Providing Home- and Community-Based Nutrition Services to Low-Income Older Adults: Promising Health Plan Practices

By Stephanie Gibbs*, Center for Health Care Strategies and Amy Herr, West Health Policy Center

*Stephanie Gibbs was previously a senior program officer at the Center for Health Care Strategies.

IN BRIEF

State Medicaid agencies and Medicaid health plans increasingly recognize the importance of social support services, including nutritious food, as part of a holistic approach to addressing the needs of low-income older adults and enabling them to live independently. Medicaid health plans are especially well-positioned to identify nutrition- related needs for this population and address them through partnerships with community-based organizations (CBOs). This brief highlights promising community-based nutrition practices for older adults used by Medicaid health plans.

By 2050, the number of people in the United States age 65 and older will nearly double, the number over age 85 will more than triple, and, simultaneously, the number of older adults living in poverty will increase. This aging population will need help meeting their care needs, with an estimated 70 percent of them requiring long-term services and supports (LTSS), such as personal care, supportive technologies, and adult day health services. Today, the majority of care provided to low-income older adults with functional support needs is covered under state Medicaid programs. To better meet this growing demand for care, state Medicaid agencies are rebalancing LTSS spending away from high-cost, institutional care toward lower-cost, home- and community- based services (HCBS). Nutrition-related HCBS, including home-delivered meals, congregate meals, nutrition education, diet modification, adaptive eating devices, and nutrition counseling, offer essential supports to help people remain living at home.

Many states use Medicaid HCBS waivers to provide nutrition-related services, but an increasing number — more than 20 states to date — have created Medicaid managed long-term services and supports (MLTSS) programs to assume broad responsibility for home- and community-based care as well as institutional services. In these programs, which enroll both older adults and individuals with disabilities, MLTSS plans coordinate all physical and behavioral health care and LTSS needs, including nutrition-related services, in return for a capitation payment. Because MLTSS plans are at risk for all Medicaid-covered LTSS, they have an incentive to address their community-based members’ nutrition-related needs as part of their efforts to prevent or delay higher-cost institutional care. MLTSS plans also have the flexibility to put in place wraparound services that provide whole-person care. A recent study found that providing home-delivered meals reduced emergency department use and medical spending among individuals dually eligible for Medicare and Medicaid.

With support from the West Health Policy Center, the Center for Health Care Strategies (CHCS) interviewed Medicaid managed care plans serving older adults, including MLTSS plans and Medicare- Medicaid Plans, to determine how they are addressing the nutrition needs of their members. This brief describes promising managed care plan practices for providing nutrition-related services to help inform the spread and scale of these activities.

Promising Practices

Several promising practices to address the nutrition-related needs of community-dwelling older adults emerged from the interviews, including:

1. Investing in staff with nutrition expertise.

Some plans, such as Molina and Aetna, contract with nutrition counselors or dieticians to develop proactive strategies to address nutrition-related needs and provide ongoing support for members. These experts can play a valuable role on multi-disciplinary care coordination teams. They can also be helpful in addressing members’ barriers to good nutrition including: loss of appetite; oral health issues; digestion problems; medication side effects; lack of transportation; difficulty with shopping and preparing food; and other psychosocial factors.

Leveraging the knowledge of its staff regarding food insecurity, AmeriHealth Caritas Michigan developed an emergency food bank —located in its office space — to support members with urgent food needs. Plan staff can refer members to the food bank as a short-term solution, especially over the weekend or at the end of the month when local food banks may have shortages.

Some plans contract with nutrition counselors or dieticians to develop proactive strategies to address nutrition-related needs and provide ongoing support for members.

2. Using assessment data to target nutrition-related interventions.

Plans can use existing data collection efforts, such as member assessments, to monitor nutrition- related needs and design interventions. In-home visits may be especially helpful to understand members’ nutrition status and ability to prepare meals.

CareSource includes questions in its health risk assessment to identify member needs related to a variety of social determinants of health, including hunger. Understanding that isolation and hunger may be linked for those who are frail and living in the community, CareSource also asks specific screening questions related to social relationships and the quality of those relationships.

Assessments can document nutrition-related programs and resources that members are already utilizing. At the same time, plan care coordinators can help the member to understand additional benefits for which he or she may qualify, such as the Supplemental Nutrition Assistance Program (SNAP), which has historically been underutilized by older adults. Plans can help members to apply for SNAP benefits and address other factors, such as lack of transportation, to help members better use those benefits.

SNAP Offers New Online Meal Delivery Service Options

In 2017, the United States Department of Agriculture announced an online purchasing pilot for individuals who receive SNAP benefits. Receiving meals though an online delivery service may help older adults to maximize autonomy and choice. Online meal delivery services may also allow remote caregivers to take a more active role in helping their family member or friend choose healthy meal options. Additionally, Amazon recently announced that SNAP benefits can be used for online ordering and delivery.

3. Replicating best practices from other member populations.

Many of the plans interviewed also offer products for general Medicaid populations, and have developed nutrition-related interventions for those groups that may work well for older, low-income adults. AmeriHealth Caritas District of Columbia provides “shopper aides” who accompany members — pregnant women and individuals with chronic conditions are prioritized — to the grocery store to help them select nutritious food options. Older adults may benefit from a similar approach, and training LTSS direct care workers to provide this type of support may contribute to their increased job satisfaction and professional development.

4. Leveraging community-based resources.

Though home-delivered meals play an important role in meeting members’ nutritional needs, older adults may also benefit from and even prefer dining with others. Plans may consider: (a) educating members on community-based options, such as congregate meals; and (b) providing transportation options for meals in these settings.

Community-based resources can also be tapped for members who can prepare their own meals. Several health plans have expanded access to community-based food options. For example, Anthem uses vouchers so members can shop at farmers markets for fresh produce. UCare has partnered with the Amherst H. Wilder Foundation to offer a refrigerated mobile pantry — a bus converted into a grocery store — so members with scarce food resources in their communities can access fresh produce and healthy food options. UCare staff reported that before one member began to visit the mobile pantry, she ate only from the vending machine in her apartment building. Access to the mobile pantry helped her to achieve lower blood pressure, a healthier weight, and improved blood sugar levels.

Plans can leverage the expertise of community- based organizations, many of which have been serving their communities for years and are trusted by plan members, to deliver cost- effective nutrition services.

Plans can leverage the expertise of community-based organizations (CBOs), many of which have been serving their communities for years and are trusted by plan members, to deliver cost-effective nutrition services. Kaiser Permanente partnered with Hunger Free Colorado, a nonprofit organization that connects families and individuals to food resources, to assist members who screen positive for food insecurity by helping them to apply for federal food assistance programs (e.g., SNAP) and connecting them to other community-based food resources. Aetna’s Community Care program connects members to community-based services that provide food delivery, transportation, home improvement, and physical exercise.

To facilitate plan-CBO interactions, the Administration for Community Living (ACL) has invested in developing the business acumen of CBOs. One area of focus is better equipping CBOs to engage in emerging alternative payment methodologies. These payment efforts establish shared accountability between plans and CBOs or other providers that deliver nutrition services by aligning all entities on common performance and quality measures. These arrangements may help to improve the sustainability of nutrition services programs and related outcomes. ACL recently awarded several grants to CBOs to advance innovation in nutrition services. An innovative Meals on Wheels pilot supported by West Health and Brown University explored the benefits of home-delivered meals that go beyond nutritional needs to provide social and care management supports (see Beyond Nutrition sidebar).

Beyond Nutrition: Testing Enhanced Services via Meals on Wheels

For many older adults receiving delivered meals, the delivery person is often their only contact with the community. Meal delivery personnel are potentially valuable resources who could identify changes in an individual’s condition or recognize other medical or social issues that may be important to the individual’s health. The Gary and Mary West Health Institute, Meals on Wheels America, and Brown University Center for Gerontology and Healthcare Research conducted a two-year research study to explore ways to address unmet needs and improve the health and well-being of older adults through an enhanced meal- delivery service that includes daily wellness checks. Meals on Wheels delivery personnel were trained to use a mobile application to submit electronic wellness alerts when they noticed a change in a client’s condition or had a concern about a client’s health, safety, or well-being. Wellness alerts were received by a care navigator, who followed up with clients and helped connect them with the care and support they needed to stay safe and healthy in their homes.

Conclusion

As states and Medicaid managed care plans consider ways to address the needs of an aging population and better serve individuals in the community, states can drive innovations, including nutrition-related supports, through plan contracting approaches that may include performance incentives. As plans provide more nutrition-related services, they will need to monitor member outcomes and assess the impact of their investments. Data demonstrating improved outcomes will help support continued investments in this area. These data may also help states to make the case that Medicaid managed care programs provide value by connecting members to community-based supports that address social determinants of health.

ACKNOWLEDGEMENTS

The authors thank the representatives of the following managed care organizations for helping to inform this brief: Aetna, Amerigroup/Anthem, AmeriHealth Caritas (District of Columbia and Michigan), CareSource, Kaiser Permanente, Molina Healthcare, UCare, and UPMC for You.

ABOUT THE CENTER FOR HEALTH CARE STRATEGIES

The Center for Health Care Strategies (CHCS) is a nonprofit policy center dedicated to improving the health of low-income Americans. It works with state and federal agencies, health plans, providers, and consumer groups to develop innovative programs that better serve people with complex and high-cost health care needs. For more information, visit www.chcs.org.