Sometimes a name doesn’t tell the full story. That’s the case for Arlington, Virginia-based Meals on Wheels, a meal-delivery service that does more than its name suggests.

“In addition to a whole array of nutrition services, [Meals on Wheels] programs are doing in-home assessments,” Lucy Theilheimer, chief strategy and impact officer at Meals on Wheels, said. “They’re assessing the condition of the individual, they’re assessing the environment [and] they’re identifying and alleviating hazards.”

In the current Medicare Advantage (MA) climate, those services are a boon. In fact, they’ve helped Meals on Wheels foster partnerships with at least two of the country’s largest insurers: Humana Inc. (NYSE: HUM) and Aetna.

Such partnerships were the topic of a panel discussion at last month’s Medicare Advantage Summit hosted by the Better Medicare Alliance in Washington, D.C.

“Social determinants of health aren’t happening in a vacuum,” panelist and Humana Senior Population Health Strategy Lead Jennifer Spear said. “People are not just food insecure, they’re not just lonely, they’re not just medication insecure. … Through Meals on Wheels, we are actually addressing at least three of those [social determinants] when we look at transportation and food insecurity as well as social isolation and loneliness.”

Addressing multiple social determinants while improving health and reducing readmission is the goal of the pilot partnership, which serves select Humana MA members in Richmond, Virginia; Louisville, Kentucky; and Tampa, Florida. All three locations are Humana Bold Goal communities, where the Louisville, Kentucky-based insurer aims to tackle clinical and social needs to improve health 20% by 2020.

The benefit is available to members with multiple chronic conditions following a hospital or skilled nursing stay — or to help manage certain conditions regardless of an institutionalization. Vulnerable members in special needs plans are also eligible.

Ahead of the benefit’s Jan. 1 launch, about 6,000 members were eligible to participate in the pilot, according to a press release.

In addition to delivering meals and monitoring condition changes, Meals on Wheels monitors the daily condition of members in the pilot and measures for loneliness using the UCLA Loneliness Scale.

Those who screen positive for loneliness will then receive “friendly visitors” services. In other words, a volunteer will visit the senior at home once a week for 13 weeks, Theilheimer said.

“The hope is that relationship is going to take hold and, once the benefit portion stops, that connection will remain and that senior will now have a new connection in their community,” she said.

Aetna partnership

Meanwhile, Meals on Wheels’ partnership with Aetna is more exclusively focused on care coordination for the Hartford, Connecticut-based insurer’s highest risk, highest need members.

To make it happen, Meals on Wheels took its informal observations of clients and formalized them by creating a technology-based platform called the change-of-condition monitoring protocol, Theilheimer told summit attendees.

While delivering food, trained volunteers use a device to log changes to a client’s condition, whether it’s a change in appearance, demeanor, hygiene or housekeeping. The report then goes to a program staff who follows up with the senior to understand what’s happening.

“We’ve been working with Aetna in four markets, serving 50 clients in each market,” Theilheimer said. “The partnership connects the Aetna care managers and local Meals on Wheels programs to monitor what’s happening with those members upon referral.”

Partnership results

Meals on Wheels has been shown to have an overall positive effect on the health of seniors while also helping to save the health care system money.

For example, about eight out of 10 seniors who had fallen reported Meals on Wheels helped them not fall again, both according to a 2017 study funded by AARP and conducted by researchers at Brown University.

“Meals on Wheels can serve a senior for a full year for the cost of one day in a hospital or 10 days in a nursing home,” Theilheimer said. “Seems like a no brainer that [plans] should be looking at community-based organizations like Meals on Wheels.”

But those factors don’t automatically equate to successful MA partnerships.

“What seems to be a challenge is we get it all set up, we’ve tested it, gotten the kinks out of it, but for whatever reason, the referrals aren’t flowing through the pipeline,” Theilheimer said. “I think attending to that upfront [is important] because if we can’t drive the referrals to the local programs none of this will work.”

One reason panelist from both Humana and Aetna agree is lack of insight regarding the social needs of our members.

“We all have data … but it’s just a starting point,” panelist and Aetna Senior Director of Public Policy Greg Jones said.

“We’re working very hard to supplement the data that we do have,” Spear agreed. “The fact of the matter is even when we do get it, it’s a snapshot in time. … I think the big problem is really having the right data to identify the right member at the right time.”