NEW CHALLENGES AND
OPPORTUNITIES FOR NUTRITION
PROGRAMS IN THIS CHANGING
ENVIRONMENT
Linda Netterville, MA, RD, LD
Dietitian Consultant, DADS
SESSION OVERVIEW
 The changing community and healthcare
environment
 Challenges
 Opportunities
 Building sustainability for the future
Healthcare
Business
Resources
Demographics
CHANGING ENVIRONMENT
Factors
CHANGING DEMOGRAPHICS
 More older people
 More healthy older
people
 More frail older
people
 More minorities
 More HCBS, less
nursing home care
MOST OLDER TEXANS 60+ YEARS LIVE
IN THE COMMUNITY
 Community
4.01 M; 97.7%
 Nursing Homes
95,640; 2.3%
AGID Database
TEXAS PERCENT OF
6O+POPULATION
15.80%
16.0%
15.4%
% of Total State Population
15.5%
15.1%
14.8%
15.0%
14.5%
14.5%
14.0%
14.2%
13.9%
13.5%
13.0%
12.5%
2006
2007
2008
2009
Years
2010
2011
2012
PROJECTED POPULATION 60+
Texas 60+
8,000,000
7,000,000
6,000,000
5,000,000
4,000,000
6.7 mil
3,000,000
2,000,000
5.3 mil
3.8 mil
1,000,000
2010
Projection 2020
Projection 2030
Texas 60+
TEXAS POPULATION OF 60+
1,800,000
1,645,334
1,600,000
1,400,000
1,263,643
1,200,000
1,000,000
800,000
594,875
600,000
472,257
400,000
200,000
Texas
60 to 64 years
65 to 74 years
75 to 84 years
85+ years
PERCENT OF AMERICANS AGE 65
EXPECTED TO SURVIVE TO AGE 90
50
42
40
30
20
10
25
26
1980
2000
14
7
0
1940
1960
2050
CHANGING LIFE EXPECTANCY
Life Expectancy by Age
90
80
70
60
50
40
30
20
10
0
68.1
70.8
76.8
78.5
59.2
51.5
At Birth
At age 65
11.6
4
1910
12.2
4.2
1930
13.8
15
4.7
5.3
1950
1970
17.3
19.2
6.2
6.7
1990
2009
At age 85
Older Americans 2012: Key Indicators of Well-Being
CHANGING RESOURCES
GOVERNMENT/PUBLIC FUNDING
 Older Americans Act
Title III (C1, C2,
NSIP), V, VI
 Other Federal
Social services or
community service
block grants
 State-Vary by State
EXPENDITURES PER MEAL-TEXAS
BASED ON STATE PROGRAM
REPORTS SUBMITTED TO ACL/AOA
Congregate Meals-TX
Home-delivered MealsTX
$7.00
$6.00
$5.00
$4.77
5.18 $5.13
$5.52 $5.60 $5.47
$5.80
$4.50
$4.00
$3.50
$4.00
$2.58 $2.62
$3.00
$4.01
$2.84 $2.67
$3.05
$3.35
$2.17
$3.42 $3.39
$3.00
$2.50
$2.00
$1.50
$2.00
$3.13 $3.13 $3.08 $3.22
$1.34 $1.34
$1.39
$1.18 $1.14 $1.26 $1.28
$1.00
$1.00
$0.50
$0.00
$0.00
2006 2007 2008 2009 2010 2011 2012
Expenditures per meal
Title II per meal
2006 2007 2008 2009 2010 2011 2012
Expenditures per meal
Title III per meal
% OF TITLE III IN TOTAL
EXPENDITURES FOR MEALS
% of Title III Home-Delivered- Texas
43.0%
42.9%
38.3%
35.4%
2006
2007
2008
2009
36.9%
37.8%
2010
2011
34.7%
2012
FEDERAL FUNDING SOURCES
OAA Funding
(Title III)
$2.1 Billion
Medicare/Medicaid
(ACOs, MLTSS, Duals)
$11.5 Billion
BUSINESS DEMANDS
 Service needs
 Quality Services
 Appropriate services:
cultural, religious,
therapeutic
 Choice
 Diversity
 HCBS Services
CHANGING BUSINESS
PRACTICES
 For Profits
 Expanding into non-traditional markets
 Offering competing services
 Restaurants, groceries, fitness options
 Non-Profits
 Becoming more entrepreneurial
 Developing community partnerships
 Identifying other funding streams
TECHNOLOGY TO ASSIST
 Data collection and sharing information
with healthcare
 Billing systems compatible with
healthcare
 Improved service and delivery models
 Routing/scheduling
 Telemedicine
THE CHANGING HEALTHCARE
MARKET
Patient Protection and Affordable
Care Act of 2010
Triple Aim
Better care
Healthier people
Smarter spending
THE CHANGING HEALTHCARE
MARKET DRIVEN BY CMS
Medicare-Title XVIII of the Social Security Act, long term
disabilities, end stage renal, 65 or older
 Part A
 Part B
 Part C- (Medicare Advantage)
 Part D-(Prescription)
Medicaid -Title XIX of the Social Security Act, low
income, children, elderly, blind or disabled (Jointly
funded by the state)
THE CHANGING HEALTHCARE
MARKET

Services must meet the needs
 Customer- Payer (MCO, Insurance, Hospital)
 Consumer-Beneficiary (client)

Focused on quality metrics and improved
outcomes

Payers assume the risk

Want a clearly defined Return on Investment
(ROI)

Opens the door to For-Profit entities
CHANGING CARE SYSTEMS
 Medicaid LTSS- Managed Care
 Long Term Services and Supports (LTSS)
 Home and Community Based Services
(HCBS)
 Health Care/Care Transitions
 Accountable Care Organizations
 Bundled Payment Initiatives
LONG TERM SERVICES AND
SUPPORTS (LTSS)
 Target Audience
 Older adults
 People with
disabilities
 Include:
 Residential care in
facilities
 Home and
community-based
(HCBS)
 Support:
 Managing chronic
conditions
 Accomplishing
everyday tasks (IADL,
ADL)
HOME AND COMMUNITY BASED
SERVICES (HCBS)
 Target Audience
 Older adults
 People with disabilities
 Support Living in the
Community
 Funding Sources
 Older Americans Act
(OAA)
 Medicaid
 Social Services Block
Grant (SSBG)
 Education and
Rehabilitation Funds
 State General Funds
 Local Funds
CARE TRANSITIONS
 Coordination and continuity of health care based on
a plan of care
 Include:
 Hospitals
 Sub-acute And Post-acute Nursing Facilities
 The Patient's Home,
 Primary And Specialty Care Offices
 Long-term Care Facilities
ACCOUNTABLE CARE
ORGANIZATION (ACO)
 Groups of doctors, hospitals, and other health care
providers
 Provided to Medicare beneficiaries.
 Provide coordinated care and chronic disease
management while lowering costs.
OPPORTUNITY KNOCKS!
OPPORTUNITIES-WHO ARE
CURRENTLY BEING SERVED- TEXAS
Current Population
Percent
60+- TX
4,105,225
Nutrition Program
Served Total (2012)
134,760
3.3%
Congregate Served
71,318
1.7%
Home-Delivered
Served
63,442
1.5%
http://www.agid.acl.gov -State Program Reports- 2012
OPPORTUNITIES TO BUILD
SUSTAINABLE RESOURCES
Social Entrepreneurship
For Pay options
Healthcare entities
SOCIAL ENTREPRENEURSHIP
Catering Contracts
 Expansion of Nutrition Services
Nutrition Counseling
Grocery Shopping
Other Program Opportunities
USDA Child Nutrition Programs
FOR PAY OPTIONS
Relook at “for pay” options
Other services
Tiered services
Expanded services
THE ROLE OF NUTRITION SERVICES
Something Magical Happens!
CLIENTS VALUE THE PRODUCT
Home Delivered
Congregate
Able to eat
healthier foods
83%
78%
Meal enabled
living at home
92%
60%
AoA Survey of OAA Participants, December, 2011, http://www.agidnet.org
ROLE OF NUTRITION SERVICES
Value of Nutrition to Chronic Health Conditions
 Heart disease
 Hypertension
 Diabetes
 Osteoporosis
 Kidney disease
 Obesity
ROLE OF NUTRITION SERVICES
Other Nutrition Services
 Nutrition Counseling
 Nutrition Education
 Nutrition Assessment
ROLE OF NUTRITION SERVICES
Value Add
 Wellness/Safety Check
 Regular contact in the home
 Trusted in the home
 Client status (moved, hospital, nursing home)
 Perform Regular In-home Assessments
KEY FINDINGS-MORE THAN A
MEAL STUDY
 Those receiving home-delivered meals:
 Improvements
 Anxiety
 Self-rated health
 Isolation
 Loneliness
 Reduced rates of:
 Hospitalizations
 Falls
KEY FINDINGS-MORE THAN A
MEAL STUDY
Those receiving daily meal delivery:
 Improvement in mental health (anxiety)
 Improvement in self-rated health
 Reductions in the rate of falls
 Improvement in feelings of isolation and loneliness
 Decreases in worry about being able to remain in
home
KEY FINDINGS-MORE THAN A
MEAL STUDY
Those receiving daily delivered compared to
weekly:
 Feel safer
 Helped them to eat healthier food
 More social contacts
 Less loneliness
KEY FINDINGS-MORE THAN A
MEAL STUDY
Those receiving daily delivered and lived
alone:
 Decrease worry about being able to
remain in the home
 Improvements in feelings of isolation and
loneliness
OPPORTUNITIES FOR
NUTRITION PROGRAMS
 Valued added service
 Service and delivery structure in place
 Trusted entity with long history of success
 Linked to other community-based service
 Community partnerships
WHAT CAN YOU DO?
Know:
 Health Reform activity in your community
 Medicare Advantage Plans
 Medicaid Managed Care initiatives
 ACOs
 Bundled Payment Initiatives
 Competition
 Partners
 Champions
41
WHAT ARE HEALTH ENTITIES
SEEKING
 Meet consumer needs
 Choice of meals, special or modified diets,
flexibility)
 Access to the consumer
 Coverage for the entire service area (1 contract)
 Easy to submit referrals for services
 Meet quality metrics
 Data provided to show improved outcomes
HOW CAN YOU COMPETE?
 Organizational culture change (staff qualifications,
characteristics, inter-organizational operations)
 Strategic business plan
 Development and structure of community-based
networks
 Service packages (identifying, pricing and
packaging services)
 Marketing and sales strategies
HOW CAN YOU COMPETE?
• Communication and negotiation techniques
 Addressing program capacity challenges
(developing, increasing, and managing the
capacity of the program to deliver services)
 Continuous quality improvement (setting
standards, defining and measuring outcomes,
monitoring)
 Risk management (identifying, accepting, and
managing)
 Information technology (IT) system
ASSURE THE CAPACITY OF YOUR
ORGANIZATION TO DELIVER
 Services
 Methods of production/delivery - Meals
 Methods of development/delivery
 Steps necessary to provide to provide the
product (meal, nutrition education, etc.) and
services
 Capacity, expertise, human resources
PILOT PROJECT
 Pilot through the National Resource Center on
Nutrition and Aging and MOWAT
• Understand the changing landscaper
• Identify the opportunities for the Nutrition Program
• Help to develop the skills needed to:
• Develop support services
• Negotiate Contracts
• Billing
• Reporting
PILOT PROJECT- 5 PROGRAMS
FINAL WORDS
Know Your Market
Know Your Competition
Study Your Customer
Organize, Plan, and Execute
THE ROLE OF NUTRITION
SERVICES
BUILDING THE BRIDGE
HCBS
Nutrition
Services
Healthcare
WE HAVE TO GET IT RIGHT!
DISCUSSION
 What is the vision for your nutrition program?
 What are the tools and resources that you need to
position your program now and into the future?
RESOURCES:
WWW.NUTRITIONANDAGING.ORG
 Recorded NRCNA Webinars—Positioning Your HCBS
Program in the Healthcare Market Webinar Series
 Part 1: Overview of Health Reform Initiatives - How this
Affects Your Organization and Terminology 101
 Part 2: Market Analysis - Determine Health Reform
Initiatives in Your Market Area
 Part 3: Network Collaboration -The Need for Collaboration
 Part 4: Developing a Strategy and a Business Model for
Your Organization
 Part 5: Positioning Your HCBS Program in the Healthcare
Market
RESOURCES:
More That a Meal Study
http://www.mealsonwheelsamerica.org/theissue/fac
ts-resources/more-than-a-meal
The Growth of Managed Long-Term Services and Supports (MLTSS)
Programs: (January 2012)
http://www.medicaid.gov/medicaid-chip-programinformation/by-topics/deliverysystems/downloads/mltssp_white_paper_combined.
pdf