For many homebound elderly, the driver who delivers their weekly meals may be their only human contact all week. These volunteers often act as defacto eyes and ears; noticing changes in a client’s physical or mental health, social needs or home environment, before anyone else.
An innovative pilot program which uses a mobile app to alert care coordinators about these changes is expanding across the U.S. in the coming months. This joint effort by Meals on Wheels America, the West Health Institute and the Brown University Center for Gerontology and Healthcare Research will grow to include up to 30 Meals on Wheels sites across the country, helping ensure the wellness of an estimated 40,000 seniors.
As part of Meals on Wheels’ “more than just a meal” service model, staff and volunteer drivers deliver meals and visit clients in their homes regularly. Collectively, the nutritious meals, friendly visits and routine check-ins help address three of the biggest threats to successful aging: hunger, isolation and loss of independence. By setting up drivers who know their clients with an app-based monitoring program, they are able to quickly and proactively notify Meals on Wheels care coordinators about any health or safety issues among their clients, facilitating connections with additional services and supports.
“We know that the social determinants of health, such as nutrition, play a key role in determining your health care trajectory, especially for seniors who are vulnerable, low income, or somewhat homebound. This can be a very critical situation,” said Zia Agha, M.D., medical director of West Health, a nonprofit focused on helping older adults age in place.
The idea was to leverage an existing program, where some of the drivers were already alerting their supervisors to changes in clients’ health or social situations, but in a very haphazard and uncoordinated way. This approach puts a framework in place, using principles of care coordination and case management, along with light, easy to use technology, he said. It creates a new way to triage, and respond to alerts as they happen, connecting clients to community services or with their health care provider, as needed.
“When Meals on Wheels staff and volunteers are equipped with simple, yet effective screening tools while on their deliveries, they’re better able to react to changing conditions in seniors’ physical and mental state or environment before a particularly harmful health event occurs,” said Ellie Hollander, president and CEO of Meals on Wheels America. “This ability to respond in close to real-time can ultimately contribute to more agile coordination across medical and community-based service providers, improving outcomes and reducing costs.”
The pilot of the alert and response program was conducted at two sites — Meals on Wheels San Diego County and Meals on Wheels Guernsey County, Ohio. Within the two pilot sites, the program was tested across approximately 20 meal delivery routes serving nearly 900 clients.
Before the app was developed, some drivers would write information down on a piece of paper, or rely on their memory; when they called in to a supervisor, there was no real system in place for next steps, according to Andrea Morris, Ph.D., one of the principal investigators of the pilot.
A driver might notice that it took a client longer to get to the door that day, or meals were stacking up, or their breathing was a bit more labored, or that the person seemed unusually quiet or sad. “A mobile app installed on their phone makes it easy for drivers to still maintain those personal relationships with their clients, while also reporting back any concerns through a few simple taps on their phone,” she said.
A trained local care coordinator receives the reports in real time and, depending on the situation, will reach out to the client, a designated emergency contact or health care provider. “It’s really about understanding what the issue is, and then connecting them to the services they need,” said Cheryl Hassoldt, an associate program manager with West Health, who coordinated these efforts for the San Diego pilot.
It could be a three-way call with the primary care physician, because perhaps the client wasn’t taking her medication properly, or they might need some home care assistance or transportation to their next appointment. “It was always really a warm handoff versus just giving them a phone number and say here, call. The warm handoff, that was really the kind of a unique thing,” she said.
Hassoldt described one case where a client’s air conditioning wasn’t working during an intense heat wave. “So it was trying to work to work with service organizations that could provide him, potentially, a new air conditioner,” she said. In case of a suspected medical emergency, the drivers are trained to call 911 and remain with the person until emergency responders arrive.
Currently, many health care systems, social service organizations and other providers still work in silos, but the vision is to integrate this program across the board, and bring healthcare payers and providers as partners into the mix, according to Agha.
“They don’t share any warm handoffs or referrals. So a lot of work still has to happen for them to share resources and a care pathway for the individual patient,” he said.
List of locations
The expansion of this app-based alert and response program includes the following Meals on Wheels locations, and will continue through 2020:
- Athens, GA – Athens Community Council on Aging
- Alexandria, VA – Senior Services of Alexandria
- Baltimore, MD – Meals on Wheels of Central Maryland
- Brooklyn Center, MN – CEAP Meals on Wheels
- Cleburne, TX – Meals on Wheels of Johnson & Ellis Counties
- Colorado Springs, CO – Silver Key Senior Services
- Greenville, NC – Pitt County Council on Aging
- Honolulu, HI – Hawaii Meals on Wheels
- Houston, TX – Interfaith Ministries’ Meals on Wheels for Greater Houston and Galveston County
- Jewett City, CT – Thames Valley Council for Community Action, Inc.
- Knoxville, TN – Mobile Meals
- Lebanon, OH – Warren County Community Services, Inc.
- Merrillville, IN – Meals on Wheels of Northwest Indiana
- Minneapolis, MN – Community Emergency Service
- Nanuet, NY – Meals on Wheels Programs & Services of Rockland, Inc.
- Salisbury, NC – Meals on Wheels of Rowan
- San Antonio, TX – Meals on Wheels San Antonio
- Suisun City, CA – Meals on Wheels of Solano County
- Syracuse, NY – Meals on Wheels of Syracuse
- Toledo, OH – Mobile Meals of Toledo
- Tulsa, OK – Meals on Wheels of Metro Tulsa
- Tyler, TX – Meals on Wheels East Texas
- Vero Beach, FL – Senior Resource Association
- Anaheim, CA – SeniorServ
- Walnut Creek, CA – Meals on Wheels Diablo Region
- Wilmington, NC – New Hanover County Senior Resource Center
Local journalists have a wealth of story opportunities to explore issues like senior nutrition, food deserts, social isolation, housing, or perhaps do a ride-along with a driver. Reach out the local Meals on Wheels program listed above.
Agha suggests also including health care leaders in the story as another way to raise awareness about the effort.