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Recommendations Summary

MiOA: Home Delivered Meals and Congregate Meals (2023)

Click here to see the explanation of recommendation ratings (Strong, Fair, Weak, Consensus, Insufficient Evidence) and labels (Imperative or Conditional). To see more detail on the evidence from which the following recommendations were drawn, use the hyperlinks in the Supporting Evidence Section below.


  • Recommendation(s)

    MiOA: Home Delivered Meals and Congregate Meals

    Older adults living in the community, especially those considered malnourished or at risk for malnutrition, should be referred to home-delivered and congregate meal services to improve calorie and protein intake and reduce incidence and risk of malnutrition.

    Rating: Level 1(C)
    Imperative

    • Risks/Harms of Implementing This Recommendation

      The senior meal programs are highly feasible, are widely available and are cost-effective services which do not have documented risks.1 Stakeholders, including older adults, their families and caregivers, and healthcare professionals, value the outcomes noted earlier which are associated with home-delivered and congregate meal benefits.  

      The national network of home-delivered and congregate meals is authorized by the Older Americans Act of 1965, as amended and funded by federal grants to states as well as funding from state and local government, foundations, direct payments, fundraising, participants’ voluntary contributions of time and/or money, and other sources.2 Separately, CMS may also support home-delivered meals for medically eligible low-income seniors.3 Older Americans Act meal programs are offered at no cost (donations requested) to persons 60 years of age and above and their spouses of any age, regardless of income.4 Additional eligible individuals, such as volunteers who assist during meal service and others, will vary by locality.  Home-delivered programs which operate separately from federal funding may not meet federal nutrition standards, may charge for meal delivery and may not include referrals to other community-based social service programs, which can assist with allowing older adults to remain healthfully in the community.

      Participation in meal programs has reduced malnutrition, which in turn reduces healthcare expenditures, improves the strength and resilience of communities, and the quality of life for older adults.5 

      References:

      1. Guide to Community Preventive Services. TFFRS - Nutrition: Home-delivered and Congregate Meal Services for Older Adults. 2022. Accessed June 13, 2023.
      2. Administration for Community Living. Older Americans Act of1965 Pages:116–131.
      3. Administration for Community Living. Nutrition Services.  Accessed June 13, 2023.
      4. Medicare Coverage of Meal Delivery Programs for Seniors. MEDICARE FAQ Web site. Published 2023. Accessed June 28, 2023.
      5. Meals on Wheels America. Report Explores Partnerships Between Community-Based Organizations and Healthcare Entities Using Outcomes-Based Financing. Published 2023. Accessed June 13, 2023.

    • Conditions of Application

      Program implementation can vary widely, to meet local population needs while targeting those in the highest social and economic need and is generally based not only on available resources but also state or local requirements.1 

      Acceptability

      Older Americans Act congregate and home-delivered meal programs are widely available across the United States and >95% of participants would recommend the service, demonstrating extraordinarily high acceptance rates by the population being served. Meal delivery and congregate meals are considered highly acceptable to older adults because of their potential nutritional impact, and opportunities for social engagement (congregate) (Robinson et al. 2020, Arjuna et al. 2018) to (home-delivered) (Rondanelli et al. 2016) percent of participants indicate the program helps them live independently in the community. Some older adults, however, may decline the service over perceived lack of autonomy or for other reasons. 

      Table. Potential Barriers and Facilitators for the Use of Congregate and Home-delivered Meals for Older Adults Living in the Community

      Barrier Facilitator
      Participants may have limited incomes and have concerns regarding the cost of congregate and home-delivered meals.
      • Congregate and home-delivered meals are supported through a wide variety of funding sources including participant donations, Older Americans Act (OAA), Medicaid/Medicare, for-profit companies, philanthropy, local and state funding, and more.  
      • Persons 60 and over, and their spouses of any age, are eligible to receive meals on a donation basis; services can not be denied due to lack of ability to contribute towards the cost of a meal. 
      Organizations providing the services may have limited resources to cover the cost of congregate and home-delivered meal services. 
      • In addition to paid staff, services often rely on volunteers or other in-kind resources as well as additional funding, which can be provided through local governments, businesses, healthcare, private donations, and philanthropy.
      • Organizations providing these programs benefit from having strong business skills to diversify funding sources and meet the increasing need for services. Federal funding, if used to provide the program requires states to provide a 15% match.192
      State and local government budgets may be limited and have competing priorities.
      • If using OAA funding, state and local entities establish program implementation policies to address local needs and account for available resources. Prioritizing participants to receive services who are most in need using validated tools and establishing wait lists may be required. 
      • Medicare/Medicaid policies are established and jointly paid by the federal government and states. However, Medicare Advantage supplemental benefits and Medicaid waiver nutrition services increase access to these interventions. 
      Existing community health inequities may exist, including under-resourced localities with populations experiencing high food insecurity rates and other nutrition-related conditions.
      • If using OAA funding, programs are required to target persons with the highest social and economic needs. 
      • Home-delivered and congregate meals are sustainable with existing funding but can only serve a small portion of the eligible population. Therefore, expansion of services to address or prevent malnutrition in community-based older adults require increased funding from a variety of sources. 

    • Potential Costs Associated with Application

      Funds needed to provide congregate and home-delivered programs vary based on a number of factors including the types of meals provided (eg, “regular” healthy meals, medically tailored meals, kosher, halal), number and types of staff (eg, volunteers, in-kind donation of production kitchen, paid staff, chefs, on-site dietitian nutritionist), delivery method (e.g., hot-holding equipment, food trucks, company purchased vehicles), location (urban, rural, US regions and territories), size of program (eg, cost efficiency, group purchasing, large or small jurisdiction), and meal production method (eg, catered meal vendor, in-house production, restaurant meals). When calculating the total cost of the meal, it is important to consider both paid components and those provided in-kind.1 Based on analysis from 2015, the cost per meal has been estimated at approximately $11, 186. However, food supply and other varied and inflationary factors may cause considerable variability. One analysis estimated the cost of providing a home-delivered meal for one year is approximately the cost of just one day in the hospital.2

      References:

      1. Ziegler J, Redel N, Rosenberg L, Carlson B. Older Americans Act Nutrition Programs Evaluation: Meal Cost Analysis. In: Center for Policy and Evaluation, U.S. Department of Health and Human Services, ed. Washington, DC 2015.
      2. Meals on Wheels America. Fact Sheets Sources & Methods 2019: Delivering So Much More Than Just A Meal. . Published 2019. Accessed June 13, 2023.

    • Recommendation Narrative

      Congregate and home-delivered meals programs are highly feasible and impactful, as demonstrated by their 50-year existence across the nation and review of its evidence base. Referral to home-delivered and congregate meal programs should be considered standard practice by healthcare and social service professionals for older adults living in the community as well as patients being discharged from hospital, rehabilitation, and nursing home stays (Chaudhuri et al. 2023). Approximately 1 million congregate and home-delivered meals are served per day. Meal programs funded by the Older Americans Act prevent and address malnutrition risk by providing one-third of the Recommended Dietary Intakes per meal and aligning with the Dietary Guidelines for Americans.  

      Home-delivered and congregate meals may be especially helpful for older adults who live alone,  who do not want to live alone, or those who, due to disability, cannot cook for themselves or obtain sufficient, healthy foods. Older adults may also be living on a fixed income with limited funds allocated for nutritious meals. Others may have chronic conditions that limit mobility and their ability to shop for food and cook. Older adults who do not require meals to be delivered to their homes may benefit from referral to the congregate meal program where access to physical activity programs, socialization and linkages to community social services. 

      The Community Preventive Services Task Force (CPSTF) conducted systematic reviews and found that home-delivered and congregate meals significantly increased calorie and protein intake and decreased rates of malnutrition (low certainty). No significant effect was found on hand-grip strength (very low certainty).  

      Results on home-delivered and congregate meal services from the National Survey of Older Americans Act Participants (2022) report:

      • 71% (congregate) – 79% (home-delivered) – say they eat healthily because of the program.
      • 73% believe their health improved as a result of the meal program.
      • 47% (congregate) – 57% (home-delivered) – indicate the meals provide one-half or more of their total food for the day.
      • 84% (congregate) – 87% (home-delivered) – rate the meals as good to excellent
      • 80% (congregate) – 92% (home-delivered) – report the program helped them continue to live independently in the community.
      • Over 95% would recommend the services to a friend (2021).  

    • Recommendation Strength Rationale

      The evidence supporting the recommendation is based on Grades C (Low) and D (Very Low).

    • Minority Opinions

      None