Older Americans Act Nutrition Performance Outcome Report Mathematica Policy Research Administration on Community Living Final Report – Part 1 April 21, 2017

Preliminary Analysis – July 17, 2017 Completed by Susan C. Real, Executive Director East Central Illinois Area Agency on Aging To be presented to ECIAAA Nutrition Service Providers during the July 17, 2017 Quarterly Nutrition Provider Webinar PowerPoint will also be posted on ECIAAA’s Website

Evaluation Objectives Provide information to support program planning, including an analysis of program processes Develop information about program efficiency and cost issues Assess program effectiveness, as measured by the program’s effects on a variety of important outcomes, including diet quality, socialization opportunities, health outcomes and – ultimately – helping older adults avoid institutionalization.

Sampling Design The evaluation used a multistage clustered sample design. The stages of sampling were: 1. AAAs 2. Local Service Providers within AAAs 3. Congregate meal sites and HDM distribution locations within Local Service Providers 4. HDM routes within HDM distribution locations 5. Congregate participants and HDM participants

Response Data Random sampling of OAA Nutrition Service Program (NSP) Participants 591 Congregate Participants 502 HDM Participants 76.1% Response Rate – Congregate 54.1% Response Rate - HDM

Study Findings NUTRITION SERVICES PROGRAM participant characteristics and circumstances 1. Demographic characteristics- Congregate and home-delivered meal participants were similar in terms of gender, veteran status, living alone. Home-delivered meal participants, on average, were older, had less education and were more likely to be widowed.

Study Findings NUTRITION SERVICES PROGRAM participant characteristics and circumstances 1. Demographic characteristics-continued 77 average age of congregate participant 82 average age of home-delivered meal participant More than 2/3 of congregate and home-delivered meals participants were women Non-Hispanic blacks constituted 14% of Congregate and 18% of HDM clients served Hispanics constituted 13% of Congregate and9 % of HDM clients served

Study Findings NUTRITION SERVICES PROGRAM participant characteristics and circumstances 2. Health status, functional ability and mobility Nearly half (46%) of home-delivered meal participants reported being in fair or poor health, compared to 23 percent of congregate meal participants Nutrition Risk Assessment reports conditions such as underweight, trouble eating due to tooth problems, taking 3 or more medications daily

Study Findings NUTRITION SERVICES PROGRAM participant characteristics and circumstances 2. Health status, functional ability and mobility Prevalence of doctor-diagnosed chronic health conditions was higher for HDM participants Prevalence of recent falls and injuries from falls was much higher for HDM participants compared to congregate meal participants A substantial proportion of HDM participants reported functional impairments and needed help performing one or more activities critical for them to remain in their homes. 12% of HDM participants reported unable to walk.

Study Findings NUTRITION SERVICES PROGRAM participant characteristics and circumstances 3. Diet and eating behaviors 11% Congregate participants reported appetite as poor 29% HDM participants reported appetite as poor 27% Congregate participants reported on special diets 34% HDM participants reported on special diets

Study Findings NUTRITION SERVICES PROGRAM participant characteristics and circumstances 3. Diet quality The evaluation used 24-hour dietary recalls to measure total nutrient intakes Found that NSP meals contribute substantially to both Congregate and HDM participants’ diets Congregate participants obtained 41% of daily calories from NSP meals HDM participants obtained 38% of daily calories from NSP meals

Study Findings NUTRITION SERVICES PROGRAM participant characteristics and circumstances 4. Receipt of nutrition and supportive services 43% Congregate participants receiving 5+ meals per week 82% Congregate participants receiving 3+ meals per week 71% HDM participants receiving 5+ meals per week 85% HDM particpiants receiving 3+ meals per week

Study Findings NUTRITION SERVICES PROGRAM participant characteristics and circumstances 4. Receipt of nutrition and supportive services Many participants reported using supportive services outside the scope of NSP 41% of HDM participants reported using personal care services versus 6% of Congregate participants 61% of HDM participants reporting using case management services versus 13% of Congregate participants

Study Findings NUTRITION SERVICES PROGRAM participant characteristics and circumstances 5. Food security and food coping strategies 16% of Congregate participants and 23% of HDM participants reported food access limitations during the past month due to lack of money or other resources – they were food insecure 42% of Congregate participants and 61% of HDM participants indicated they would skip meals or eat less if no OAA Nutrition Service Program

Outcome Measures FOOD SECURITY SOCIALIZATION DIET QUALITY

The Effect Summarized The effect of Congregate and HDM participation on food security, socialization, diet quality was estimated using data from program participants and a matched sample of nonparticipants. Congregate Program - 619 nonparticipants HDM Program – 514 nonparticipants

Food Security Congregate participants had a lower rate of food insecurity than did nonparticipants The prevalence of very low food security was 4.2 percentage points higher among participants compared to nonparticipants For the vast majority of participants who receive meals 5+ per week, the prevalence of very low food security among participants was similar to nonparticipants For participants receiving meals fewer than 5 d/p/w experienced greater rates of very low food security than did nonparticipants

Socialization Impact of program participation on socialization outcomes was assessed using three measures: 1. Loneliness – Revised UCLA Loneliness Scale The scale is based on responses to three questions related to how often individuals feel they lack companionship, feel left out, and feel isolated from others

Socialization Impact of program participation on socialization outcomes was assessed using three measures: 2. Depression – Patient Health Questionnaire 2 (PHQ-2) assesses the frequency of depressed mood over a two-week period

Socialization Impact of program participation on socialization outcomes was assessed using three measures: 3. Socialization – based on a single question measuring individuals’ self-reported satisfaction with spending time with other people

Socialization Outcomes - Congregate Congregate participants generally had greater socialization outcomes compared to nonparticipants No significant difference in loneliness scores between participants and nonparticipants Congregate participants were less likely than nonparticipants to screen positively for depression Participants reported greater satisfaction with their socialization opportunities (+8%) than nonparticipants.

Socialization Outcomes – Home Delivered Meals Results were mixed Average loneliness score was higher for HDM participants compared to nonparticipants No significant effects of HDM participants screening positively for depression when compared to nonparticipants However, for HDM participants receiving fewer than five meals per week, experienced greater loneliness and were less likely to be satisfied with socialization opportunities when compared to nonparticipants

Diet Quality Effect of program participation on diet quality outcomes was estimated using two measures: 1. the prevalence of adequate and excessive nutrition intakes 2. the HEI-2010, which assesses overall diet quality Both measures were estimated based on participants’ and nonparticipants’ daily intakes

Diet Quality – General Outcomes The findings indicate that congregate meal participants generally had healthier diets compared to nonparticipants, both in terms of adequacy of their usual daily nutrient intakes and overall quality of their diets Participants were more likely than nonparticipants to have adequate intakes of many nutrients, participants were more likely to have excessive sodium intakes Percentage of Congregate participants with excessive sodium intakes was 30.6% higher compared to nonparticipants

Diet Quality – General Outcomes Sizeable difference between Congregate participants and nonparticipants in total HEI-2010 scores, which provides an overall measure of diet quality The total score for participants was 6.1 points higher than for nonparticipants Congregate participants received higher scores for three “adequacy” components (total fruit, dairy and total vegetables)

Diet Quality – General Outcomes HDM participants were more likely than nonparticipants to have adequate nutrition intakes Few significant differences existed between HDM participants and nonparticipants in the HEI-2010 scores Scores for dairy and refined grains were significantly higher for participants than non participants (indicating higher diet quality) There were no significant differences in scores for any other components or for the total score

Final Observations Majority of participants had a positive impression of the Nutrition Services Program 92% Congregate participants and 96% HDM participants rated the nutrition program overall as good, very good, or excellent Most participants (81% Congregate & 96% HDM) reported the NSP helped them eat healthier foods 68% Congregate & 78% HDM participants indicated the NSP had improved their health and helped them achieve or maintain a healthy weight

Final Observations The majority, 71% of Congregate and 90% HDM participants reported the program helped them to live independently and remain in their own home The evaluation brought to light a few areas that warrant further exploration: 1.Findings suggest many HDM participants may not be receiving a sufficient number of meals per week – resulting in increased levels of food insecurity 2.Findings suggest that low-income Congregate participants were not as satisfied with socialization opportunities presented at meal sites