients (60) served will not have another 

hospital admission during the project period. 

– This outcome was achieved. 

89.9% (N=80) 90.2% (N=46)

11.1% (N=9) 9.8% (N=5)

0.0%

20.0%

40.0%

60.0%

80.0%

100.0%

3 months 6 months

No ER Visits ER Visits

Target Goal: 50%
Outcome Achievement: 

Emergent Care Assessment 

• 10% of clients (12) served will reduce their 

Emergent Care Assessment (an evidence-based 

tool used to determine a persons’ risk of 

hospitalization) score upon ending the meal 

program. 

– This outcome was achieved. 

– Average Emergent Care score at intake was 6.24. 

– 49 clients to date have Emergent Care Assessment 

data at 6 months, of which, 27 (55.1%) have reduced 

their score. 
Outcome Achievement: HomeMeds 

Alerts 

• 50% of clients served participating in the 

HomeMeds program will have eliminated all 

medication alerts within 30 days. 

– This outcome was achieved. 

– 93 clients enrolled in the HomeMeds Program and 51 

(55%) had medication alerts identified (mean=2.06 

alerts). 

– Based on the 41 clients with data on alert resolution, 

40 (98%) clients with alerts had them resolved within 

30 days. 
Findings: Meals Program 

• Clients served were identified to be at high 

risk of readmission or other negative health 

outcomes 

• After starting the meals program, the number 

of clients with readmissions was very low. 

– At 3 months, of the 89 clients, 75.3% were not 

hospitalized and 89.9% had not gone to the ER. 

– At 6 months, of the 51 clients, 80.4% of them had 

not hospitalized and 90.2% had not gone to the 

ER. 
Findings: Meals Program + HomeMeds 

• Clients who enrolled in both HomeMeds and the 

meals program had significant improvements 

– 55% of clients enrolled in both meals and HomeMeds 

had at least one medication alert identified 

• Average of 2.06 alerts per client 

– Of those with information on alert resolution, 98% of 

clients had their alerts resolved within 30 days. 
Additional Analyses Will Occur 

• Building a collaboration with the DFWHC 

Foundation to explore inpatient health care 

utilization data 

• Three way partnership: Meals on Wheels, 

DFWHC Foundation and Baylor Scott & White 

Health 

• We will attempt to match personal identifiers 

collected by MOWs with the claims data held by 

DFWHC Foundation 

• Health economist will be engaged in these new 

analyses 
Providing More Home-Delivered 

Meals Is One Way To Keep Older 

Adults With Low Care Needs Out 

Of Nursing Homes 

Kali S. Thomas, PhD 

Research Health Scientist, Providence VAMC 

and 

Assistant Professor, Department of Health Services, 

Policy and Practice, Brown University 
Outline 

 Low-Care Residents 

 Findings from Initial Study 

 Financial Impact on States 

 How to Utilize this Information 

 Current Work and Future Directions 
Background 

 Olmstead Decision in 1999 

 Increase in home and community based services 

(HCBS) 

 Increase in acuity of nursing home (NH) residents 

 Despite these increases, still alarming proportion 

of NH residents with low care needs 

 Measure of quality of long-term care (LTC) 

system 
Who are Low-Care Residents? 

 Do not require 

assistance in Bed 

Mobility, Toileting, 

Transferring, or Eating 

 Are not “Clinically 

Complex” or require 

“Special Rehab”

 Could be cared for in a 

less-restrictive setting 
How big is the issue? 
Why are they there? 

 Much variation among states in the prevalence of 

low-care NH residents

 A greater share of Medicaid LTC expenditures on 

HCBS is related to fewer NH residents with lowcare needs 

 More assisted living = fewer low-care residents 

 More NH competition = fewer low-care residents 

 Missing from the literature was relationship of 

additional HCBS programs (i.e. Older Americans 

Act services) to low-care residents in NHs
Hypothesis 

 We hypothesized that higher per capita state 

expenditures on OAA Title III services will be 

associated with a lower percentage of NH 

residents with low-care needs
Data 

 AGing Integrated Database (AGID) 

– AoA related data files and surveys 

– U.S. Census data 

 2000-2009 OAA Expenditures 

– Personal care, homemaker, chore, home-delivered 

meals, adult day care, and case management per 

older adult aged 65+ 
Data 

 LTCfocUS.org 

– 2000-2009

– Facility characteristics 

– Market characteristics 

– State policy variables 
Results 

 Out of all the programs, including Medicaid 

HCBS, increased spending in home-delivered 

meals was the only significantly associated 

with decreases in the proportion of low-care 

residents in nursing homes during the decade 

Reference: Thomas, KS & Mor, V (2012) Health Services Research 
Results in Context 

 Every additional $25 states spend on homedelivered meals per year, per person aged 65+ in 

the state, is associated with a decrease in the lowcare NH population of 1 percentage point 

 A state like Washington, that spent approximately 

$8.10 per capita aged 65+ would have an average 

low-care population of 16.8% 

 A state like Wyoming, who spent $82.46 per 

capita aged 65+, would have an average low-care 

population of 13.8% 
Follow-up Analysis 

 Relationship between the proportion of older 

adults in a state receiving home-delivered 

meals and low-care residents 

 Calculated the potential savings to states 
Results 

 Every 1% increase in the proportion of older 

adults receiving meals is associated with a 

0.2% decrease in the proportion of low-care 

residents 

 The majority of low-care residents are duallyeligible 

 Calculated each state’s potential costs/savings 

by increasing proportion of older adults served 
Potential Annual Financial Impact 

Reference: Thomas, KS & Mor, V (2013) Health Affairs 
Conclusions 

 Decreases in low-care NH residents coincides 

with increased HCBS spending over the past 

decade 

 Increased expenditures on home-delivered meals 

and increased prevalence of older adults receiving 

meals are related to decreasing proportions of 

low-care residents in NHs

 Home-delivered meal services provide more than 

just food 

 These services may be key to allowing older 

adults to remain independent in their homes 
How Can This Information be Utilized? 

 Ex: legislative testimony, letters to elected 

officials, grant writing 

 Visit LTCfocUS.org for local low-care figures 

and population characteristics 

 Visit www.agid.acl.gov for SPR, National 

Survey of OAA Participants, Census data 

 Make the business case that home-delivered 

meals matter 
Current Work and Future Directions 

 8 Programs across the US 

 619 older adults on waiting lists 

– 212 control group 

– 194 once weekly frozen meals 

– 213 daily hot meals 

 Pre- and Post-Survey and Medicare claims 

 Evaluating improvements in quality of life, social 

isolation, health, and healthcare utilization after 

15 weeks 
More to come... 

Thank you! 

kali_thomas@brown.edu 

Supported by the 

Providence VAMC Center of Innovation (COIN) for Long Term 

Services and Supports, 

the National Institute on Aging (P01 AG-027296), 

and the Agency for Healthcare Research and Quality 

(T32 HS-000011)