DELIVERING MORE 

THAN A MEAL
MEASURING SUCCESS

Are we making a difference?

2
WHY OUTCOMES MATTER FOR MEALS ON WHEELS PROGRAMS

3
WHY OUTCOMES MATTER

What are we doing right?

What improvements are needed?

New funding possibilities?

We provide valuable service to a large population but the lack of data has led to lack of 

evidence-based need for our services.

“How do we demonstrate a need beyond outputs?

(Thomas 2015)

Outputs- a measurement of something your organization does– “producing 3000 

meals/day”

Outcomes- a measurement of the impact your organization has– “improved nutrition 

status in x clients after 3 months of meals”

“Quality in a product or service is not what the 

supplier puts in. It is what the Customer gets 

out.”

-Peter Drucker (1909-2005)
OK, SO......WHAT DO WE 

MEASURE??
ROLE OF PROVIDERS IN MEETING OLDER ADULT WELLNESS 

NEEDS

FOUNDATIONAL PURPOSE

• Reduce hunger, food insecurity and

malnutrition of older adults

• Promote socialization of older adults

• Promote health and well-being in older

people (nutrition education and

nutrition support)

6
IMPACT OF MEALS

Past SEVERAL Decades

• Nutrient intake is lower in homebound population

• On the days HDM participants do NOT receive a meal, their nutrient intake is

significantly lower

• Homebound population is at an even higher risk of poor nutrition status than

independent older adult counterparts

• HDM Meal contributes markedly to the participants’ intake

NOW– PAST DECADE: More work is being done to show whether we impact

- Malnutrition

- Food insecurity

- Healthcare Expenditures

- Chronic disease management

Fayrouz et al 2021, Fleury et al 2021, Ullevig et al 2018, Wright et al 2015, Sahyoun and Vaudin 2014, Zhu and An 

2013, Dasgupta et al 2005, Sharkey et al 2003, Sharkey et al 2022, Krondl et al 2003, Lokken et al 2002, Millen et al 

2001, MacLellan 1997, Ritchie 1997, Goth et al 1996, Herndon 1996, Payette 1995, Stevens et al 1992, Bunker et al 

1986, Lipshitz et al 1985, Davies et al 1981

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MEASURING IMPACT ON MALNUTRITION

8
TRAINING GUIDE

https://www.mna-elderly.com/
MINI NUTRITIONAL ASSESSMENT (MNA)
MINI NUTRITIONAL ASSESSMENT (MNA) CONTINUED

• Full MNA validated & considered Gold Standard (MDs

assessments, biochemical, anthropometrics)

• Extensively tested for validity, sensitivity, specificity,

reliability

• MNA validated & has high specificity, sensitivity, and

diagnostic accuracy

• MNA most appropriate for elderly community setting

(when compared with other tools)

Guigoz, Vellas, & Garry, 1994; Guigoz et al., 1996, Sieber, 2006, Green & Watson, 2006, Rubenstein et al., 2001, Kaiser et al., 2009, Wikby et al., 2008; Cuervo et al., 

2008, Isenring et al., 2012, Phillips et al 2010
NUTRITION SCREENING INITIATIVE (NSI) AKA NUTRITION RISK ASSESSMENT (NRA)

Nutrition Screening Initiative (NSI) AKA Nutrition Risk Assessment (NRA)

American Academy of Family Physicians, Academy of Nutrition and Dietetics, and National Council on Aging, Inc.

Developed as awareness tool; Does not accurately flag malnourishment

(Phillips et al 2010, Charlton et al 2007, Guigoz 1996, Sayhoun et al 1997, Marshal et al 2001, Quigley et al 2008, Sinett et al 2010)
NUTRITION RISK ASSESSMENT

Pros

 Used widely in HDM; HDM comparison

 Identifies ‘risk factors’- educational purposes

 Quickly administered- 10 ‘yes/no’ questions

Cons

 Lacks validation, has low specificity, & overestimates nutrition risk Phillip et 

al., 2010; Coulston et al., 1996

 Limited effect on ability to detect malnutrition MacLellan & Van Til, 1998

 Designed as an effective awareness/educational tool Sayhoun et al., 1997; Marshal et 

al., 2001

 Uses beyond education?
MNA

Pros

- Full MNA validated & considered Gold Standard (MDs assessments, 

blood work, measurements) Guigoz, Vellas, & Garry, 1994; Guigoz et al., 1996, Sieber, 2006

- Extensively tested for validity, sensitivity, specificity, reliability Green & Watson, 2006

- MNA-SF validated & has high specificity, sensitivity, diagnostic accuracy 

Rubenstein et al., 2001, Kaiser et al., 2009, Wikby et al., 2008; Cuervo et al., 2008, Isenring et al., 2012

- MNA-SF most appropriate for elderly community setting (when 

compared with other tools) Phillips et al 2010

Cons

 Requires Training

 Calf measurement
RESEARCH PROJECT 2010– THESIS WORK

MEALS ON WHEELS CENTRAL TEXAS, AUSTIN, TX
WHAT DID THE TOOLS SHOW?

AFTER MEALS

NSI: ‘HIGH RISK’

28 (70%)

BEFORE MEALS

NSI: ‘HIGH RISK’

31 (77.5%)

MNA-SF: ‘MALNOURISHED’

13 (32.5%)

MNA-SF: ‘MALNOURISHED’

3 (7.5%)

MNA-SF more sensitive to nutrition status change

More people moved out of ‘malnourished’ category versus ‘ high risk’ category
WHAT DID THE TOOLS SHOW? CONTINUED

BEFORE MEALS

NSI: ‘GOOD’

0

MNA-SF: ‘NORMAL STATUS’

8 (20%)

AFTER MEALS

NSI: ‘GOOD’

2 (5%)

MNA-SF: ‘NORMAL STATUS’

19 (47.5%)

MNA-SF more sensitive to nutrition status change

More moved into ‘normal’ category versus ‘good’ category 
SO, LET’S GET STARTED! BRIDGING THE GAP!!

Academic Research Application in 

Community Setting

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FOCUS GROUP WITH CASE MANAGERS

Initial concerns

 “We are not medical professionals”

 Calf Circumference:

 What if the client has weeping wounds?

 Amputations?

 Client not comfortable with measurement?

 Client makes me uncomfortable?

 “Will this increase time of home visit?”
3 MONTH FEASIBILITY PILOT

• Timed both screening tools

• Asked client’s permission to do measurement

• Asked how comfortable client was with measurement

afterwards

• Case manager documented their comfort level with

measurement
RESULTS OF PILOT

• 60 clients screened

• Client Comfort Level (scale of 1-5)= 4.4

• Only 1 client felt uncomfortable with calf circumference measurement 

afterwards

• Case manager comfort level

• Average Time Spent MNA: 3.65 minutes

• Average Time Spent NRA: 3.5 minutes
MNA AT MOWCTX

PROS

• More specific 

• Takes same time

• Is now used to: 

o Program Evaluation

o Prioritize enrollment for second 

meals program

CONS

• Only used on 60+

• If don’t have calf 

circumference- can’t score 

tool

• Does not replace other toolsis an additional tool to use
MNA (PROCESS)
FY 2019

2 out of 3 new Meals on Wheels clients who 

were malnourished or ‘at risk’ improved in just 

3 months

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BOTTOM LINE

MNA strongly supported by research in identifying

malnourished

MNA was a more sensitive indicator of change in nutrition

status in our research

MNA can assist in prioritizing those most in need

Metric now widely desired by Development and Funders
MEALS ON WHEELS PROGRAM SHOWN TO 

SIGNIFICANTLY IMPROVE NUTRITION STATUS 

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MEASURING SUCCESS

IMPACT ON FOOD INSECURITY

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USDA FOOD SECURITY QUESTIONNAIRE

• Food bought didn’t last and didn’t have money to get more

• Couldn’t afford to eat balanced meals

• Ever cut the size of or skip meals because there wasn’t enough

money for food (how often)

• Eat less than you felt you should because wasn’t enough money

for food

• Ever hungry because there wasn’t enough money for food
USDA FOOD SECURITY SURVEY

SCORING GUIDE

0 = High Food Security

1 = Marginal Food Security

2-4 = Low Food Security

5-6 = Very Low Food Security

USES

Prioritize Limited Resources:

• Eligibility for our Breakfast

Meal Program

• Prioritize the most food

insecure (5-6)

Funding cuts
USDA FAQ
IMPROVEMENT IN FOOD INSECURITY (MOW PROGRAM)

New Enrollees identified as Food Insecure 

FY 20

51% 83%

% improvement after 1 Year 

FY 21

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ADDITIONAL OPTIONS AND 

CONSIDERATIONS
HUNGER VITAL SIGN SURVEY
MALNUTRITION SCREENING TOOL (MST)
NEW FOOD SECURITY SCREENING.....JUST FOR OLDER 

ADULTS!

https://www.ncbi.nlm.nih.gov/pmc/articles/PMC8599055/

35
USDA FOOD SECURITY SURVEY CULTURALLY RELEVANT TO 

ALL GROUPS?

• Not necessarily....

• “And, in turn, may result in misunderstandings of the 

survey questions and data that do not quantify the full 

extent of food insecurity”.

• “For example, respondents from Latinx households report 

that ‘running out of food’ is not an issue because there is 

‘always something to make to eat’.” 

• “This disconnect can lead to underestimating the extent of 

severity of food insecurity.”

https://news.txst.edu/research-and-innovation/2021/usda-grant-seeks-to-improve-measurement-offood-insecurity.html

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EXPANDED FOOD SECURITY SCREENER

https://nfsc.umd.edu/extension/expanded-food-security-screener
QUICK TIP

Descriptive Statistic of YOUR Population
DEFINING ‘ECONOMIC INSECURITY’ IN YOUR POPULATION

• % ‘low income’?

• % ‘living in poverty’?

Recommend using: https://elderindex.org/

The Gerontology Institute at the University of Massachusetts 

Boston developed The Elder Index– estimates the minimum 

amount seniors need to meet monthly expenses, based on 

county, household size, housing and health status. 

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ELDER INDEX

40
KEY ACTION ITEM

Explore the use of a tool to measure food insecurity or 

nutrition status (is a nutrition provider of some kind). 

• Operational workflow on onboarding

• What can be done via phone, where in the process

• Discuss with your leadership

• Conduct a feasibility pilot– learn, gain buy in

• Don’t be afraid to fail...Fail Forward...real example SCREEN 

II

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CONTACT INFO

Seanna Marceaux, MS RDN LD

Chief Strategy & Impact Officer

Meals on Wheels Central Texas

smarceaux@mealsonwheelscentraltexas.org

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DELIVERING MORE 

THAN A MEAL