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Background and Purpose

A. Goal: 

To improve the nutritional and health status of rural adults 60 and older with multiple chronic conditions 

following hospital discharge. 

B. Objectives: 

• Developing a referral pathway and protocol that will facilitate reaching adults 60 and older with multiple 

chronic conditions most in need of nutritional support and management.

• Identifying and serving 100 older adults with multiple chronic conditions through the Ibis system nutrition 

support module with meals in their homes.

• Leveraging AI technology and data to drive nutritional program improvements to better serve this atrisk population.

• Establishing AAA revenue enhancement capacity for nutritional support services that will then be 

replicable by other community organizations. 

C. Overview of Project: 

The Nutrition Innovations Project was a partnership between the University of Maine Center on Aging, 

Senscio Systems, Eastern Area Agency on Aging, and St. Joseph Healthcare to test a nutrition intervention 

for older adults with chronic conditions who have been recently discharged from hospital to home. The 

intervention paired the Ibis Health Management System with delivery of meals and nutrition counseling with 

the goal of improving outcomes related to nutrition, chronic disease self-efficacy, ER visits, and 

hospitalizations. 

D. Project Results: 

A total of 185 individuals were referred to the program - 162 declined to participate, 14 withdrew prior to 

study completion, and 9 completed the study. Of the nine completers, four participants were in the control 

group and five participants were in the intervention group. Due to the small sample size, the results of the

outcome study were inconclusive. 

Participants were generally satisfied with Ibis. Participants did not cook and were unlikely to use nutrition 

information from Ibis. Most valued intervention supports were vitals monitoring and check-in 

calls/reminders. Least valued supports were the recipes and nutrition information offered through Ibis.

Process evaluation findings indicated that adoption of nutrition and chronic disease self-management 

technology and support may be more successful outside of acute care settings. Interventions should be 

piloted in alternate recruitment settings to gauge potential for adoption. Flexibility in meals options and 

volume, and interactions with health monitoring technology, are important for successful utilization. 

A survey was done with Eastern Area Agency on Aging’s Meals on Wheels population to identify desired 

features of health technology and barriers to use. Vital signs monitoring was the most valuable feature 

identified, followed by remote access to classes and events at Area Agencies on Aging, and video visits with 

medical providers. Barriers to health management technology utilization were affordability and privacy 

concerns. 

This project was supported, in part by grant number 901NNU0015, 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.