1

1

 People who are homebound 

because of disability, illness, or isolation and are ages 60 and older are 

eligible for home-delivered meals.

June 2020

MATHEMATICA.ORG

IssueBRIEF

Marisa Shenk, James Mabli, Arkadipta Ghosh, and Bob Schmitz, Mathematica

Older Americans Act Title III-C Nutrition 

Services Program: Examining Adverse 

Health Events Preceding Entry to the 

Home-Delivered Meal Program

BACKGROUND

The Older Americans Act Title III-C Nutrition Services Program (NSP) is the largest program in the 

United States that provides prepared meals to older adults in need. Overseen by the Administration 

on Aging (AoA) within the Administration for Community Living of the U.S. Department of Health 

and Human Services (DHHS), the NSP strives to promote the health and well-being of and reduce 

hunger and food insecurity among older adults by providing congregate and home-delivered meals, 

nutrition education, nutrition-risk screening, and nutrition counseling.

Although studies have examined NSP participants’ health outcomes, little is known about whether 

changes in older adults’ health precipitate program entry. Older adults who experience an adverse 

health event such as a hospitalization might learn about the NSP, particularly the availability of 

home-delivered meals, through hospital discharge planners or social workers. To provide patients with 

the most effective hospital-to-home transition program, health care administrators and practitioners 

can link patients to home and community-based services as part of a broader array of long-term care. 

This can help maximize the chances of a successful recovery and decrease the likelihood of hospital 

readmission, particularly for rehospitalizations that occur soon after discharge.

The scarcity of research on how changes in older adults’ health correspond to starting to receive homedelivered meals might be due to the lack of comprehensive, longitudinal data required to assess health 

events and changes in NSP participation over time. To address this gap, the research team combined 

self-reported information identifying when older adults entered the NSP, survey data describing 

their personal characteristics and circumstances, and longitudinal Medicare administrative records 

indicating the types and timing of health events they experienced. 

This issue brief assesses the types and prevalence of adverse health events experienced by new homedelivered meal participants; the timing of these events relative to starting to receive home-delivered 

meals; and how these events varied by participants’ characteristics. These findings can help the AoA, 

local program administrators, and policymakers better understand the types of health events that can 

lead to homebound status among older adults, often resulting in their participation in the homedelivered meal program. Therefore, the findings could help to better understand the specific needs of 

new home-delivered meal participants.1

METHODS

The data used in the analysis were collected as part of the Title III-C NSP Evaluation, which 

Mathematica conducted for AoA (Mabli et al. 2017, 2018). To estimate the effect of receiving a 

congregate or home-delivered meal on a range of outcomes, including food security, health, and 

health care use, the study team compared outcomes for participants and a matched comparison group 

of program-eligible nonparticipants using data collected in surveys conducted in 2015 to 2017, as 

PRINCETON, NJ - ANN ARBOR, MI - CAMBRIDGE, MA - CHICAGO, IL - OAKLAND, CA - SEATTLE, WA 

TUCSON, AZ - WASHINGTON, DC - WOODLAWN, MD
2

2

 Because Medicare claims are not 

available for beneficiaries enrolled in 

managed care plans such as Medicare Advantage, the analysis also 

required participants to be enrolled 

in fee-for-service Medicare (known 

as Original Medicare).

3

 Medicare-covered SNF stays are 

typically no longer than two to three 

weeks’ duration. It is likely, though 

not certain, that meal participation 

began after SNF discharge to home.

well as Medicare claims and enrollment data 

obtained through the Centers for Medicare 

& Medicaid Services (CMS) Research Data 

Assistance Center. Because the evaluation report 

found that home-delivered meal participants were 

more likely than congregate meal participants to 

experience health events, this issue brief focuses 

on pre-program health events experienced by 

home-delivered meal participants only.

The outcomes survey asked participants how 

long ago they first received a home-delivered 

meal. Based on their responses and the dates of 

their interviews, the study team estimated the 

calendar month and year of program entry using 

actual dates if the response was in days or weeks 

or using calendar months if the response was in 

months or years. Because Medicare claims data 

were available starting in January 2015 and the 

first survey interview occurred in October 2015, 

the study team had to limit the analysis to homedelivered meal participants who had recently 

entered the program to have a sufficient number 

of months during which to assess the occurrence 

of health events. For analyses of health events 

over a three-month period before and including 

the month of program entry, the study team 

restricted the original evaluation sample of 310 

home-delivered meal participants with Medicare 

claims to the 84 participants who entered the 

program in April 2015 or later. Similarly, for 

analyses of health events over a six-month period 

before the month of program entry, the study 

team restricted the sample to 42 participants 

who entered the program in July 2015 or later.2

Because these sample sizes are smaller than 

the size of the original evaluation sample, these 

analyses should be considered exploratory.

The analysis also compared the prevalence of 

adverse health events to other groups of older 

adults. It includes 169 ongoing participants who 

reported receiving their first home-delivered meal 

at least one year before their baseline interview 

and 255 nonparticipants who reported that they 

had not participated in the NSP in the year before 

or after their baseline interview. For ongoing 

participants and nonparticipants, the team 

analyzed health events in the three months leading 

up to and including their baseline survey month.

The outcomes analyzed include whether the 

individual experienced adverse health events in 

a three- or six-month window before program 

entry (new participants) or before their baseline 

survey interview (ongoing participants and 

nonparticipants). The following adverse health 

events were examined: hospital admission, 

emergency department visit, home health 

episode, and admission to a skilled nursing 

facility (SNF). Medicare home health episodes 

cover 60-day periods and involve at least one or 

a mix of the following services for homebound 

patients: skilled nursing care; physical, speech, 

or occupational therapy; home health aide; and 

medical social services.

FINDINGS

Incidence of adverse health events 

before program entry

Most new home-delivered meal participants 

experienced an adverse health event in the three 

months before program entry (Table 1). About 

one-third (31 percent) of program entrants had 

a home health episode during this period, 24 

percent had an emergency department visit, and 

22 percent had a hospital admission.

The incidence of any adverse health event was 

greater for new participants (53 percent) in the 

three months before receiving home-delivered 

meals than for ongoing participants (42 percent) 

and nonparticipants (22 percent) in the three 

months before the baseline interview (Table 1). 

This was especially true for inpatient hospital 

admissions, experienced by 22 percent of new 

participants compared to 10 and 2 percent 

of ongoing participants and nonparticipants, 

respectively. Home health episodes were also 

more common (31 percent for participants 

versus 27 percent for ongoing participants and 

6 percent for nonparticipants). Although a small 

share of each group (less than 3 percent) were 

admitted to a SNF, the incidence was greatest 

for new participants (3 percent) compared 

to ongoing participants and nonparticipants 

(1 and 0 percent, respectively).3

The incidence and types of adverse health 

events experienced in the three months before 

program entry for the 84 people in the first 

column of Table 1 differed according to 

participants’ living arrangement, geography, and 

income. New participants who lived alone were 

more likely to have experienced any adverse 

health event in the three months before entry 

than those who lived with others (61 versus 

43 percent) (Table 2). In particular, new 

participants who lived alone were more likely 
3

TABLE 1: Percentage of older adults experiencing adverse health events in 

the three months before program entry or baseline survey interview

Experienced event in three months 

before entry or baseline interview

Health event New participants Ongoing participants Non-participants

Inpatient hospital admission 22.3 10.4 1.7

Emergency department visit 23.8 21.5 17.3

Home health episode 31.3 26.5 6.3

Skilled nursing facility admission 2.6 1.1 0.0

Any adverse health event 53.1 41.7 22.3

Sample size 84 169 255

Source: Medicare claims and enrollment data matched to AoA NSP outcomes survey, 2015–2016, weighted data.

Note: All units are percentages of the indicated sample.

Tabulations are based on unweighted sample sizes of 508 home-delivered meal participants and non-participants.

to experience a home health episode compared 

to those who lived with others (36 versus 

25 percent). The majority (59 percent) of 

new participants living in urban households 

experienced an adverse health event shortly 

before participating in the program, compared to 

less than half (38 percent) of those living in rural 

areas. The urban and rural subgroups differed 

largely in hospital admissions and emergency 

department visits (28 versus 8 percent, and 

30 versus 6 percent, respectively). Individuals 

in lower-income households, defined as having 

income below 122 percent of the DHHS 

federal poverty guidelines, were several times 

more likely to have experienced an emergency 

department visit than those living in higherincome households (41 versus 5 percent), but 

overall had a smaller difference in experiencing 

any adverse health event (57 versus 49 percent).

TABLE 2: Percentage of older adults experiencing adverse health events in 

the three months before program entry, by subgroup

Experienced event in three months before entry

Health event

Individuals 

who live 

alone

Individuals 

who live 

with other 

family 

members

Individuals 

who live in 

an urban 

area

Individuals 

who live in 

a rural area

Individuals 

in lowerincome 

households

Individuals 

in higherincome 

households

Inpatient hospital admission 23.3 21.1 27.7 7.6 22.9 21.7

Emergency department visit 26.9 19.7 30.3 5.7 40.6 4.8

Home health episode 36.4 24.5 30.7 32.9 34.5 27.7

Skilled nursing facility admission 2.5 2.9 2.7 2.5 3.1 2.1

Any adverse health event 60.6 43.3 58.5 38.2 57.3 48.5

Sample size 42 42 47 37 41 43

Source: Medicare claims and enrollment data matched to AoA NSP outcomes survey, 2015–2016, weighted data.

Note: All units are percentages of the indicated sample.

Tabulations are based on unweighted sample sizes of 84 new home-delivered meal participants.
4

Incidence of adverse health events in 

the six months before program entry

Although the analysis of the incidence of adverse 

health events using a three-month observation 

period yields a larger number of participants in 

the sample, it precludes examining when these 

events occur relative to starting to receive homedelivered meals. Over the six-month period 

before program entry, a greater percentage of 

new participants experienced an adverse health 

event in the month immediately preceding 

program entry than in any other month (Table 

3). One-third (33 percent) of program entrants 

experienced any adverse health event in the 

month before program entry, compared to 20 to 

24 percent in earlier months. 

Inpatient hospital admissions were the most 

common adverse health event in the month 

before entry (19 percent), and spiked in the 

month before program entry compared to the 

five previous months. Emergency department 

visits and admissions to skilled nursing facilities 

were also most common in the one to two 

months before entry. In contrast, the incidence 

of home health episodes was consistently high 

in all periods before entry (11 percent or more 

in all months), peaking at 19 percent four to five 

months before entry and falling slightly in the 

months leading up to entry.

DISCUSSION

Many NSP participants started receiving homedelivered meals after experiencing an adverse 

health event, such as a hospital admission, 

emergency department visit, or home health 

episode. Those who began receiving homedelivered meals were almost two-and-a-half 

times more likely to have experienced an 

adverse health event than those who remained 

nonparticipants. Furthermore, the use of health 

care spiked before program entry. Emergency 

department visits and hospital admissions were 

not frequent until about two months before 

program entry. An adverse health event in the 

month before entry is likely to have been a 

trigger event leading to homebound status and 

entry into a home-delivered meal program for 

one-third of new participants. Alternatively, a 

hospital admission or emergency department 

visit might, for some beneficiaries, be a conduit 

for information about home-delivered meals 

programs, leading to enrollment at some point 

after discharge. In addition, 10 to 20 percent 

of new entrants experienced a home health 

episode in all six months before program entry, 

suggesting that continuing physical limitations, 

as opposed to a sudden acute event, could also 

precede entry into the program. It is possible 

that survey respondents applied for meal 

delivery before the adverse health event for 

other reasons but did not begin to receive meals 

until later, after the health event itself. It seems 

more plausible, however, that meal provision was 

initiated as part of a clinical planning process 

associated with receipt of health care. 

Source: AoA LSP survey, 2014, weighted data. 

* Difference statistically significant at the 0.10 level, two-tailed test.

TABLE 3:

Six month history of adverse health events before program entry

Experienced event in month before entry (t)

Health event t-6 t-5 t-4 t-3 t-2 t-1

Inpatient hospital admission 0.0 1.0 3.2 2.0 3.5 18.8

Emergency department visit 11.6 0.5 8.4 3.2 15.3 8.2

Home health episode 11.6 18.6 19.0 16.8 14.3 13.5

Skilled nursing facility admission 0.0 1.0 0.8 1.3 2.0 1.7

Any adverse health event 23.2 20.1 24.1 22.1 22.0 33.2

Sample size 57 59 59 61 60 61

Source: Medicare claims and enrollment data matched to AoA NSP outcomes survey, 2015–2016, weighted data.

Note: All units are percentages of the indicated sample.

Tabulations are based on unweighted sample sizes of 84 new home-delivered meal participants.
5

The differences in health care use before 

entry according to older adults’ characteristics 

showed some clear patterns. The observed 

differences suggest that for entrants into the 

home-delivered meal program, an adverse 

health event among those living alone, those 

living in an urban area, and those who have less 

income more frequently precedes program entry. 

Limited availability of caregivers and resource 

constraints among specific groups of older 

adults could, in turn, drive these patterns. Some 

of these differences, such as the large observed 

differences in use of the emergency department 

by income and urbanicity, could also arise from 

a combination of other factors, such as poorer 

health and lack of a regular care provider among 

lower-income households, and easier access to 

emergency care in urban areas.

This study is the first to pair a nationally 

representative sample of home-delivered 

meal participants with administrative data 

to examine the health events experienced by 

new and ongoing participants. Its findings 

should be interpreted in the context of several 

limitations. First, date of entry into the program 

is determined by self-reported survey data, 

which may be affected by recall bias. Although 

there are clear differences in the incidence 

of health events between new and ongoing 

participants, the exact timing of events may be 

obscured by this bias. Second, because events 

in older adults’ lives such as losing a caretaker 

or experiencing a decrease in income may 

precipitate both adverse health events and need 

for home-delivered meals, the findings presented 

in this brief represent an association between 

health events and program entry, rather than a 

causal relationship. Finally, this brief examines 

the events that precede program entry, but 

does not examine the effect of participation 

on the likelihood of experiencing subsequent 

health events. An assessment of these types of 

program effects on health events and healthcare 

utilization can be found in a recent evaluation 

report (Mabli et al. 2018).

The findings in this brief underscore the 

importance of practitioners promoting awareness 

of the NSP to older adults experiencing adverse 

health events. Health care providers, particularly 

those in hospitals and emergency departments 

and home health staff, are in a favorable position 

to provide information about the NSP and should 

be recognized as prospective entry points into the 

program. In addition to receiving nutritious meals, 

home-delivered meal participants can interact 

with meal delivery drivers and other volunteers, 

and receive nutrition education, screening, and 

counseling as well as other services that promote 

health and prevent disease. To provide patients 

with the most effective transitions from hospital, 

skilled nursing facilities, or other rehabilitation 

facilities to home, practitioners could inform 

patients of the broad array of services available 

through the NSP. They can also explain how 

the NSP provides homebound participants with 

a primary access point for many home- and 

community-based services to help meet their 

health and nutrition needs.

Practitioners and administrators in the Aging 

Network should learn more about the process 

through which older adults who experience 

adverse health events come to participate in 

the NSP. Identifying best practices among 

healthcare providers in referring older adults 

who experience these events to the NSP could 

strengthen partnerships among agencies and 

lead to a stronger continuum of care model. This 

could also help to bolster referrals in areas in 

which older adults who experience these events 

currently are not being referred to the NSP.

REFERENCES

Mabli, James, Arkadipta Ghosh, Bob Schmitz, 

Marisa Shenk, Erin Panzarella, Barbara Carlson, 

and Mark Flick. “Evaluation of the Effect of 

the Older Americans Act Title III-C Nutrition 

Services Program on Participants’ Health Care 

Utilization.” Washington, DC: U.S. Department 

of Health and Human Services, Administration 

for Community Living, September 14, 2018. 

Available at https://acl.gov/sites/default/

files/programs/2018-10/NSPevaluation_

healthcareutilization.pdf. Accessed April 22, 2019.

Mabli, James, Elizabeth Gearan, Rhoda Cohen, 

Katherine Niland, Nicholas Redel, Erin Panzarella, 

and Barbara Carlson. “Evaluation of the Effect of 

the Older Americans Act Title III-C Nutrition 

Services Program on Participants’ Food Security, 

Socialization, and Diet Quality.” Washington, DC: 

U.S. Department of Health and Human Services, 

Administration for Community Living, April 21, 

2017. Available at https://www.mathematica-mpr.

com/our-publications-and-findings/publications/

evaluation-of-the-effect-of-the-older-americansact-title-iii-c-nutrition-services-program. Accessed 

January 23, 2018.