SixtyPLUS: 

How Meals-on-Wheels 

Redefines Population 

Health

Appendix Documents
Table of Contents

Appendix Documents..............................................................................................................................................................................1

Appendix A: Home Care Frailty Scale.........................................................................................................................................3

Appendix B: Frailty Scale Training................................................................................................................................................4

Appendix C & D: Relevant Articles.................................................................................................................................................5

Appendix E: Frontiers HDM Frailty Implementation..........................................................................................................6

Appendix F: Yard Sign (Partner and Volunteer) .................................................................................................................7

Appendix G: SixtyPLUS Magnet.........................................................................................................................................................8

Appendix H: Partner Presentation .................................................................................................................................................9

Appendix I: Partner Meeting Questions...................................................................................................................................10

Appendix J: Functional Home Assessment............................................................................................................................11

Appendix K: SixtyPLUS Project Columbus................................................................................................................................12

Appendix L: Business Associate Agreement........................................................................................................................13

Appendix M: Patient Referral Form.............................................................................................................................................14

Appendix N: Registered Dietitian Call Tracker...................................................................................................................15
Appendix A: Home Care Frailty Scale
Home Care Frailty Scale—LifeCare Alliance

Item Response Response

Function (last 3 days)

Housework  No issue  Requires extensive help (1)

Meals  No issue  Requires some help (1) OR

 Requires extensive help (2)

Phone use  No issue  Requires help (1)

Personal hygiene  No issue  Requires help (1)

Walking  No issue  Requires physical help (1)

Transfers  No issue  Requires extensive help (1)

Toilet use  No issue  Requires help (1)

Movement

Climbing stairs in last 3 days  No issue  Requires help (1)

Physical activity hours  2+ hours 

in 3 days

 <2hrs in 3 days (1)

Fell in last 90 days  No  Yes (1)

Dizzy in last 90 days  No  Yes (1)

Cognition & Comm.

Decision-making in last 90 days  No issue  Requires help (1)

Medication mgmt.  No issue  Requires extensive help (1)

Financial mgmt.  No issue  Requires help (1)

Dementia (not Alzheimer’s)  No  Yes (1)

Understands others  Yes  No (1)

Social

Decline in social activities in 90 days  No  Yes (2)

Reduced social interactions in the last 3 days  No  Yes (1)

Withdrawal from activities of interest in the last 2 

days

 No  Yes (1)

Nutritional status (in last 90 days)

Weight loss (unintentional)  No  Yes (1)

Loss of appetite  No  Yes (1)

Decrease in food eaten (unintentional)  No  Yes (1)

Clinical symptoms and diagnoses

Bowel incontinence – last 3 days  No  Occasional (1)

Urinary tract infection -last 30 days  No  Yes (1)

Renal failure - current  No  Yes (1)

Pneumonia - current  No  Yes (1)

Congestive heart failure - current  No  Yes (1)

Emphysema - current  No  Yes (1)

TOTAL SCORE: _______/30 maximum

Comments:

This project was supported, in part by grant number 90INNU0016, from the Administration for Community Living, U.S. Department of 

Health and Human Services, Washington, D.C. 20201. Grantees undertaking projects with government sponsorship are encouraged to 

express freely their findings and conclusions. Points of view or opinions do not, therefore, necessarily represent official ACL policy.

Home Care Frailty Scale drawn from: Morris, J. N., Howard, E. P., & Steel, K. R. (2016). Development of the interRAI 

Home Care Frailty Scale. BMC Geriatrics, 16(1), 188. https://doi.org/10.1186/s12877-016-0364-5
Appendix B: Frailty Scale Training
Frailty Scale Training

LifeCare Alliance

This project was supported, in part by grant number 90INNU0016, from the Administration for Community Living, U.S. Department of Health and Human 

Services, Washington, D.C. 20201. Grantees undertaking projects with government sponsorship are encouraged to express freely their findings and 

conclusions. Points of view or opinions do not, therefore, necessarily represent official ACL policy.
What we will cover...

 General characteristics of clients

 Review of Frailty Scale items

 Q&A
Health characteristics of clients (national estimates)

 Home- and community-based services (HCBS) or Long term

supports and services (LTSS)
The Frailty Scale—What is it?

 Two components: Score of frailty (out of 30 points)

and your impression of frailty (from 1 to 7)

 Frailty: A relative state of weakness with expected

gradual decline in multiple functional and health

domains

 Function

 Movement

 Cognitive performance

 Communication

 Social engagement

 Nutritional issues

 Clinical symptoms

and diagnoses

These domains are all 

assessed through the 

Frailty Scale
The Frailty Scale—Review of Function items

Function items
The Frailty Scale

Review of Function items 1

 Item 1: Housework

Housework  No issue  Requires 

extensive help (1)

Scoring tip:

Housework Requires extensive help = help needed 

with more than 50% of household tasks 

such as cleaning, laundry, vacuuming, and 

dishes
The Frailty Scale

Review of Function items 2

 Item 2: Meals

Meals  No issue  Requires some 

help (1) OR

 Requires 

extensive help (2)

Scoring tip:

Meals Requires some help = help needed with less than 50% of meal 

tasks (i.e. client can prepare cereal and use microwave but 

requires assistance with complex meal preparation.)

Requires extensive help = help needed with more than 50% of 

meal tasks such as retrieving food, beverage prep, using stove, 

using oven, using microwave. 
The Frailty Scale

Review of Function items 3

 Item 3: Phone use

Phone use  No issue  Requires help (1)

Scoring tip:

Phone use Requires help = help needed with any part of 

basic phone use (e.g. dialing)
The Frailty Scale

Review of Function items 4

 Item 4: Personal hygiene

Personal hygiene  No issue  Requires help (1)

Scoring tip:

Personal 

hygiene

Requires help = help needed with ANY part 

of hand washing, grooming, face washing, 

oral care, etc.
The Frailty Scale

Review of Function items 5

 Item 5: Walking

Walking  No issue  Requires physical 

help (1)

Scoring tip:

Walking Requires physical help = hands-on assistance is 

required for safe walking. Mark as “No issue” if a 

client uses a cane or walker but does not require 

hands-on help. If using a wheelchair, mark 

“Requires physical help” and place note in the 

comments section
The Frailty Scale

Review of Function items 6

 Item 6: Transfers

Transfers  No issue  Requires 

extensive help (1)

Scoring tip:

Transfers Requires extensive help = hands-on help for 

helping a client move off a piece of 

furniture/equipment (such as a bed, couch, 

or wheelchair)
The Frailty Scale

Review of Function items 7

 Item 7: Toilet use

Toilet use  No issue  Requires help (1)

Scoring tip:

Toilet use Requires help = hands-on help OR 

supervision/cueing during toileting. This 

does NOT include help getting on/off the 

toilet
Movement Items

Movement items
The Frailty Scale

Review of Movement items 8

 Item 8: Climbing stairs

Climbing stairs in last 

3 days

 No issue  Requires help (1)

Scoring tip:

Climbing 

stairs

Requires help = any hands-on help OR 

supervision assistance needed to ensure 

safety with climbing stairs
The Frailty Scale

Review of Movement items 9

 Item 9: Physical activity

Physical activity 

hours

 2+ hours 

in 3 days

 <2hrs in 3 days (1)

Scoring tip:

Physical 

activity hrs

<2 hrs in 3 days = less than two hours of 

movement (walking outside or purposefully 

walking in home for exercise)
The Frailty Scale

Review of Movement items 10

 Item 10: Fall history

Fell in last 90 days  No  Yes (1)

Scoring tip:

Fell in last 90 

days

Yes = report or indicator of a fall
The Frailty Scale

Review of Movement items 11

 Item 11: Dizziness

Dizzy in last 90 days  No  Yes (1)

Scoring tip:

Dizzy in last 

90 days

Yes = report or indicator of dizziness
Cognition and Communication Items

Cognition and Communication 

Items
The Frailty Scale

Review of Cognition items 12

 Item 12: Decision-making

Decision-making in 

last 90 days

 No issue  Requires help (1)

Scoring tip:

DecisionmakingRequires help = help with basic decisions such 

as choosing items of clothing, knowing when to 

eat meals, asking for help with tasks when 

necessary, knowing when it’s necessary to use 

cane/walker, knowing when and how to use a 

calendar to plan the week
The Frailty Scale

Review of Cognition items 13

 Item 13: Medication management

Med mgmt. Requires extensive help = help with filling 

and removing pill box or verbal reminders to 

take medication. The use of a pill box alone 

does NOT indicate “extensive help”

Scoring tip:

Medication mgmt.  No issue  Requires 

extensive help (1)
The Frailty Scale

Review of Cognition items 14

 Item 14: Financial management

Financial mgmt.  No issue  Requires help (1)

Scoring tip:

Financial 

mgmt.

Requires help = any help with bill paying, 

writing checks, counting money
The Frailty Scale

Review of Cognition items 15

 Item 15: Dementia

Dementia (not 

Alzheimer’s)

 No  Yes (1)

Scoring tip:

Dementia Yes = indicators from client, family, or chart 

that client has symptoms consistent with 

dementia
The Frailty Scale

Review of Cognition items 16

 Item 16: Comprehension

Understands others  Yes  No (1)

Scoring tip:

Understands 

others

No = requires repetition of instructions, 

does not appear to comprehend 

conversation, slower processing
Social Engagement Items

Social engagement Items
The Frailty Scale

Review of Social Engagement items 17

 Item 17: Social activities

Decline in social 

activities in 90 days

 No  Yes (2)

Scoring tip:

Decline in 

social 

activities in 

last 90 days

Yes = as indicated by client or caregiver
The Frailty Scale

Review of Social Engagement items 18

 Item 18: Social interaction

Reduced social 

interactions in the last 

3 days

 No  Yes (1)

Scoring tip:

Reduced 

social 

interaction in 

last 3 days

Yes = decreased interaction with others in 

last three days
The Frailty Scale

Review of Social Engagement items 19

 Item 19: Activities of interest

Withdrawal 

from 

activities of 

interest

Yes = decline in hobbies that may/may not 

include socializing with others (reading, 

crosswords, jigsaw puzzles, knitting)

Scoring tip:

Withdrawal from 

activities of interest in 

the last 2 days

 No  Yes (1)
Nutritional Issues Items

Nutritional issues Items
The Frailty Scale

Review of Nutritional Issues items 20

 Item 20: Weight loss 

Weight loss 

(unintentional)

 No  Yes (1)

Scoring tip:

Weight loss Yes = unintentional weight loss in last 90 

days
The Frailty Scale

Review of Nutritional Issues items 21

 Item 21: Appetite 

Loss of appetite  No  Yes (1)

Scoring tip:

Loss of 

appetite

Yes = in last 90 days
The Frailty Scale

Review of Nutritional Issues items 22

 Item 22: Food intake 

Decrease in food 

eaten (unintentional)

 No  Yes (1)

Scoring tip:

Decrease in 

food eaten 

Yes = unintentional decrease in food 

consumption in last 90 days.
Clinical Symptoms and Diagnoses

Clinical symptoms and diagnoses
The Frailty Scale

Review of Clinical Symptoms items 23

 Item 23: Bowel incontinence 

Bowel incontinence –

last 3 days

 No  Occasional (1)

Scoring tip:

Bowel 

incontinencelast 3 days

Occasional = report of 1 or more incontinent 

episodes in last 3 days
The Frailty Scale

Review of Clinical Symptoms items 24

 Item 24: Urinary tract infection 

Urinary tract infection, 

last 90 days

 No  Yes (1)

Scoring tip:

UTI – last 90 

days

Yes = report of UTI in last 90 days
The Frailty Scale

Review of Clinical Symptoms items 25

 Item 25: Renal failure

Renal failure - current  No  Yes (1)

Scoring tip:

Renal failure Yes = report of present renal failure
The Frailty Scale

Review of Clinical Symptoms items 26

 Item 26: Pneumonia

Pneumonia - current  No  Yes (1)

Scoring tip:

Pneumonia Yes = report of present pneumonia
The Frailty Scale

Review of Clinical Symptoms items 27

 Item 27: Congestive heart failure

Congestive heart 

failure - current

 No  Yes (1)

Scoring tip:

Congestive 

heart failure

Yes = report of present congestive heart 

failure
The Frailty Scale

Review of Clinical Symptoms items 28

 Item 28: Emphysema

Emphysema - current  No  Yes (1)

Scoring tip:

Emphysema Yes = report of present emphysema
The Frailty Scale—Final score

__________ out of 30
Questions?

Q&A?

This project was supported, in part by grant number 90INNU0016, from the Administration for Community Living, U.S. Department

of Health and Human Services, Washington, D.C. 20201. Grantees undertaking projects with government sponsorship are 

encouraged to express freely their findings and conclusions. Points of view or opinions do not, therefore, necessarily represent

official ACL policy.
Appendix C & D: Relevant Articles
Relevant Articles

Appendix C – Article: Development of the interRAI home care frailty scale published in BMC

Geriatrics on November 21, 2016. 

Summary: The concept of frailty, a relative state of weakness reflecting multiple functional and 

health domains, continues to receive attention within the geriatrics field. It offers a summary of 

key personal characteristics, providing perspective on an individual’s life course. The interRAI 

Home Care Frailty Scale is based on a strong conceptual foundation and in the analysis, 

performed as expected. Given the use of the interRAI Home Care Assessment System in 

multiple, diverse countries, the Home Care Frailty Scale will have wide applicability to support 

program planning and policy decision-making impacting home care clients and their formal and 

informal caregivers throughout the world. Read the full article here.

Appendix D – Article: Implementing a Community-Based Initiative to Improve Nutritional 

Intake among Home-Delivered Meal Recipients published in Public Health Nutrition and Health 

Aging on February 23, 2022. 

Summary: Home-delivered meal (HDM) recipients are a highly vulnerable group of older adults 

at risk for malnutrition and subsequent health decline. To help HDM recipients increase their 

nutritional intake, HDM agencies may provide expanded meal options that allow older adults to 

have greater autonomy over their meal selection; however, the extent to which recipients are able 

to select nutritious meals that are responsive to their health complexities is unknown. This study 

examined the nutritional content of meals selected by HDM recipients enrolled in an expanded 

menu plan through a large HDM agency. Data were drawn from a retrospective chart review of 

130 HDM recipients who had the option of selecting their own HDM meals and frequency of 

meal delivery. Findings indicate that older adults who selected their own meals chose meals that 

were significantly lower in protein, potassium, fat, and calories. The lack of these nutrients 

suggests that older adults enrolled in expanded menu plans should be referred to registered 

dietitian nutritionists who can provide skilled guidance in meal selection. To address this need, 

we also describe and provide preliminary data representing a referral program designed to 

connect HDM recipients to dietetic services with the goal of optimizing older adult nutrition and 

health-related outcomes. Read the full article here.

This project was supported, in part by grant number 90INNU0016, from the Administration for 

Community Living, U.S. Department of Health and Human Services, Washington, D.C. 20201. Grantees 

undertaking projects with government sponsorship are encouraged to express freely their findings and 

conclusions. Points of view or opinions do not, therefore, necessarily represent official ACL policy.
Appendix E: Frontiers HDM Frailty Implementation

Published Article available for download.
Strategies for Implementing the Home Care Frailty Scale with HomeDelivered Meal Clients

Lisa A. Juckett1*, Haley V. Oliver1, Govind Hariharan2, Leah E. Bunck3, Andrea L. Devier3 1

1 2 Occupational Therapy Division, School of Health and Rehabilitation Sciences, College of Medicine, 

3 The Ohio State University, Columbus, Ohio, United States 

2 4 Coles College of Business, Kennesaw State University, Kennesaw, Georgia, United States

3 5 Lifecare Alliance, Columbus, Ohio, United States

6 *Correspondence: 

7 Lisa A. Juckett

8 lisa.juckett@osumc.edu

9

10 Keywords: Evidence-based practice; home- and community-based care and services; evaluation; 

11 nutrition implementation science

12 Abstract

13 Introduction: Frailty is a complex condition that is highly associated with health decline and the loss 

14 of independence. Home-delivered meal programs are designed to provide older adults with health 

15 and nutritional support that can attenuate the risk of frailty. However, home-delivered meal agencies 

16 do not routinely assess frailty using standardized instruments, leading to uncertainty over the 

17 longitudinal impact of home-delivered meals on frailty levels. Considering this knowledge gap, this 

18 study aimed to facilitate home-delivered meal staff’s implementation of a standardized frailty 

19 instrument with meal clients as part of routine programming. This article (a) describes the use of 

20 Implementation Mapping principles to develop strategies supporting frailty instrument 

21 implementation in one home-delivered meal agency and (b) examines the degree to which a 

22 combination of strategies influenced the feasibility of frailty instrument use by home-delivered meal 

23 staff at multiple time points.

24

25 Methods and Materials: This retrospective observational study evaluated staff’s implementation of 

26 the interRAI Home Care Frailty Scale (HCFS) with newly enrolled home-delivered meal clients at 

27 baseline-, 3-months, and 6-months. The process of implementing the HCFS was supported by five 

28 implementation strategies that were developed based on tenets of Implementation Mapping. Rates of 

29 implementation and reasons clients were lost to 3- and 6-month follow-up were evaluated using 

30 descriptive analyses. 

31

32 Results. Staff implemented the HCFS with 94.8% (n = 561) of eligible home-delivered meal clients 

33 at baseline. Of those clients with baseline HCFS data, staff implemented the follow-up HCFS with 

34 43% of clients (n = 241) at 3-months and 19.4% of clients (n = 109) at 6-months. Insufficient client 

35 tracking and documentation procedures complicated staff’s ability to complete the HCFS at follow36 up time points.

37
HDM frailty implementation

2

38 Discussion. While the HCFS assesses important frailty domains that are relevant to home-delivered 

39 meal clients, its longitudinal implementation was complicated by several agency-level factors that 

40 limited the extent to which the HCFS could by feasibly implemented over multiple time points.

41 Future empirical studies are needed to design and test theoretically derived implementation strategies 

42 to support frailty instrument use in the home- and community-based service setting.

43 

44 Keywords: Evidence-based practice; home- and community-based care and services; evaluation; 

45 nutrition and feeding issues; D&I/implementation science/pragmatic trials

46 

47 Introduction

48 Home-delivered meal programs provide community-dwelling older adults with health and nutritional 

49 support that help optimize wellness and reduce the need for more advanced healthcare services (1,2). 

50 Programming often targets older adults who are unable to safely and independently perform routine 

51 mealtime activities (e.g., shopping, meal preparation), who live alone and below the poverty line, and 

52 experience fair-to-poor health (3,4). In a recent nationwide sample, 76% of home-delivered meal 

53 clients had at least one activity of daily living (ADL) impairment, 74% had five or more reported 

54 health conditions, and 33% experienced difficulty affording food items on a routine basis (5). 

55 

56 The aforementioned characteristics of home-delivered meal clients also place them at elevated risk 

57 for frailty – a complex condition associated with age-related declines in physiological health (6–8). 

58 Frailty-related health declines drastically minimize older adults’ ability to tolerate health stressors 

59 (e.g., acute illness), leading to poorer health outcomes and individual healthcare costs that can total 

60 over $30,000 annually (9,10). Although various health professionals (e.g., physicians, nurse 

61 practitioners) can address frailty and its associated risk factors (11), the assessment of frailty can be 

62 time- and resource-intensive (12,13), particularly with older adults, such as home-delivered meal 

63 clients, who present with complex needs and chronic comorbidities (3,14). Given that over 70% of 

64 home-delivered meal clients experience frailty (15), innovative approaches are needed to regularly 

65 assess and monitor the frailty levels of older adults enrolled in home-delivered meal programs.

66 

67 Frailty has previously been assessed in the home-delivered meal setting by means of secondary data 

68 analyses (e.g., chart review) (15) but has yet to be examined longitudinally through the use of 

69 standardized frailty instruments administered directly to clients. The implementation, also referred to 

70 as “uptake” or “use,” of such instruments by home-delivered meal staff has the potential to provide 

71 home-delivered meal agencies with metrics representing clients’ improvement or maintenance of 

72 frailty levels – metrics that are necessary for demonstrating the valuable impact of these meal 

73 programs overtime (16,17). 

74 

75 Despite the high prevalence of frailty and the importance of monitoring frailty levels, there is little 

76 guidance for how home-delivered meal staff members can effectively implement instruments that 

77 validly and reliably assess frailty, particularly when those instruments are implemented at multiple 

78 time points (e.g., baseline, 3-month, and/or 6-month follow-up). Accordingly, the purpose of this 

79 paper is to (a) describe the use of Implementation Mapping (18) principles to develop strategies 

80 supporting frailty instrument implementation in one home-delivered meal agency and (b) examine 

81 the degree to which a combination of strategies influenced the feasibility of frailty instrument use by 

82 home-delivered meal staff at multiple time points. Insights from agency staff and leadership also 

83 illuminate challenges and opportunities for implementing frailty instruments within the home84 delivered meal context. This work underscores practical considerations for how home-delivered meal 

85 providers may assess frailty and continuously monitor health status changes among a highly 

86 vulnerable group of community-dwelling older adults. 
HDM frailty implementation

3

87 Materials and Methods

88 Study Design

89 To evaluate our implementation strategies, we used a retrospective observational design and 

90 examined home-delivered meal staff’s implementation the interRAI Home Care Frailty Scale (HCFS; 

91 Morris et al., 2016) at baseline (program enrollment), 3-months, and 6-months. 

92 

93 Setting

94 The agency partner for this study was a not-for-profit organization that provided home-delivered 

95 meals and nutritional support services to older adults, age 60 and over, in the five surrounding 

96 counties of Columbus, Ohio. With a staff of over 200 full- and part-time individuals, our partner 

97 agency employed a diverse group of staff members representing the fields of social work, nursing, 

98 community health, and dietetics, as examples. 

99 

100 Frailty Instrument Description

101 The HCFS is a 30-point scale developed from a secondary analysis of client-level interRAI Home 

102 Care data (Morris et al., 2016). HCFS items cover the following five domains: function, movement, 

103 cognition and communication, social interaction, and nutrition, with higher HCFS scores indicating 

104 greater levels of frailty. Agency staff members and leaders, in collaboration with our research team, 

105 selected to implement the HCFS given its perceived ease of use by clinical and non-clinical staff, 

106 implementability via telephone (a requirement per state COVID-19 restrictions on in-home visits), 

107 and evidence of acceptable internal consistency and criterion-related validity (see Morris et al., 2016, 

108 Table 2). Unlike the agency’s standard in-take assessment that was implemented with clients upon 

109 enrollment and every 12-months thereafter, staff implemented the HCFS at 3-month and 6-month 

110 follow-up points for the purposes of the present study. 

111 

112 Implementation Mapping

113 Implementation Mapping is a systematic, theory- and evidence-informed process designed to guide 

114 the development of implementation strategies – or the approaches used to support the uptake of high115 quality interventions, assessments, programs, or practices (18,20). It consists of a series of tasks that 

116 culminate in implementation strategy deployment and the evaluation of implementation outcomes 

117 (e.g., feasibility, adoption, fidelity) (21). The manner in which these tasks were applied to HCFS 

118 implementation is described below and expand upon prior methods used to develop implementation 

119 strategies in the community-based setting (22). All Implementation Mapping tasks (Figure 1) were 

120 co-led by agency partners (assistant director of nutrition programs, a case manager, and three 

121 administrators) in collaboration with our research team.

122 

123 [Insert Figure 1]

124 

125 Task 1. Conduct a needs assessment. Our needs assessment was conducted in two phases. Phase 1 

126 involved 1-on-1 interviews and focus groups with home-delivered meal staff as well as personal care 

127 assistants, homemakers, nurses, and dietitians employed by our partner agency. Interview and focus 

128 group guides were structured to evaluate the factors (i.e., determinants or barriers and facilitators) 

129 influencing evidence-based practice implementation in the context of home- and community-based 

130 services more broadly. Qualitative data underwent directed content analysis to identify key 

131 determinants of evidence implementation, and complete methodological details are reported 

132 elsewhere (23). In Phase 2, we held three, one-hour meetings with agency leadership and staff to 

133 understand current workflow procedures and how those procedures may be altered as a result of 

134 implementing the HCFS with home-delivered meal clients. 

135 
HDM frailty implementation

4

136 Task 2. Identify implementation determinants, outcomes, and performance objectives. Through 

137 our needs assessment, we identified that determinants at the agency-level – rather than policy-level, 

138 staff-level, or client-level – served as major determinants of HCFS implementation. In recognition of 

139 these determinants, home-delivered meal program directors, assessment staff, and the research team 

140 established the target outcomes (21) and performance objectives that needed to be achieved in order 

141 for HCFS implementation to be successful. Establishing target outcomes and performance objectives 

142 also informed the research team’s selection of data sources available within the agency that were 

143 needed for our outcome evaluation. 

144

145 Task 3. Choose guiding theory; select implementation strategies. The identification of 

146 determinants (Task 2) was informed by the Consolidated Framework for Implementation Research 

147 (CFIR) – a meta-theoretical framework of constructs representing the dynamic context within which 

148 organizations may implement new practices (24). Thus, the CFIR also guided the research team’s 

149 selection of HCFS implementation strategies that were vetted and confirmed by agency partners. 

150 Strategies were drawn from the Expert Recommendations for Implementing Change (ERIC) 

151 taxonomy (Powell et al., 2015) using the CFIR-ERIC matching tool (Powell et al., 2015; Waltz et al., 

152 2019). Whereas the CFIR provides uniform nomenclature to define implementation barriers and 

153 facilitators, the ERIC taxonomy is a compilation of over 70 implementation strategies hypothesized 

154 to promote the uptake of evidence-based practices into routine care. The CFIR-to-ERIC matching 

155 tool uses expert opinion data to generate a rank-ordered list of specific strategies to support evidence 

156 -based practice implementation.

157

158 Task 4. Design and deploy implementation strategies and materials. Our team began designing 

159 our implementation strategies and materials over the course of 5-months prior to HCFS 

160 implementation. Strategy development was led primarily by the agency’s assistant director of 

161 nutrition programs as well as our research team. All strategies were designed and operationalized 

162 according to recommendations by Proctor et al. (2013). These recommendations include: clearly 

163 identifying the individuals involved in providing (actors) and receiving each strategy (action targets), 

164 describing how the strategy is delivered (action), and establishing the strategy’s main goal (outcome), 

165 justification (rationale), and frequency (temporality, dosage).

166

167 Task 5. Evaluate implementation outcomes. To evaluate HFCS implementation outcomes, data 

168 were collected retrospectively from our agency’s custom HCFS documentation website from the 12-

169 month time period of June 1, 2020 – May 31, 2021, as per chart audit recommendations for 

170 implementation studies (Prusaczyk et al., 2018). HCFS data were examined monthly by the research 

171 team to determine rates of HCFS implementation for individual clients at baseline, 3-months, and 6-

172 months. Rates were established by calculating the proportion of clients who had documentation of 

173 the HCFS being completed compared to the total number of clients eligible for the HCFS. 

174 Documented reasons why staff were unable to complete the HCFS with clients were also analyzed 

175 descriptively. All associated research activities were approved by the Institutional Review Board at 

176 The Ohio State University (#2020E1238). 

177 Results

178 Results from Task 1: Conduct a needs assessment

179 Our needs assessment found three key, agency-level determinants influencing the implementation of 

180 evidence-based practices in the home-delivered meal setting. These determinants, as defined by the 

181 CFIR (24), were: (1) networks and communications, (2) available resources, and (3) compatibility

182 (23). Networks and communications referred to the nature and quality of how HCFS data were 

183 documented and shared within the agency; available resources included the time, staff, and 

184 equipment needed to implement the HCFS; and compatibility referred to the perceived “fit” of the 
HDM frailty implementation

5

185 HCFS with the agency’s existing workflow and values. Our meetings with agency leadership and 

186 staff also allowed our team to gather robust understanding of standard in-take assessment procedures 

187 and the extent to which these procedures would be altered by implementing the HCFS at multiple 

188 time points. Figure 2 compares staff’s processes of implementing both the standard in-take 

189 assessment and the HCFS.

190 

191 [Insert Figure 2]

192 

193 Results from Task 2: Identify implementation determinants, outcomes, and performance 

194 objectives

195 Determinants of implementation were identified through the completed needs assessment (see 

196 above). Consensus from agency leadership and staff indicated their primary outcome of interest was 

197 staff’s feasibility of implementing the HCFS longitudinally. For the present study, feasibility was 

198 defined as the utility or suitability of an evidence-based innovation for everyday use, which can be 

199 measured through the collection and analysis of administrative or health record data (21,27). Lastly, 

200 agency partners identified the following, single performance objective for staff: To implement the 

201 HCFS with 100% of home-delivered meal clients – funded through Title-IIIC – at baseline as well as 

202 3-months and 6-months after program enrollment, for all clients still enrolled in a meal plan.

203 

204 Results from Task 3: Choose guiding theory and select implementation strategies 

205 Identified determinants from the CFIR, recommendations from the CFIR-ERIC matching tool, and 

206 input from agency leadership and staff facilitated our selection of five implementation strategies to 

207 address the determinants of networks and communications, available resources, and compatibility. 

208 These included (a) conduct ongoing training, (b) identify and prepare a HCFS champion, (c) 

209 complete pilot testing, (d) change record systems, and (e) perform chart audits and provide feedback. 

210 

211 Results from Task 4: Design and deploy implementation strategies and materials 

212 The five implementation strategies designed and deployed by our team are described below and 

213 specified in (Table 1):

214 

215 Conduct ongoing training. When developing the structure for HCFS staff training, our team 

216 purchased the HCFS training manual ($65) (28), which contained instructions for how to administer 

217 and interpret each of the 29 HCFS items. We then converted the training manual into a presentation 

218 format that was delivered to home-delivered meal staff members during an initial training session. 

219 Initial training consisted of an in-depth review of all HCFS items, examples of how to score the 

220 HCFS, demonstration of how to document the HCFS (see “Change record systems” description 

221 below) and a question-and-answer session. Five months after initial training, a 1-hour follow-up 

222 “booster” training session was held. Training materials were updated with additional examples of 

223 how to administer and interpret client responses to individual HCFS items. Staff were also provided a 

224 “cheat sheet” document for interpretation and scoring of item responses. 

225 

226 Identify and prepare a HCFS champion. The agency’s assistant director of nutrition programs held 

227 the role of HCFS champion. In addition to their leadership within the agency, the champion had 

228 extensive knowledge of agency workflow and oversaw assessment procedures completed by staff. In 

229 this role, the HCFS champion received advanced training in administering and interpreting the 

230 HCFS, facilitated our research team’s receipt of monthly HCFS data files for auditing and analysis, 

231 and maintained a tracking log of clients to indicate when each baseline HCFS was completed as well 

232 as anticipated dates for 3-month and 6-month HCFS collection. Each month, the HCFS champion 

233 emailed staff the updated tracking log and also sent weekly emails containing a list of clients due to 
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234 have their HCFS completed. Staff were responsible for administering the HCFS within a 14-day 

235 window of clients’ estimated 3- or 6-month HCFS follow-up date. Moreover, the champion held 

236 biweekly phone calls with our research team to discuss concerns with HCFS implementation and to 

237 clarify discrepancies in staff’s interpretation of individual HCFS items.

238 

239 Complete pilot testing. After initial HCFS training, home-delivered meal staff (n = 7) pilot tested 

240 the HCFS with a minimum of 10 clients over a 30-day period. Piloting the HCFS allowed for home241 delivered meal staff and leadership to gain comfort with its administration and allowed our research 

242 team to clarify any challenges with HCFS interpretation prior to formally rolling out the HCFS with 

243 all home-delivered meal clients. Results from pilot testing also informed how our research team 

244 structured “booster” training sessions with staff, such as by including specific examples of how to 

245 interpret/score responses to each HCFS item.

246 

247 Change record systems. As part of our agency’s routine operating procedures, all standard in-take 

248 assessments were completed by staff and entered into the agency’s main EHR system. Building 

249 HCFS items into the main EHR required involvement from programmers external to the agency, thus 

250 complicating the extent to which staff could feasibly document the HCFS electronically. As a 

251 solution to this documentation issue, the agency’s information technology (IT) department developed 

252 their own HCFS website that allowed staff to document HCFS data electronically but separately from 

253 the agency’s EHR system. Staff accessed the HCFS website to enter the following data: (a) client ID, 

254 (b) date HCFS was attempted, (c) HCFS completion [yes/no], (d) reason if HCFS was not completed

255 [unable to reach client after three attempts, client unenrolled from services, client deceased, client on 

256 hold, etc.], (e) responses to all 29 HCFS items, (f) date follow-up HCFS was expected, and (g) name 

257 of staff member completing the HCFS.

258 

259 Perform chart audits and provide feedback. The HCFS champion shared monthly data sets with 

260 our research team who monitored the extent to which staff completed the HCFS at baseline, 3-month, 

261 and 6-month time periods. Implementation rates were reported to agency leadership during each 

262 monthly team call. When rates of implementation fell below 60-70%, the HCFS champion provided 

263 additional reminders to staff via email and encouraged staff to share any challenges they experienced 

264 relative to HCFS use or scoring. Further details on this audit-and-feedback approach and our four 

265 additional implementation strategies are described in Table 1.

266 

267 [Insert Table 1]

268 

269 Results from Task 5: Evaluate implementation outcomes

270 Feasibility of implementation. Analyses from our retrospective chart review indicated that rates of 

271 implementation were highest in June 2020 (94.6%) and lowest in May 2021 (57.1%) (Figure 3). Staff 

272 completed the HCFS with 94.8% of eligible clients at the baseline timepoint. Of those who 

273 completed the HCFS at baseline, however, staff were only able to obtain HCFS data from 43% of 

274 clients at 3-months and 19.4% of clients at 6-months. 

275 

276 [Insert Figure 3] 

277 

At baseline, the most common reason staff were unable to complete the 

HCFS was attributed to clients (n = 13) being “on hold” as they were 

recently hospitalized or admitted to a care facility (e.g., rehabilitation 
HDM frailty implementation

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facility), had a family member who could temporarily provide 

nutritional support, or were in the process of relocating. At 3-month 

and 6-month follow-up, clients having “unenrolled” from their meal 

plan was the most frequently documented reason staff could not 

complete the HCFS (n = 77 at 3-months; n = 24 at 6-months) (Figure 4). 

Overwhelmingly, however, staff did not or were not able to document 

the reasons clients were lost to follow-up. The reason for missed followup was not documented for 53.8% of clients at 3-months and 83.9% of 

clients at 6-months.

278 Discussion

279 This study examined one home-delivered meal agency’s process of implementing the HCFS – an 

280 instrument for measuring the frailty levels of home-delivered meal clients at multiple time points. 

281 Although our strategies to support HCFS use by home-delivered meal staff were systematically 

282 developed using principles from Implementation Mapping (18,22), our strategies did not lead to the 

283 feasible collection of HCFS data from clients overtime. Though staff demonstrated a high rate of 

284 HCFS implementation at baseline (94.8%), our findings also indicated that follow-up HCFS data 

285 were not collected from as high as 84% of home-delivered meal clients for reasons such as staff 

286 being unable to contact clients, clients having meal deliveries placed on temporary “holds,” or clients 

287 becoming unenrolled from services. Insights provided by our agency partners, described below, shed 

288 light on the complex challenges associated with HCFS implementation and opportunities for 

289 improvement given the importance of monitoring the frailty levels of home-delivered meal clients 

290 over time. Specifically, these insights draw attention to the intricate details that may have been 

291 overlooked when our agency and research team members were designing strategies to support HCFS 

292 implementation. Consistent with our guiding framework, insights are organized by constructs from 

293 the CFIR (24). 

294 

295 Agency Insights: HCFS Implementation Challenges 

296 Networks and communications. Perhaps the most significant agency-level factor influencing HCFS 

297 implementation was the manner in which it was documented and how HCFS data were 

298 communicated across the agency. Given that modifications within the main EHR system could not be 

299 made directly by the agency, its IT department built a custom website – accessible only to agency 

300 staff – for HCFS documentation. Though this solution was initially a viable option to support HCFS 

301 use, it ultimately posed challenges for our team over the course of our study period. For instance, as 

302 indicated in Figure 2, both the in-take assessment and HCFS evaluated areas related to functional 

303 status and nutrition. These areas of overlap were duplicative and interrupted the flow of staff’s 

304 assessment procedures, especially as staff were required to access two different documentation 

305 systems to complete all in-take and baseline HCFS items. This interruption also hindered staff’s 

306 natural course of conversation in the first encounter during which staff could build rapport with 

307 clients. Further, staff found substantial difficulty in tracking which clients needed to be contacted for 

308 their 3-month and 6-month HCFS. Although the HCFS champion’s tracking log and reminder emails 

309 helped alert staff when they needed to contact clients for follow-up, these reminders did not indicate 

310 if clients were still actively receiving meals, nor did they list client phone numbers. Accordingly, 
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311 staff were expected to log into their EHR system account, verify that the client had an active meal 

312 plan, and obtain the client’s phone number, increasing the total amount of time staff were expected to 

313 dedicate to HCFS follow-up activities.

314 

315 Available resources. Our agency’s lack of integrated documentation systems also limited the extent 

316 to which HCFS data could be entered longitudinally for individual clients. To accommodate for this 

317 barrier, the research team had one dedicated member who was responsible for merging baseline, 3-

318 month, and 6-month HCFS data together for individual clients, but this was not a sustainable solution 

319 for tracking client frailty levels. An additional, though minor, barrier to HCFS implementation was 

320 staff’s lack of access to dual-monitor computers during standard in-take assessments. After 

321 completing in-take assessments in the EHR system, staff immediately transitioned to implementing 

322 the baseline HCFS with clients. However, given the challenge of logging out of the EHR system, 

323 opening a web browser, and accessing the custom HCFS website on the same computer, staff often 

324 completed the HCFS on a paper form and entered client responses – at a later time – through the 

325 HCFS website. The timing of data entry, though, was occasionally delayed given staff’s other 

326 demands and work responsibilities. 

327 

328 Compatibility. The concept and format of the HCFS were initially perceived to be compatible by our 

329 agency’s administrative leaders. Despite these perceptions, leaders later expressed their concern that 

330 the information collected via the HCFS was being underutilized internally. Once HCFS 

331 implementation began, agency staff and leaders quickly learned of the additional needs of clients 

332 (e.g., mobility needs, social interaction needs) that were not necessarily being met by meal delivery 

333 alone. Our agency partners expressed their discomfort with assessing but not addressing these needs 

334 that were revealed as a result of implementing the HCFS longitudinally. 

335 

336 Agency Insights: Opportunities to Advance HCFS Implementation

337 Advancing networks and communications. Given that documentation was arguably the primary 

338 barrier to HCFS implementation, integrating the 29 HCFS items directly into the agency’s main EHR 

339 system could have likely streamlined documentation, particularly during the baseline period where 

340 staff completed both the in-take assessment and HCFS. Going forward, centralizing this information 

341 in one location has the opportunity to decrease staff burden, improve assessment workflow, and 

342 enhance staff’s interaction with clients (29). The return to in-person baseline assessments, pending 

343 statewide adjustments to COVID-19 restrictions, may also facilitate more streamlined assessments of 

344 frailty as staff can leverage their professional judgment and observational skills to determine the 

345 extent to which frailty domains (e.g., mobility, ADLs) are impaired (30,31). 

346 

347 Advancing available resources. Notably, staff who implemented the HCFS were partially 

348 compensated through a demonstration project grant which reduced the agency’s expenditures towards 

349 implementation activities. As these funds were temporary, alternative strategies are needed to support 

350 staff’s future ability to implement the HCFS feasibly and more consistently. Integrating HCFS items 

351 into the agency’s main EHR system is a first step towards minimizing assessment and documentation 

352 burden on staff. Though, while customized changes to EHR systems have shown promise for 

353 improving the quality of staff documentation behaviors (32), these system-level changes may need to 

354 be augmented by additional sources of support to promote assessment implementation (33). One 

355 additional option for this support is through clinical alerts which have served as effective reminders 

356 for staff who are involved in client documentation activities (34,35). These alerts may take the forms 

357 of e-mails, electronic “flags” directly within client charts, and/or pop-up notices within the EHR. 

358 Such alert systems can also be configured to deliver text message reminders to staff if documentation 

359 is not completed for clients on a specified date (36). While these alert systems have led to 
HDM frailty implementation

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360 improvements in documentation, there is also the threat of “alert fatigue” which may negatively 

361 impact staff job performance and satisfaction (37). Thus, use of these alerts, how often they are 

362 triggered and under what circumstances should be thoughtfully considered in collaboration with staff 

363 and leaders involved in documentation procedures (38).

364

365 Advancing HCFS compatibility. Implementation of the HCFS revealed frailty-related needs (e.g., 

366 fall risk factors, mental health concerns) that staff did not feel fully equipped to address. Although 

367 home-delivered meal providers can serve as “gatekeepers” to other community-based services and 

368 supports for older adults (39), our agency’s staff were not sufficiently aware of recommendations 

369 and local resources that could be shared with clients who indicated specific frailty needs. Cataloging 

370 these resources for staff, prior to the study period, may have facilitated their ability to make 

371 recommendations or referrals to other health and nutrition services, thereby improving the “fit” of the 

372 HCFS with the mission of our partner agency to maximize older adult health and well-being (14,40). 

373

374 Limitations

375 Although this study makes unique contributions to the understudied home-delivered meal context, it 

376 is not without limitations. First, our application of Implementation Mapping principles could have 

377 been strengthened by selecting a behavioral change theory to guide predictions about staff’s HCFS 

378 use. While strategy selection was informed by the CFIR (24) – comprehensive implementation 

379 framework – frameworks are not explanatory in nature and can rarely help predict relationships 

380 among theoretical constructs. Secondly, our implementation strategy named “complete pilot testing” 

381 is not a discrete strategy as defined in the ERIC taxonomy (25) but was a strategy that was 

382 recommended by our agency partners prior to staff’s use of the HCFS. We also recognize that our 

383 strategies only targeted agency-level implementation determinants whereas policy-level, staff-level, 

384 and client-level determinants may have also played an influential role in our implementation efforts. 

385 Third, given that this was a natural, observational study, we did not conduct an a priori power 

386 analysis but rather collected data retrospectively from clients over a 12-month time frame, as 

387 recommended for studies of implementation that include chart review methodology (26). Lastly, 

388 though we specified our five implementation strategies (Table 1), more robust details were needed to 

389 understand the mechanisms that promoted – or hindered – HCFS implementation. In addition to our 

390 own future work, we encourage other teams to consider routinely tracking their implementation 

391 activities to obtain thorough information on the types of implementation activities completed, their 

392 purpose, their duration, and the individuals involved (41). 

393

394 Conclusion

395 Home-delivered meal agencies are essential for providing health and nutrition services to a 

396 population of older adults at great risk for frailty-related health decline. Frailty instruments, such as 

397 the Home Care Frailty Scale (19), can serve as tools to help home-delivered meal staff assess and 

398 monitor the frailty levels of their clients. However, prior to adopting such instruments, home399 delivered meal providers are encouraged to comprehensively evaluate and address barriers that 

400 pertain to the longitudinal electronic documentation of frailty data, the staff and resources needed to 

401 implement frailty instruments consistently, and the extent to which instruments “fit” within agency 

402 workflow and values.

403

404 Conflict of Interest

405 The authors declare that the research was conducted in the absence of any commercial or financial 

406 relationships that could be construed as a potential conflict of interest.

407

408 Author Contributions
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409 LAJ conceptualized this study, led study activities, and led manuscript development. HVO completed 

410 data management and preliminary data analysis activities. GH assisted with developing the study 

411 design and approach to data analysis. LEB and AD completed project management activities and 

412 provided agency insights, as described in the Discussion section. All authors contributed to 

413 manuscript development and approved the final submitted version. 

 414 

415 Funding

416 This project was supported, in part by grant number 90INNU0016, from the Administration for 

417 Community Living, U.S. Department of Health and Human Services, Washington, D.C. 20201. 

418 Grantees undertaking projects with government sponsorship are encouraged to express freely their 

419 findings and conclusions. Points of view or opinions do not, therefore, necessarily represent official 

420 ACL policy. 

421 

422 Acknowledgments

423 The authors extend their sincere gratitude to Charles W. Gehring and John R. Gregory for their 

424 support throughout this project and their dedication to improving the health and nutrition of older 

425 Central Ohioans. 

 426 

427 Data Availability Statement 

428 Data collected and analyzed for this manuscript are not publicly available as to comply with our 

429 partner agency’s data sharing policies; however, materials used to deploy our implementation 

430 strategies with staff are available upon request made to the corresponding author. 

431 

432 References

433 1. Berkowitz SA, Terranova J, Hill C, Ajayi T, Linsky T, Tishler LW, DeWalt DA. Meal Delivery 

434 Programs Reduce The Use Of Costly Health Care In Dually Eligible Medicare And Medicaid 

435 Beneficiaries. Health Affairs (2018) 37:535–542. doi: 10.1377/hlthaff.2017.0999 

436 2. Lloyd JL, Wellman NS. Older Americans Act Nutrition Programs: A Community-Based 

437 Nutrition Program Helping Older Adults Remain at Home. JNutrGerontolGeriatr (2015) 34:90–

438 109. doi: 10.1080/21551197.2015.1031592 

439 3. Choi NG, Sullivan JE, Marti CN. Low‐income homebound older adults receiving home‐

440 delivered meals: Physical and mental health conditions, incidence of falls and hospitalisations. 

441 Health & Social Care in the Community (2019) 27:e406–e416. doi: 10.1111/hsc.12741 

442 4. Sonnega A, Robinson K, Levy H. Home and community-based service and other senior service 

443 use: Prevalence and characteristics in a national sample. Home Health Care Serv Q (2017) 

444 36:16–28. doi: 10.1080/01621424.2016.1268552 

445 5. Administration for Community Living. 2018 National Survey of Older Americans Act Nutrition 

446 Programs: Home-Delivered Meals. 

447 https://agid.acl.gov/DataFiles/Documents/NPS/HomeDeliveredMeals2018/Codebook_Home_M

448 eals_2018.pdf [Accessed January 6, 2021] 

449 6. Clegg A, Young J, Iliffe S, Rikkert MO, Rockwood K. Frailty in elderly people. Lancet (2013) 

450 381:752–762. doi: 10.1016/S0140-6736(12)62167-9 
HDM frailty implementation

11

451 7. Costenoble A, Knoop V, Vermeiren S, Vella RA, Debain A, Rossi G, Bautmans I, Verté D, 

452 Gorus E, De Vriendt P. A Comprehensive Overview of Activities of Daily Living in Existing 

453 Frailty Instruments: A Systematic Literature Search. Gerontologist (2021) 61:e12–e22. doi: 

454 10.1093/geront/gnz147

455 8. Welstead M, Jenkins ND, Russ TC, Luciano M, Muniz-Terrera G. A Systematic Review of 

456 Frailty Trajectories: Their Shape and Influencing Factors. The Gerontologist (2021) 61:e463–

457 e475. doi: 10.1093/geront/gnaa061

458 9. Mondor L, Maxwell CJ, Hogan DB, Bronskill SE, Campitelli MA, Seitz DP, Wodchis WP. The 

459 Incremental Health Care Costs of Frailty Among Home Care Recipients With and Without 

460 Dementia in Ontario, Canada: A Cohort Study. Medical Care (2019) 57:512–520. doi: 

461 10.1097/MLR.0000000000001139

462 10. Evenhuis HM, Hermans H, Hilgenkamp TIM, Bastiaanse LP, Echteld MA. Frailty and disability 

463 in older adults with intellectual disabilities: results from the healthy ageing and intellectual 

464 disability study. J Am Geriatr Soc (2012) 60:934–938. doi: 10.1111/j.1532-5415.2012.03925.x

465 11. Macdonald SH-F, Travers J, Shé ÉN, Bailey J, Romero-Ortuno R, Keyes M, O’Shea D, Cooney 

466 MT. Primary care interventions to address physical frailty among community-dwelling adults 

467 aged 60 years or older: A meta-analysis. PLOS ONE (2020) 15:e0228821. doi: 

468 10.1371/journal.pone.0228821

469 12. Abbasi M, Khera S, Dabravolskaj J, Garrison M, King S. Identification of Frailty in Primary 

470 Care: Feasibility and Acceptability of Recommended Case Finding Tools Within a Primary 

471 Care Integrated Seniors’ Program. Gerontology and Geriatric Medicine (2019) 

472 5:2333721419848153. doi: 10.1177/2333721419848153

473 13. Karunananthan S, Bergman H. Managing frailty in primary care: Evidence gaps cannot be 

474 ignored. CMAJ (2018) 190:E1122–E1123. doi: 10.1503/cmaj.181151

475 14. Morris AM, Engelberg JK, Schmitthenner B, Dosa D, Gadbois E, Shield RR, Akobundu U, 

476 Thomas KS. Leveraging Home-Delivered Meal Programs to Address Unmet Needs for At-Risk 

477 Older Adults: Preliminary Data. Journal of the American Geriatrics Society (2019) 67:1946–

478 1952. doi: https://doi.org/10.1111/jgs.16013

479 15. Hutchins-Wiese HL, Walsh SE. Frailty and Nutrition Risk Screening in Home-Delivered Meal 

480 Clients. Journal of nutrition in gerontology and geriatrics (2020) 39:114–130. doi: 

481 10.1080/21551197.2020.1719258

482 16. Campbell A, Godfryd A, Buys D, ... Does participation in home-delivered meals programs 

483 improve outcomes for older adults? Results of a systematic review. Journal of nutrition in ...

484 (2015) http://www.tandfonline.com/doi/abs/10.1080/21551197.2015.1038463

485 17. Thomas KS. Outcomes Matter: The Need for Improved Data Collection and Measurement in 

486 Our Nation’s Home-Delivered Meals Programs. Journal of Nutrition in Gerontology and 

487 Geriatrics (2015) 34:85–89. doi: 10.1080/21551197.2015.1031591

488 18. Fernandez ME, ten Hoor GA, van Lieshout S, Rodriguez SA, Beidas RS, Parcel G, Ruiter RAC, 

489 Markham CM, Kok G. Implementation Mapping: Using Intervention Mapping to Develop 
HDM frailty implementation

12

490 Implementation Strategies. Frontiers in Public Health (2019) 7: 

491 https://www.frontiersin.org/article/10.3389/fpubh.2019.00158 [Accessed June 24, 2022] 

492 19. Morris JN, Howard EP, Steel KR. Development of the interRAI home care frailty scale. BMC

493 Geriatrics (2016) 16:188. doi: 10.1186/s12877-016-0364-5 

494 20. Proctor EK, Powell BJ, McMillen JC. Implementation strategies: Recommendations for

495 specifying and reporting. Implementation Science (2013) 8:139. doi: 10.1186/1748-5908-8-139 

496 21. Proctor E, Silmere H, Raghavan R, Hovmand P, Aarons G, Bunger A, Griffey R, Hensley M.

497 Outcomes for Implementation Research: Conceptual Distinctions, Measurement Challenges, 

498 and Research Agenda. Adm Policy Ment Health (2011) 38:65–76. doi: 10.1007/s10488-010-

499 0319-7 

500 22. Kang E, Foster ER. Use of Implementation Mapping With Community-Based Participatory

501 Research: Development of Implementation Strategies of a New Goal Setting and Goal 

502 Management Intervention System. Frontiers in Public Health (2022) 10: 

503 https://www.frontiersin.org/article/10.3389/fpubh.2022.834473 [Accessed June 24, 2022] 

504 23. Juckett LA, Bunger AC, Jarrott SE, Dabelko-Schoeny HI, Krok-Schoen J, Poling RM, Mion

505 LC, Tucker S. Determinants of Fall Prevention Guideline Implementation in the Home- and 

506 Community-Based Service Setting. The Gerontologist (2021) 61:942–953. doi: 

507 10.1093/geront/gnaa133 

508 24. Damschroder LJ, Aron DC, Keith RE, Kirsh SR, Alexander JA, Lowery JC. Fostering

509 implementation of health services research findings into practice: a consolidated framework for 

510 advancing implementation science. Implementation Science (2009) 4:50. doi: 10.1186/1748-

511 5908-4-50 

512 25. Powell BJ, Waltz TJ, Chinman MJ, Damschroder LJ, Smith JL, Matthieu MM, Proctor EK,

513 Kirchner JE. A refined compilation of implementation strategies: results from the Expert 

514 Recommendations for Implementing Change (ERIC) project. Implementation Science (2015) 

515 10:21. doi: 10.1186/s13012-015-0209-1 

516 26. Prusaczyk B, Fabbre V, Carpenter CR, Proctor E. Measuring the Delivery of Complex

517 Interventions through Electronic Medical Records: Challenges and Lessons Learned. EGEMS 

518 (2018) 6: doi: 10.5334/egems.230 

519 27. Lengnick-Hall R, Gerke DR, Proctor EK, Bunger AC, Phillips RJ, Martin JK, Swanson JC. Six

520 practical recommendations for improved implementation outcomes reporting. Implementation 

521 Science (2022) 17:16. doi: 10.1186/s13012-021-01183-3 

522 28. Morris JM, Fries BE, Bernabei R, Steel K, Ikegami N, Carpenter GI, Gilgen R, Frijters D,

523 Henrard JC, Hirdes JP, & Belleville-Taylor P. (2019). interRAI Home Care (HC) Assessment 

524 Form and User’s Manual. (2019) Open Book Systems, Inc.

525 29. Guo U, Lu Chen, Mehta PH. Electronic health record innovations: Helping physicians -- One

526 less click at a time. Health Information Management Journal (2017) 46:140–144. doi: 

527 10.1177/1833358316689481 
HDM frailty implementation

13

528 30. Feuering R, Vered E, Kushnir T, Jette AM, Melzer I. Differences between self-reported and

529 observed physical functioning in independent older adults. Disabil Rehabil (2014) 36:1395–

530 1401. doi: 10.3109/09638288.2013.828786 

531 31. Nielsen LM, Kirkegaard H, Østergaard LG, Bovbjerg K, Breinholt K, Maribo T. Comparison of

532 self-reported and performance-based measures of functional ability in elderly patients in an 

533 emergency department: implications for selection of clinical outcome measures. BMC 

534 Geriatrics (2016) 16:199. doi: 10.1186/s12877-016-0376-1 

535 32. Richardson KJ, Sengstack P, Doucette JN, Hammond WE, Schertz M, Thompson J, Johnson C.

536 Evaluation of Nursing Documentation Completion of Stroke Patients in the Emergency 

537 Department: A Pre-Post Analysis Using Flowsheet Templates and Clinical Decision Support. 

538 Comput Inform Nurs (2016) 34:62–70. doi: 10.1097/CIN.0000000000000206 

539 33. Carpenter JG, Scott WJ, Kononowech J, Foglia MB, Haverhals LM, Hogikyan R, Kolanowski

540 A, Landis‐Lewis Z, Levy C, Miller SC, et al. Evaluating implementation strategies to support 

541 documentation of veterans’ care preferences. Health Services Research (2022)1. doi: 

542 10.1111/1475-6773.13958 

543 34. Giovannelli J, Coevoet V, Vasseur C, Gheysens A, Basse B, Houyengah F. How can screening

544 for malnutrition among hospitalized patients be improved? An automatic e-mail alert system 

545 when admitting previously malnourished patients. Clin Nutr (2015) 34:868–873. doi: 

546 10.1016/j.clnu.2014.09.008 

547 35. Hamade N, Terry A, Malvankar-Mehta M. Interventions to improve the use of EMRs in primary

548 health care: a systematic review and meta-analysis. BMJ Health Care Inform (2019) 26:0. doi: 

549 10.1136/bmjhci-2019-000023 

550 36. Tollinche LE, Shi R, Hannum M, McCormick P, Thorne A, Tan KS, Yang G, Mehta M, Yeoh

551 C. The impact of real-time clinical alerts on the compliance of anesthesia documentation: A

552 retrospective observational study. Comput Methods Programs Biomed (2020) 191:105399. doi:

553 10.1016/j.cmpb.2020.105399

554 37. Kizzier-Carnahan V, Artis KA, Mohan V, Gold JA. Frequency of Passive EHR Alerts in the

555 ICU: Another Form of Alert Fatigue? Journal of Patient Safety (2019) 15:246–250. doi: 

556 10.1097/PTS.0000000000000270 

557 38. Shultz CG, Malouin JM, Green LA, Plegue M, Greenberg GM. A Systems Approach to

558 Improving Tdap Immunization Within 5 Community-Based Family Practice Settings: Working 

559 Differently (and Better) by Transforming the Structure and Process of Care. American Journal 

560 of Public Health (2015) 105:1990–1997. doi: 10.2105/AJPH.2015.302739 

561 39. Thomas KS, Smego R, Akobundu U, Dosa D. Characteristics of Older Adults on Waiting Lists

562 for Meals on Wheels: Identifying Areas for Intervention. J Appl Gerontol (2017) 36:1228–1242. 

563 doi: 10.1177/0733464815614918 

564 40. Juckett LA, Bunger AC, Bunck L, Balog EJ. Evaluating the Implementation of Fall Risk

565 Management Practices within Home-delivered Meal Organizations. Journal of Gerontological 

566 Social Work (2021) 64:372–387. doi: 10.1080/01634372.2021.1894521 
HDM frailty implementation

14

567 41. Bunger AC, Powell BJ, Robertson HA, MacDowell H, Birken SA, Shea C. Tracking

568 implementation strategies: a description of a practical approach and early findings. Health

569 Research Policy and Systems (2017) 15:15. doi: 10.1186/s12961-017-0175-y

570 

571 

572 
573 Table 1. Specification of strategies to promote HCFS implementation. 

Specification

Criteria

Implementation 

strategies

Conduct ongoing 

training

Identify and prepare a 

HCFS champion

Complete pilot testing Change record systems Perform chart audits 

and provide feedback

Actor Research team Research team Research team Research team, HCFS 

champion, IT 

department

Research team

Action Conduct initial and 

follow-up training 

sessions

Prepare internal staff 

member to serve as onsite HCFS resource 

and liaison to research 

team

Conduct HCFS with 

HDM clients prior to 

full HCFS roll-out

Develop a web-based 

portal to increase ease 

of HCFS 

documentation

Review rates of HCFS 

adoption

Action target HDM assessment staff Assistant director of 

nutrition programs

HDM assessment staff IT department; 

documentation systems

HDM assessors

Dose 1-hour in-person

training; 1-hour online

training

2-hour review of

administration and

documentation of

HCFS

1-month pilot of

staffing administering

the HCFS with HDM

clients

Development of the 

30-item web-based

HCFS

Monthly chart review 

of completed HCFS

Temporality Initial in-depth training 

in Jan 2020; follow-up 

training in June 2020; 

as needed emails and 

phone calls

Bi-weekly phone calls

with research team;

monthly phone calls

with research team and

assessors

7 HDM assessors

completed up to 10

HCFS with clients

Initial development of 

web-based HCFS; 

modifications to webbased HCFS made 

after pilot testing was 

complete (Jan 2020)

Every month for the 

first 3-months of 

implementation

Outcome HCFS feasibility HCFS feasibility HCFS feasibility HCFS feasibility HCFS feasibility

Justification CFIR-ERIC matching 

tool; agency input

CFIR-ERIC matching 

tool; agency input

CFIR-ERIC matching 

tool; agency input

CFIR-ERIC matching 

tool; agency input

CFIR-ERIC matching 

tool; agency input

574 Note. Table adapted from Proctor et al.’s recommendations for specifying implementation strategies (20). HCFS = Home Care Frailty Scale; HDM = home-delivered 

575 meal; IT = information technology. CFIR = Consolidated Framework for Implementation Research; ERIC = Expert Recommendations for Implementing Change.

576 
577

578
HDM frailty implementation

17

579

580

581
HDM frailty implementation

18

582

583 

584 

585 

586 This project was supported, in part by grant number 90INNU0016, from the Administration for 

587 Community Living, U.S. Department of Health and Human Services, Washington, D.C. 20201. 

588 Grantees undertaking projects with government sponsorship are encouraged to express freely their 

589 findings and conclusions. Points of view or opinions do not, therefore, necessarily represent official 

590 ACL policy. 
Appendix F: Yard Sign (Partner and Volunteer)
This project was supported, in part by grant number 90INNU0016, from the Administration for Community Living, U.S. Department of Health and Human 

Services, Washington, D.C. 20201. Grantees undertaking projects with government sponsorship are encouraged to express freely their findings and conclusions. 

Points of view or opinions do not, therefore, necessarily represent official ACL policy.
This project was supported, in part by grant number 90INNU0016, from the Administration for Community Living, U.S. Department of Health and Human 

Services, Washington, D.C. 20201. Grantees undertaking projects with government sponsorship are encouraged to express freely their findings and conclusions. 

Points of view or opinions do not, therefore, necessarily represent official ACL policy.
Appendix G: SixtyPLUS Magnet
This project was supported, in part by grant number 90INNU0016, from the Administration for Community Living, U.S. Department of Health and 

Human Services, Washington, D.C. 20201. Grantees undertaking projects with government sponsorship are encouraged to express freely their 

findings and conclusions. Points of view or opinions do not, therefore, necessarily represent official ACL policy.
Appendix H: Partner Presentation
Overview of Organization

Mission Statement

LifeCare Alliance leads our community in identifying and delivering health and 

nutrition services to meet the community's changing needs. 

About Us

• Located in Columbus, Ohio, LifeCare Alliance was founded in 1898 and currently 

provides a wide array of services, including home-delivered meals, congregate 

dining centers, diabetes counseling, homemaker services, and wellness centers.

• LifeCare Alliance delivers hot meals 365 days a year through its home-delivered 

meal congregate meals programs to over 8,000 consumers annually.

• LifeCare Alliance nutrition programs services five Ohio counties: four rural; one 

urban/suburban- Champaign, Franklin, Madison, Marion, and Logan

• LifeCare Alliance also has several “social entrepreneurship” ventures, including LA 

Catering, Corporate Wellness, and Adult Immunizations.
LifeCare in Marion County

• 225 Clients served in 

2020 to Date

• 149 Clients currently 

being served through 

home delivered meals 

• 26,541 meals delivered 

in 2019

• 21,609 in 2020 through 

July 31

• 10% of clients are 90 

years or older

• 58% live alone

• 20% live with their 

spouse 

• 90% of clients are in 

Marion proper

• Over 50% have diabetes
How did we get here?

• In 2018, noticed more referrals from EMS services and 

started researching community paramedicine. 

• Starting offering in home diabetes counseling and 

online referral system. 

• Looked for ways to continue partnerships, grow reach, 

and collect data on interventions.

• Awarded an Innovations in Nutrition Programs and 

Services grant through Administration of Community 

Living

• Only 1 of 7 group awarded this grant, and only one in 

the Midwest region

• Allows us to expand services to rural areas
Marion County “Silver Tsunami”
SixtyPLUS is Born! 

What is it?

SixtyPLUS bridges the gap between the 

healthcare and community-based service 

systems, to ensure the safety and wellbeing of 

seniors. 

Together, we can position our community to 

meet the growing demand of seniors.
SixtyPLUS: a New Program! 

How It Works 

• Through strategic partnerships with first responders, 

medical professionals, discharge planners, etc., LifeCare

Alliance intervenes to provide non-emergency assistance in 

the home, reducing seniors’ reliance on excessive 

emergency resources. 

• A few basic helps in the home — such as meals, wellness 

checks, or diabetes management — can help seniors to 

remain safe, independent, and in their own homes, where 

they want to be!

• Partners will securely share relevant data with LifeCare

Alliance to identify senior needs and, over time, measure 

improvements in both service delivery and client outcomes.
Meet Ronald

• 75 year old male, lives alone, family lives in 

Maryland

• Diabetes, COPD, High Blood Pressure

• Loves his 2 Chihuahuas and the Price is Right

• Calls 9-1-1 every other week because blood 

sugar spikes. Forget to check blood sugar 

regularly. 
SixtyPLUS: A New Program!! 
Let’s Help Ronald

• We all want Ronald to improve/maintain his health

LifeCare Interventions:

• In home (or phone) assessment of needs; additional 

referral made as needed

• Offer him weekly frozen meals, selected with our dietitians 

to work with his diabetes

• Offer in home diabetes counseling at no cost to him

• Client reports falls in shower- shower chair provided 

through LifeCare

• Bring pet food to his dogs every other week

• Weekly wellness check- report on blood sugar testing

– Report back to Fire Department if client out of compliance
You Refer, We Deliver- Literally 

• Meal delivery can start immediately next day 

(Monday-Friday)

• Daily or weekly wellness check catered to the 

request of the partner

– Client to check blood pressure

– Client to check A1C

– Client to get out of bed before Meals-on-Wheels 

delivered

– Did the client eat breakfast?
One Stop Easy Referral Portal 

• https://www.lifecarealliance.org/referral/
SixtyPLUS

What’s In It For You? 

• Become a part of a growing central Ohio network of 

community partners who are paving the way nationally for 

a long-term solution to meet an increasing demand for 

senior care. 

• By measuring and evaluating service delivery and client 

outcomes, the project sets central Ohio apart as a leader. 

• When you partner with LifeCare Alliance, we provide:

– Collaborative analysis of local data to verify the project’s success 

– Targeted marketing materials to distribute to senior patients

– Shared media and press releases to highlight the innovative 

partnership
Partners

Current Partnerships:

• Fire Departments: 

– Jackson Township 

– Norwich Township

– Prairie Township

– Truro Township

• Researcher from The Ohio State University

• Administration for Community Living

• Local Area Agency on Aging

• Meals-on-Wheels of America
Importance of Data Collection 

• Can always make 

referrals

• MOU/BAA

• Enhanced 

partnership

• Frailty Scale to 

support our 

findings
Thank You!

Contact: 

Fannisha Page

Client and Community Liaison

614-437-2881

Fpage@lifecarealliance.org
Questions and Next Steps

This project was supported, in part by grant number 90INNU0016, from the Administration for Community 

Living, U.S. Department of Health and Human Services, Washington, D.C. 20201. Grantees undertaking projects 

with government sponsorship are encouraged to express freely their findings and conclusions. Points of view or 

opinions do not, therefore, necessarily represent official ACL policy.
Appendix I: Partner Meeting Questions
Partner Meeting Questions

Assessment of Partnership so far?

What/any has been beneficial for your department?

Has info sharing (BAA) been useful? Being utilized?

Have the referrals made resulted in any noticeable difference?

How many runs per year?

Is staff aware of partnership?

-of available services (MOWs vs nutrition counseling)/

-of how to refer?

-do they connect importance of good nutrition to fall reduction?

Are we capturing “frequent flyers”? (what metric designates that? How often?)

How can we capture this info?

Is there any way to follow-up with 60+ callers who call 911?

Is this an area you need help addressing?

Any benefit for you to review list of LCA clients in your county? Any known to 

you?

Would you like any follow-up from us after a referral is received?

Any other info/data you might want from us? How often?

What is currently limiting referring to LCA? Barriers?

Would a regular presence/contact be helpful? (or maybe presentations, 

bulletins, etc?)

What would you like to see from us in next 8 months?

Would you like to continue partnership?

Are you considering a paramedicine position for your department in future? 

(Factors to be considered?)

This project was supported, in part by grant number 90INNU0016, from the Administration for 

Community Living, U.S. Department of Health and Human Services, Washington, D.C. 20201. Grantees 

undertaking projects with government sponsorship are encouraged to express freely their findings and 

conclusions. Points of view or opinions do not, therefore, necessarily represent official ACL policy.
Appendix J: Functional Home Assessment
Functional Home Assessment Date_____________

Name: ___________________________________ DOB: ____________ Age: ________ Veteran? ______

Address: ________________________________________________ Phone: _______________________

Referred by: ________________________ Reason: ___________________________________________

House/Condo/Apt/Complex Rent/Own___months/years Drives Y/N Rural/urban/suburban

Occupants of home___________________________________________

Services Utilized_______________________________________________________________________

Concerns of client/other_________________________________________________________________

Physical Function

Health Hx/Disability_____________________________________________________________________

Ht______ Wt______ Vision____________________________ Hearing__________________________

R/L dominant Cognition________________________________________________________________

Pain issues_______________________________________________________________

Adaptive Equipment Utilized______________________________________________________________

Endurance/Activity Tolerance_____________________________________________________________

Fall Hx/Balance issues___________________________________________________________________

TUG score________________________ or Functional Reach score_______________________

Grip strength: R________________________________ L_______________________________________

UE function___________________________________ LE function_______________________________

Mobility/Transfers/Stairs________________________________________________________________

ADLs_________________________________________________________________________________

IADL concerns_________________________________________________________________________

Meal prep/nutritional barriers____________________________________________________________

Home Environment

Parking lot/street parking/driveway/garage_________________ Most used entrance______________

Auto doors/security doors/elevator Entrance/door: Width____________Threshold______________

Steps/ramp_________________________________ Handrail_________________________________

Additional entrance/exterior notes_________________________________________________________

_____________________________________________________________________________________

Mailbox house/curb/lobby_____________________ refuse____________________________________
Bathroom 1st/2nd floor door___________________________ threshold_________________________

Toilet round/elongated Ht______ grab bars________________________________________________

Step-in Shower/Tub step ht______ ext ht______ int ht________ lip edge_______ bottom width______

Grab bars______________________________________________Flooring________________________

Tub material______________________________ Wall material_________________________________

Shower head/hand-held/slide bar Sliding door/Curtain R/L entry Faucets knobs/lever

Sink vanity/wall-mount/pedestal Ht_____ W______D_______ Knob/lever Lighting_________________

Layout/accessibility/additional notes: ______________________________________________________

_____________________________________________________________________________________

Bedroom 1st/2nd floor Door__________________ Lighting____________________________________

Bed size_________ Ht______ W______ Closet access___________________ Phone______________

Kitchen_______________________________________________________________________________

_____________________________________________________________________________________

Living Room___________________________________________________________________________

Basement___________________________________________________________________________

Laundry_____________________________________________________________________________

Noted fall hazards______________________________________________________________________

Phones_____________________________ Smoke detector____________ CO2 detector___________

Additional Notes 

_____________________________________________________________________________________

_____________________________________________________________________________________

_____________________________________________________________________________________

_____________________________________________________________________________________

_____________________________________________________________________________________

Recommendations/Action Taken

_____________________________________________________________________________________

_____________________________________________________________________________________

_____________________________________________________________________________________

_____________________________________________________________________________________

This project was supported, in part by grant number 90INNU0016, from the Administration for 

Community Living, U.S. Department of Health and Human Services, Washington, D.C. 20201. Grantees 

undertaking projects with government sponsorship are encouraged to express freely their findings and 

conclusions. Points of view or opinions do not, therefore, necessarily represent official ACL policy.
Appendix K: SixtyPLUS Project Columbus
Innovating Care 

for Ohio’s Seniors

SixtyPLUS bridges the gap 

between the healthcare and 

community-based service 

systems, to ensure the safety 

and wellbeing of seniors.

Together, we can position 

our community to meetthe

growing demand.

Percentage of Population Age 65+ in Ohio, 2000-2050

20%

18%

16%

14%

2000 2010 2020 2030 2040 2050

Above: The share ofOhioanswho are aged 65 and above is projected

to rise steadilyin the coming decades, according to a 2019 report from 

the Scripps Gerontology Center at Miami University. SixtyPlus aims 

to provide innovative solutionsto meet the demand forseniorservices.

SixtyPLUS: A National Model for Success

HowItWorks

Through strategic partnerships 

with first responders, medical 

professionals, discharge planners, 

etc., LifeCare Alliance intervenes to 

provide non-emergency assistance 

in the home, reducing seniors’ 

reliance on excessive emergency

resources.

A few basic helps in the home — 

such as meals, home repairs, or 

chronic disease management — 

can help seniors to remain safe, 

independent, and in their own 

homes, where they want to be!

Partners will securely share 

relevant data with LifeCare Alliance 

to identify senior needs and, over 

time, measure improvements in 

both service delivery and client

outcomes.

What’s In It For You?

Become a part of a growing central 

Ohio network of community 

partners who are paving the way 

nationally for a long-term solution 

to meet an increasing demand

for senior care. By measuring and 

evaluating service delivery and 

client outcomes, the project sets 

central Ohio apart as a leader.

When you partner with LifeCare 

Alliance, we provide:

• Collaborative analysis of local 

data to verify the project’s 

success

• Targeted marketing materials 

to distribute to senior patients

• Shared media and press 

releases to highlight the 

innovative partnership

A United Front

Distressed senior calls 911 

for non-emergency help.

Public safety agencies 

respond, assessing need.

Senior referred to LifeCare 

Alliance forservices.

Long-term case 

management established.

Contact

To get started, contact: 

Fannisha Page

Community and Client Liaison 

614-437-2881

fpage@lifecarealliance.org

LifeCare Alliance • 1699West Mound Street • Columbus, OH 43223 • 614-278-3130 • www.lifecarealliance.org
SixtyPLUS: About This Project

MARION

LOGAN

CHAMPAIGN

MADISON

FRANKLIN

Above: LifeCare Alliance servesseniors and people with medicalchallenges or disabilitiesin five central 

Ohio counties — Franklin, Madison, Marion, Champaign, and Logan.

How Is This Program Possible? 

LifeCare Alliance is one of seven 

nonprofits chosen from a nationwide

pool of applicants to study the

effectiveness of services offered to 

seniors in American communities.

Through this study, called SixtyPLUS and funded by the Administration 

for Community Living, LifeCare Alliance will help create a national 

model to address the needs of the nation’s growing senior population. 

We will implement unique and innovative partnerships with fire 

departments, hospital systems, and healthcare providers while 

collecting accurate data that represent the true impact of our services.

Together, we can “bridge the gap” between the healthcare system and 

the community-based service system for the betterment of our seniors.

The Need

More than 48 percent of Ohioans aged 75 years and older 

live with a “functional difficulty,” according to 2015 data 

from the U.S. Census Bureau. As Ohio’s senior population 

continues to grow, communities will need to address the 

unique challenges faced by their older-adult residents.

% of Adults Age 75+ with Functional Difficulties, by Type, 2015

Any difficulty 48.3%

Hearing 21.8%

Vision 9.1%

Cognitive 12.7%

Ambulatory 31%

Self-Care 12.3%

Independent Living 23.8%

0% 10% 20% 30% 40% 50%

Source: U.S. Census Bureau. 2013-2017 American Community 

Survey (ACS) 5-Year Summary File. Integrated Public Use Microdata 

Sample, National Historical Geographic Information Systems 

(IPUMS NHGIS), www.nhgis.org. Compiled by Scripps Gerontology 

Center at Miami University.

Formed in 1898, LifeCare Alliance provides a comprehensive array of health and nutrition services to older 

adults and individuals living with a medical challenge or disability in central Ohio—keeping them safe, 

independent, and in their own homes, where they want to be! LifeCare Alliance operates a national model 

forits programs, leading in volunteer engagement, effective mergers, and social entrepreneurship. A notfor-profit organization, the Agency’s mission is to lead the community in identifying and delivering health 

and nutrition services to meet the community’s changing needs.

Meals-on-Wheels—Franklin, Madison, Marion, Champaign, and Logan Counties 

Senior Dining Centers | Wellness Centers | Help-at-Home | Visiting Nurses 

The Columbus Cancer Clinic | Project OpenHand-Columbus | Groceries-to-Go

IMPACT Safety | Central Ohio Diabetes Association | Senior PetCare | L.A. Catering

L.A. Wellness Works | Travel Vaccines and Immunizations | Meals-for-Kids | Carrie’s Café

This project was supported, in part by grant number 90INNU0016, from the Administration for Community Living, U.S. Department of Health and Human Services, 

Washington, D.C. 20201. Grantees undertaking projects with government sponsorship are encouraged to express freely their findings and conclusions. Points of 

view or opinions do not, therefore, necessarily represent official ACL policy.

1699 West Mound Street 

Columbus, OH 43223

o@lifecareallianc

w e.org

inf

614-278-3130

e.org 

ww.lifecareallianc
Appendix L: Business Associate Agreement
BUSINESS ASSOCIATE AGREEMENT

THIS BUSINESS ASSOCIATE AGREEMENT (“Agreement”) between FILL HERE

(“Business Associate”) and ORGANIZATION (“Covered Entity”) is to allow the parties to 

comply with the provisions of 45 C.F.R. Parts 160 and 164 (“Privacy Rule”) and Parts 160, 162, 

and 164 (“Security Rule”) of the federal Code of Regulations dealing with confidentiality and 

security of health or health-related information, as well as the requirements of the Health 

Information Technology for Economic and Clinical Health Act, as incorporated in the American 

Recovery and Reinvestment Act of 2009 (the “HITECH Act”), and any regulations issued by the 

United States Department of Health and Human Services (“DHHS”). 

SECTION 1. DEFINITIONS

Terms used but not otherwise defined in this Agreement shall have the same meaning as used in 

the Health Information Portability and Accountability Act of 1996, as amended, and all 

regulations promulgated thereunder by the United States Department of Health and Human 

Services (“HIPAA”).

1.1. “Protected Health Information” or “PHI” shall have the same meaning as the term 

“protected health information” in 45 C.F.R. 160.103, limited to information created or 

received by Business Associate from or on behalf of Covered Entity. 

1.2. “Individual” shall have the same meaning as the term “individual” in 45 C.F.R. 160.103 

and shall include a person who qualifies as a personal representative in accordance with 45 

C.F.R. 164.502(g). 

1.3. “Required By Law” shall have the same meaning as the term “required by law” in 45 

C.F.R. 164.103. 

1.4. “Secretary” shall mean the Secretary of the Department of Health and Human Services or 

his/her designee.

SECTIONS 2. PERMITTED USES AND DISCLOSURES OF PHI

2.1. Business Associate may use or disclose Protected Health Information to perform 

functions, activities, or services for, or on behalf of, Covered Entity as specified, 

provided that such use or disclosure would not violate the Privacy Rule or HITECH Act 

if done by Covered Entity. 

2.2. Business Associate may use Protected Health Information it creates or receives from 

Covered Entity for the proper management and administration of Business Associate or 

to carry out the legal responsibilities of Business Associate.

2.3. Business Associate may disclose such Protected Health Information as necessary for 

Business Associate’s proper management and administration or to carry out Business 

Associate’s legal responsibilities only if:

a. The disclosure is required by law; or 

b. Business Associate obtains reasonable assurance from any person or organization to 

which Business Associate will disclose such PHI that the person or organization 

will:
i. Hold such PHI in confidence and use or further disclose it only for the purpose 

for which Business Associate disclosed it to the person or organization or as 

required by law; and 

ii. Promptly notify Business Associate (who will in turn promptly notify Covered 

Entity) of any instance of which the person or organization becomes aware in 

which the confidentiality of such PHI was breached. 

2.4. Business Associate’s use, disclosure or request of PHI shall utilize a Limited Data Set if 

practicable. Otherwise, Business Associate will make reasonable efforts to use, disclose, 

and to request of a Covered Entity only the minimum amount of PHI reasonably 

necessary to accomplish the intended purpose. However, Business Associate will not be 

obligated to comply with this minimum necessary limitation with respect to any use or 

disclosure that is excepted from the minimum necessary limitation as specified in 45 C. 

F. R. 164.502(b)(2).

2.5. Business Associate may de-identify and use any and all Protected Health Information 

created or received by Covered Entity under this Agreement, provided that the deidentification conforms to the requirements of the Privacy Rule. Such resulting deidentified information shall not be subject to the terms of this Agreement.

2.6. Business Associate may use Protected Health Information to report violations of law to 

appropriate federal and state authorities, consistent with 42 C. F. R. 164.502(j)(1).

SECTIONS 3. OBLIGATIONS AND ACTIVTIES OF BUSINESS ASSOCIATE

3.1. Business Associate agrees to not use or disclose Protected Health Information other than 

as permitted or required by this Agreement or any other agreement with Covered Entity 

or as Required by Law. 

3.2. Business Associate agrees to establish and maintain appropriate administrative, 

technical, and physical safeguards that reasonably protect the confidentiality of PHI 

from any intentional or unintentional use or disclosure in violation of the Privacy Rule.

3.3. Business Associate agrees to establish and maintain appropriate administrative, 

technical, and physical safeguards that reasonably and appropriately protect the 

confidentiality, integrity, and availability of electronic PHI that Business Associate 

creates, receives, maintains, or transmits on Covered Entity’s behalf as required by the 

Security Rule and the HITECH Act. Business Associate will also develop and 

implement policies and procedures to meet the Security Rule documentation 

requirements as required by the HITECH Act. 

3.4. Business Associate agrees to promptly report to Covered Entity any security incident or 

unauthorized use or disclosure of the Protected Health Information of which it becomes 

aware. For purposes of this agreement, a “security incident” means the attempted or 

successful unauthorized access, use, disclosure, modification, or destruction of PHI or 

interference with Business Associate’s system operations in Business Associate’s 

information systems. This does not include routine, unsuccessful attempts that occur on 

a daily basis, including but not limited to pings on Business Associate’s firewall, port 

scans, attempts to log on to Business Associate’s system to enter a database with an 
invalid password or username, or unsuccessful attempts to penetrate computer networks 

or servers maintained by the Business Associate. 

3.5. Business Associate will report, following discovering and without unreasonable delay, 

any “Breach” of “Unsecured Protected Health Information” as these terms are defined 

by the HITECH Act and any implementing regulations. Business Associate will 

cooperate with Covered Entity in investigating the Breach and in meeting Covered 

Entity’s obligations under the HITECH Act and any implementing regulations. Any 

such report will:

a. Include the identification (if known) of each individual whose Unsecured PHI has 

been, or is reasonably believed by Business Associate to have been, accessed, 

acquired, or disclosed during such Breach; 

b. Identify the nature of the non-permitted access, use or disclosure, including the date 

of the Breach and the date of discovery of the Breach; 

c. Identify the PHI accessed, used or disclosed as part of the Breach; 

d. Identify who made the non-permitted access, use or disclosure and who received the 

non-permitted disclosure; 

e. Identify what corrective action Business Associate took or will take to prevent 

further non-permitted access, use or disclosures: and 

f. Identify what Business Associate did or will do to mitigate any deleterious effect of 

the non-permitted access, use or disclosure. 

3.6. Business Associate agrees to ensure that any agent, including a subcontractor, to whom

it provides Protected Health Information received from or created or received by 

Business Associate on behalf of Covered Entity agrees to the same restrictions and 

conditions that apply through this Agreement to Business Associate with respect to such 

information. 

3.7. Within 15 days following Covered Entity’s request, Business Associate will make 

available to Covered Entity or, at Covered Entity’s request, an Individual (or the 

individual’s personal representative) any PHI about the Individual that is in Business 

Associate’s custody or control, so the Covered Entity may meet its access obligations 

under 45 C. F. R. 164.524 and, where applicable, the HITECH Act. 

3.8. Business Associate will, upon receipt of notice from Covered Entity, promptly amend or 

permit Covered Entity access to amend any portion of the PHI which Business Associate 

created for or received from Covered Entity, so that Covered Entity may meet its 

amendment obligations under 45 C. F. R. 164.526. 

3.9. Business Associate agrees to make its internal practices, policies and procedures, books 

and records pertaining to its use and disclosure of Protected Health Information, 

available to the U.S. Department of Health and Human Services to determine 

compliance with HIPAA or this Agreement.

3.10. Business Associate agrees to document and record disclosures of Protected Health 

Information and information related to such disclosures as would be required for 

Covered Entity to meet its disclosure accounting obligations under 45 C. F. R. 164.528. 
a. Business Associate will make the disclosure information available to Covered Entity 

within 15 days following Covered Entity’s request for such disclosure information 

to comply with an individual’s request for disclosure accounting.

b. Where Business Associate is contacted directly by an individual based on 

information provided to the individual by Covered Entity, and where so required by 

the HITECH Act and/or any accompanying regulations, Business Associate will 

make such disclosure information available directly to the individual.

c. Except for repetitive disclosures of PHI as specified below, Business Associate will 

record for each accountable disclosure: (i) the disclosure date, (ii) the name and (if 

known) address of the person of entity to which Business Associate made the 

disclosure; (iii) a brief description of the PHI disclosed; and (iv) a brief statement 

of the purpose of the disclosure. Business Associate will provide any additional 

information to the extent required by the HITECH Act and any accompanying 

regulations. 

d. For repetitive accountable disclosures of PHI that Business Associate makes for a 

single purpose to the same person or entity (including Covered Entity), Business 

Associate will record (i) the disclosure information specified in Section 3.9(a) 

above for the first of the repetitive disclosures; (ii) the frequency, periodicity, or 

number or number of the repetitive accountable disclosures; and (iii) the date of the 

last of the repetitive accountable disclosures. 

e. Unless otherwise provided under the HITECH Act, Business Associate will 

maintain the disclosure information for 6 years following the date of the accountable 

disclosure to which the disclosure information relates.

SECTIONS 4. OBLIGATIONS OF COVERED ENTITY

4.1. Covered Entity shall be responsible for using appropriate administrative, physical and 

technical safeguards to maintain and ensure the confidentiality, privacy, and security of 

Protected Health Information transmitted to Business Associate pursuant to this 

Agreement in accordance with the standards and requirements of the Privacy and 

Security Rules, until such Protected Health Information is received by Business 

Associate.

4.2. Covered Entity shall notify Business Associate of any limitation(s) in its notice of 

privacy practices of Covered Entity in accordance with 45 C. F. R. 164.520, to the extent 

that such limitation(s) may affect Business Associate’s use or disclosure of Protected 

Health Information. 

4.3. Covered Entity will obtain any authorizations necessary for the use or disclosure of 

Protected Health Information so that Business Associate can perform its obligations 

under this Agreement and/or the underlying services agreement.

4.4. Covered Entity shall notify Business Associate of any changes in, or revocation of, 

permission by an Individual to use or disclose Protected Health Information, to the 

extent that such changes may affect Business Associate’s use or disclosure of Protected 

Health Information.
4.5. Covered Entity shall notify Business Associate of any restriction to the use or disclosure 

of Protected Health Information that Covered Entity has agreed to in accordance with 45 

C. F. R. 164.522, to the extent that such restriction may affect Business Associate’s use 

or disclosure of Protected Health Information. 

4.6. Covered Entity shall not request Business Associate to use or disclose Protected Health 

Information in any manner that would not be permissible under the Privacy Rule if done 

by Covered Entity, except as such use or disclosure by Business Associate is otherwise 

allowed under the Agreement for data aggregation and/or management and 

administrative activities of Business Associate.

SECTIONS 5. TERM AND TERMINATION

5.1. Term. The term of this Agreement shall be effective as of the date this Agreement is 

signed by both parties, and shall terminate when all of the Protective Health Information 

provided by Covered Entity to Business Associate, or created or received by Business 

Associate on behalf of Covered Entity, is destroyed or returned to Covered Entity, or, if 

it is infeasible to return or destroy Protected Health Information, protections are 

extended to such information, in accordance with the termination provisions in this 

Section.

5.2. Termination for Cause. Upon Covered Entity’s knowledge of a material breach of this 

Agreement by Business Associate that is directly related to the impermissible use or 

disclosure of Protected Health Information, Covered Entity shall either: 

5.2.1 Provide an opportunity for Business Associate to cure the breach or end the 

violation; provided that the Covered Entity may terminate this Agreement and any 

underlying services agreement if Business Associate does not cure the breach or end the 

violation within a reasonable period of time; or 

5.2.2 Immediately terminate this Agreement and any underlying services agreement if a 

cure is not possible. 

5.3. Effect of Termination.

5.3.1 Except as provided in Section 5.3.2, upon termination of this Agreement for any 

reason, Business Associate shall return or destroy all Protected Health Information 

received from Covered Entity, or created or received by Business Associate on behalf of 

Covered Entity. This provision shall also apply to Protected Health Information that is in 

the possession of subcontractors or agents of Business Associate. Business Associate 

shall retain no copies of the Protected Health Information. 

5.3.2 In the event that Business Associate determines that returning or destroying the 

Protected Health Information is infeasible, Business Associate shall provide to Covered 

Entity notification of the conditions that make return or destruction infeasible. Upon 

providing such notice that return or destruction of Protected Health Information is 

infeasible, Business Associate shall extend the protections of this Agreement to such

Protected Health Information and limit further uses and disclosures of such Protected 
Health Information to those purposes that make the return or destruction infeasible, for so 

long as Business Associate maintain such Protected Health Information. 

5.3.3 The respective rights and obligations of Business Associate under this Sections 5.3 

shall survive the termination of this Agreement.

SECTIONS 6. MISCELLANEOUS

6.1. Amendment. Upon the effective date of any final regulation or amendment to final 

regulations promulgated by the U.S. Department of Health and Human Services with 

respect to PHI, the Security or Privacy Rule, or the HITECH Act, the parties agree this 

Agreement shall be automatically amended as appropriate such that the obligations they 

impose on the parties remain in compliance with the most current regulations; provided, 

however, that if Business Associate provides written notice to Covered Entity that is 

unable to comply with the amended last, then either party may terminate this Agreement 

and any underlying services agreement upon thirty (30) days written notice to the other. 

6.2. Interpretation. Any ambiguity in this Agreement shall be resolved to permit the 

parties to comply with HIPAA.

6.3. Certain Provisions Not Effective in Certain Circumstances. The provisions of this 

Agreement relating to the HIPAA Security Rule shall not apply to Business Associate if 

Business Associate does not receive any Electronic PHI from or on behalf of Covered 

Entity.

IN WITNESS WHEREOF, the parties have caused this Agreement to be executed as of the 

Effective Date set forth in Section 5.1 

____________________________ ______________________________ 

____________________________ ______________________________ 

Printed Name Printed Name

____________________________ ______________________________ 

Printed Title Printed Title 

____________________________ ______________________________ 

Date Date

This project was supported, in part by grant number 90INNU0016, from the Administration for 

Community Living, U.S. Department of Health and Human Services, Washington, D.C. 20201. Grantees 

undertaking projects with government sponsorship are encouraged to express freely their findings and 

conclusions. Points of view or opinions do not, therefore, necessarily represent official ACL policy.
Appendix M: Patient Referral Form
LifeCare Alliance · Patient Referral Form

1699 W. Mound St · Columbus, OH 43223

Phone: 614-278-3141 · Fax: 614-278-3143 · Email: referral@lifecarealliance.org

Client ID# LifeCare Alliance RD’s Name (if applicable)

© 2017 LifeCare Alliance. All rights reserved. V.1711JS

• Referring Agencies: Please complete sections A, B and C of this form.

• Physician’s Offices: Please complete sections D and E of this form.

A. Referring Agency Today’s Date:

Agency Representative Making Referral:

Phone Number: Email Address:

1. As the Referring Agency representative, I have communicated the service basics and referral process for the identified LifeCare Alliance

services checked on this form to the below patient. ☐ Yes ☐ No

2. The patient referenced on this form agrees to proceed with the assessment process for the identified service(s). ☐ Yes ☐ No

If you answered no to either #1 or #2 above, provide background information so that we may proceed with initiating service:

B. PATIENT INFORMATION

Patient Name:

DOB:

Phone Number:

Street Address:

City, State:

Zip:

Emergency Contact:

Emergency Contact Relationship:

Emergency Contact Phone:

Primary Insurance:

Member ID #:

Group #:
LifeCare Alliance · Patient Referral Form

1699 W. Mound St · Columbus, OH 43223

Phone: 614-278-3141 · Fax: 614-278-3143 · Email: referral@lifecarealliance.org

Client ID# LifeCare Alliance RD’s Name (if applicable)

© 2017 LifeCare Alliance. All rights reserved. V.1711JS

Secondary Insurance:

Member ID #:

Group #:

Patient’s Physician:

Physician’s Fax:

Physician’s Phone:

Veteran ☐ Yes ☐ No If yes, please include a copy of patient’s DD214 with completed referral form, if possible.

Franklin County Senior Options Recipient ☐ Yes ☐ No If yes, provide case manager’s name: Services being 

received, if applicable:

PASSPORT/MyCare Ohio Recipient ☐ Yes ☐ No If yes, provide case manager’s name: Services being received, if 

applicable:

This person receives home-delivered meals already. ☐ Yes ☐ No If yes, what is the meal provider?

C. SERVICES BEING REQUESTED(check all that apply)
LifeCare Alliance · Patient Referral Form

1699 W. Mound St · Columbus, OH 43223

Phone: 614-278-3141 · Fax: 614-278-3143 · Email: referral@lifecarealliance.org

Client ID# LifeCare Alliance RD’s Name (if applicable)

© 2017 LifeCare Alliance. All rights reserved. V.1711JS

Diabetic or Nutritional Counseling Supportive In-Home Services

☐ Medical Nutrition Therapy (MNT) ☐ Home-Delivered Meals*+ – Daily Hot

☐ Diabetes Self-Management Training (DSMT) ☐ Home-Delivered Meals*+ – Weekly frozen

☐ Safety/Wellness Check Only (no meal needed)

Frequency: ☐ Daily ☐ Weekly ☐ Other

Verifying: ☐ Blood pressure ☐Blood sugar

☐ Weight ☐ Other

Report to referring agency when

☐ Meal Preparation

☐ Home Repair Assistance

Other Service – please provide as much detail as possible, explaining service(s) requested:

*Please pick only one.

+Meal customers must be home to receive the

delivery and mustsign/initial delivery receipt.

D. PATIENT MEDICAL HISTORY

ICD DIAGNOSIS CODE(S):

Complete the below for Diabetic or Nutritional Counseling only

MOST RECENT A1C RESULTS:

DATE OF A1C TEST:

LABS:

☐ Labs Enclosed ☐ No Current Labs

MEDICATIONS:

☐ RX List Enclosed ☐ No RX List

E. REFERRING PHYSICIAN (To be completed by physician’s office)

Practice Name:

Phone #:

Fax #:
LifeCare Alliance · Patient Referral Form

1699 W. Mound St · Columbus, OH 43223

Phone: 614-278-3141 · Fax: 614-278-3143 · Email: referral@lifecarealliance.org

Client ID# LifeCare Alliance RD’s Name (if applicable)

© 2017 LifeCare Alliance. All rights reserved. V.1711JS

Street Address:

City, State:

Zip:

PCP/Referring Physician Name (please print):

NPI #:

Medicare #:

PCP/Referring Physician Signature: 

Date Signed: 

This project was supported, in part by grant number 90INNU0016, from the Administration for Community Living, U.S. Department of Health and 

Human Services, Washington, D.C. 20201. Grantees undertaking projects with government sponsorship are encouraged to express freely their 

findings and conclusions. Points of view or opinions do not, therefore, necessarily represent official ACL policy.
Appendix N: Registered Dietitian Call Tracker
SixtyPLUS: Registered Dietitian Call Tracker

MOW Tracker Tab: Used for entering client names, dates, and services received from a Registered Dietitian

Columns include: Last Name, First Name, Date of Referral, Client ID, Type of Referral, Source of Referral, Funding Source, Action Taken by Case Manager, Primary 

Service Type, Sub-Service Type 1, Sub-Service Type 2, Notes

This project was supported, in part by grant number 90INNU0016, from the Administration for Community Living, U.S. Department of Health and Human 

Services, Washington, D.C. 20201. Grantees undertaking projects with government sponsorship are encouraged to express freely their findings and conclusions. 

Points of view or opinions do not, therefore, necessarily represent official ACL policy.
Report Tab: Used to compile client services from MOW tab into a comprehensive report
Calls YTD Tab: Used to track number of calls over a 12-month period (2022 vs. 2021)