Associate Professor, Health Services, Policy and Practice; Health Science Specialist, Providence VA Medical Center

Thomas focuses on identifying ways to improve the quality of life for older adults needing long-term services and support through applied health services research.

Countering Social Isolation to Improve Health Outcomes

The importance of social services and supports for maintaining health—like transportation, housing, access to healthy foods, and other neighborhood factors—is increasingly understood. For vulnerable populations, like older adults, social supports are especially critical. Professor Kali Thomas, a Florida native who grew up in a rural community, had long noticed that many of her neighbors and family members were living in nursing homes when they really didn’t need to be. “They could have been cared for in the community,” she said, “if there were services available, but those didn’t exist.”

Through her work as a graduate student and from research led by Professor Vincent Mor among others, Thomas knew some of the factors associated with the prevalence of low-care residents in nursing homes, including assisted living capacities, state policies, and spending on Medicaid home- and community-based services.

“What hadn’t been looked at,” Thomas said, “was the relative influence of social services, so things like transportation, homemaker services, and home delivered meals.” During her postdoctoral fellowship in the Center for Gerontology and Healthcare Research, Thomas examined ten years of data on older Americans and social service programs spending to see how those were related to the prevalence of low-care residents, adjusting for all the factors previous research had shown to be influences.

That landmark 2013 study found that, of all the programs examined, including Medicaid home- and community-based services, state expenditures on home delivered meals were associated with the greatest reductions in low-care nursing home residents over a decade.

As author of the first study of its kind to demonstrate that increased spending on home delivered meals correlates to reductions in nursing home use, and potentially health care costs, Thomas garnered national attention. “I kept getting calls,” Thomas said, “from states and programs saying ‘What does this mean? You have these model estimates, help me understand what this means for the programs in my state.’”

Thomas’ follow-up study provided a model for states showing how their increased spending on home delivered meals would result in reductions in their low-care nursing home population, which would translate into money saved by Medicaid. “Every state had a road map of what they needed to do based on these models,” Thomas said.

It wasn’t long before Ellie Hollander, the newly-named President and CEO of Meals on Wheels America, called, too.

“She had seen the study,” Thomas said, “and she said ‘I’m looking to increase the evidence base of our program, and you seem like the right person to do it.’” They met and Thomas learned the problems Meals on Wheels programs faced, including increased transportation and food costs, reduced donations and federal funding, and a new competitor in the market: lower-priced, frozen, drop-shipped meals.

To understand the impact of traditional delivered meals versus the frozen shipped meals, Thomas designed her first study with Meals on Wheels America. Called “More Than a Meal,” the randomized control pilot study found that all meals reduced falls and loneliness, but that clients who received daily delivered meals showed the greatest reductions. These initial studies relied on self-reported data, so Thomas’ next study was observational, linking client data from thirteen Meals on Wheels programs with Medicare claims data.

“We found that after folks received Meals on Wheels,” Thomas said, “they had reductions in hospitalization, nursing home placement, and emergency
department visits.”

Fewer falls, hospitalizations, nursing home placements, and emergency department visits, all thanks to a daily delivered meal? Thomas credits these effects less to the meal itself, and more to reductions in loneliness and social isolation.

“Loneliness has been shown to be a stronger predictor of mortality than
smoking,” Thomas said. To explain, Thomas draws on her personal experience. “I began volunteering for Meals on Wheels in graduate school,” she said. “For the majority of clients on my routes, I was the only person they saw during the day.

“I think a lot of what’s behind this is somebody asking how you’re doing. You have a purpose, a reason to get out of bed, to get dressed, and run a comb through your hair, because someone is going to be knocking on your door, delivering your lunch. I think that’s really what is driving our findings. The meal is important, don’t get me wrong, but our research consistently shows how important human interaction is. Meals on Wheels is so near and dear to my heart and I have been honored to be able to work closely with these programs and to help them to build evidence and attach real concrete numbers to the good they’ve been doing all along.”

Thomas’ work with Meals on Wheels continues to make an impact today. The program has expanded use of a new mobile app that allows drivers to alert care coordinators when they notice a safety issue or health change in a client. Thomas helped to develop and test the app, which is being adopted by 30 Meals on Wheels sites. More seniors are likely to benefit in the future, with her research being used in state and federal testimony in support of bills to increase expenditures on programs that help older adults to age in place.

Caring for Veterans

In addition to her faculty position in the Department of Health Services, Policy and Practice, Professor Thomas is also a Research Health Science Specialist at the Providence VA Medical Center. She works in its Center of Innovation for Long-term Services and Supports and is currently evaluating their participant-directed long-term care programs as part of a five-year career development award. In one program, Veteran-Directed Care, veterans are given a budget and support to hire and train caregivers and make needed purchases. “It gives them a lot more autonomy and flexibility and choice,” Thomas said. “They might hire their son or their wife to stay home and help with needs, like bathing, toileting, and eating, as opposed to a hiring a stranger to help with these very intimate tasks.”

Another VA benefit for veterans who need long-term care or personal care assistance gives them cash, with the freedom to spend it however they want. “This benefit has been around for decades,” Thomas said, “but it is reportedly underutilized and there has never been a formal evaluation of who uses it, how, and what their outcomes are.” Professor Thomas is working to change that.

One of the things that makes her work evaluating veterans’ long-term care so rewarding is that her research findings have direct implications on the delivery of services. Of the 18 VA Centers of Innovation (COINs) across the country, the Providence VA is the only one focused exclusively on long-term services and supports. “In our COIN, we work directly with Geriatrics and Extended Care at the VA central office and present our research to VA leaders,” she said. “I have veterans in my family so it’s nice that my work influences the care that they receive, particularly at a stage when they really need it.”

Having and Becoming a Role Model

Professor Thomas had two instrumental role models growing up who helped to shape her into someone who deeply values and respects older people, her grandmother and her mother. “My granny was dedicated to supporting older adults in her community,” Thomas said. “She was very active with the Hardee County Council for the Aging. And on Sundays after church, my mom would take my sister and me to visit loved ones in nursing homes. She said hello and touched every resident. It was really important for her that people were seen and touched. So the smells of nursing homes don’t bother me because I just grew up with it. I’ve eaten that cole slaw!”

Today, Thomas follows the example set by her grandmother and her mother. “One requirement for students who participate in the Meals on Wheels research projects,” she said “is that they have to go on at least one ride along.” She’s found that most continue to deliver meals.

She also gets students excited about aging research through her leadership of a group of MPH students enrolled in the Biostatistics and Applied Data Analysis course. “We use the National Health and Aging Trends study data,” she said. “It’s been really fun because students who weren’t thinking about aging work get interested in it and go on to base their thesis projects on aging related topics.

“Unless you live it and you see these people, you don’t really understand,”
Thomas said. “People care about what they see, and you don’t see people who need long-term care because they are homebound or they are in assisted living or a nursing home. We have to come to the realization that we all touch aging and long-term care one way or the other. It affects all of us.”