Background and Significance: Food insecurity among older adults is a critical public
health issue with implications for families, the healthcare system, and society. In 2017,
an estimated 5.5 million older adults (7.7%) in the United States were food insecure.
Among older adults, food insecurity is associated with poor health status and outcomes
and accounts for an estimated $130 billion annually in medical expenses. As a result,
healthcare entities (e.g., payers, integrated systems, providers) are increasingly
interested in addressing food insecurity, among other social risk factors, through
non-medical services such as home-delivered meals to older patients and enrollees.
Home-delivered meals, long provided through a network of community-based organizations
funded through the Older Americans Act, state dollars, and charitable contributions,
promote food security, socialization, and independence among older adults. While meals
have traditionally been provided daily to clients' homes by a volunteer or paid driver,
mailed frozen meals have emerged in recent years as a lower cost alternative. However,
there is limited evidence about what mode of delivery is most effective in promoting
community independence, reducing healthcare utilization, and improving patients' quality
of life, as well as how these outcomes may vary as a function of patients' preferences
for how meals are delivered to them.
Study Aims: The long-term goal of this research is to generate evidence to guide patient,
family, meal programs, and healthcare entities' decision-making about which mode of meal
delivery is best for promoting important, patient-centered outcomes. This will be
accomplished through three specific aims: 1) To evaluate the effectiveness of receiving
daily-delivered meals with a safety check and socialization versus frozen, drop-shipped
meals on food insecure, homebound older adults' ability to remain in the community; 2) To
understand food insecure, homebound older adults' preferences for mode of meal delivery
and the effect of receiving a meal that is concordant with their preference on their
ability to remain in the community; and 3) To measure and quantify secondary outcomes
prioritized by stakeholders related to these different modes of meal delivery.
Study Description: This is a two-arm pragmatic, randomized controlled trial that will
compare participants' health outcomes between two conventional approaches for delivering
meals to food insecure, homebound older adults at thirteen diverse Meals on Wheels
America member programs in Florida, Illinois, Maryland, Tennessee, Texas, California,
North Carolina, and South Carolina. The comparators are the two main modes of meal
delivery used in everyday practice: daily-delivered meals and drop-shipped, frozen meals.
A total of 2300 food insecure, homebound older adults (ages 66+) on waiting lists at
these programs will be enrolled in the study; 1150 older adults will receive meals
delivered five days per week, with socialization and a wellness check by a volunteer or
paid driver, and 1150 will receive a box of 10 frozen meals that will be mailed to
participants every two weeks. The primary outcome will be the ratio of days that a
participant is in an institutional setting (i.e., hospital, nursing home) in the six
months following the start of meal delivery and will be derived from data from the
Centers for Medicare and Medicaid Services; secondary outcomes include the ratio of days
in institutional settings in the three months following the start of meal delivery, food
insecurity, loneliness, and quality of life. Secondary outcomes will be derived from
Centers for Medicare and Medicaid Services' data and surveys with participants.
Self-reported dietary intake will be included as an exploratory outcome. To examine
heterogeneity of treatment effects, the investigators will test for interactions between
the two types of meals and participants' preferences for meals, as well as clients'
living arrangements. This research will be the first to prospectively evaluate the
comparative effectiveness of the two predominant meal delivery options in partnership
with a variety of stakeholders. The knowledge generated from this research will be of
tremendous value to healthcare payers, health systems, providers, community-based
organizations, patients, and their families, because it will identify the mode of meal
delivery that best meets older, homebound, and food insecure patients' needs and promotes
community independence