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Examining the benefits of senior nutrition programs as a cost savings to Medicare: a promising practice study
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Examining the benefits of senior nutrition programs as a cost savings to Medicare: a promising practice study
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Content
Running head: SENIOR NUTRITION PROGRAMS
EXAMINING THE BENEFITS OF SENIOR NUTRITION PROGRAMS
AS A COST SAVINGS TO MEDICARE: A PROMISING PRACTICE STUDY
by
Michelle L. Matter
A Dissertation Presented to the
FACULTY OF THE USC ROSSIER SCHOOL OF EDUCATION
UNIVERSITY OF SOUTHERN CALIFORNIA
In Partial Fulfillment of the
Requirements for the Degree
DOCTOR OF EDUCATION
May 2018
Copyright 2018 Michelle L. Matter
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One person can make a difference,
and everyone should try.
-John F. Kennedy
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Dedication
This is dedicated to my Grandmother, Peggy,
who inspires me to put my heart, mind, and soul
into improving the quality of life for older adults.
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Acknowledgments
This dissertation has been a true labor of love, one that would not have been completed
without the support of others. I would like to acknowledge my dissertation chair, Dr. Corinne
Hyde, for guiding me through this journey and providing invaluable mentorship. I would also
like to acknowledge my committee members, Dr. Patrick Crispen and Dr. Cathy Sloane Krop,
who helped me immensely during this process.
I want to acknowledge the support I received from my colleagues in Cohort 3 in the
Organizational Change and Leadership program at the University of Southern California. For
the past three years, Cohort 3 has shared advice, wisdom, and knowledge that has been
instrumental to my success in this program. I am proud to be part of the Trojan Family.
I want to thank my friends and family. You all made sacrifices to help me so I could
work on my dissertation. I am forever grateful for your love, support, and inspiration. I
specifically want to thank my children who I owe a debt of gratitude for allowing me to pursue
higher education at the cost of missing out on time with you. I hope that I have taught you to
dream big, to work hard, and to make a positive difference in this world.
President Reagan wrote in a letter to his wife, “I more than love you, I’m not whole
without you. You are life itself to me.” I have been blessed with a similar love story and there
are no words to adequately describe the amazing life we have together. I would not have
accomplished this without you. Thank you for everything, I love you.
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TABLE OF CONTENTS
Dedication 3
Acknowledgements 4
List of Tables 7
List of Figures 8
Abstract 9
Chapter One: Introduction 10
Background of the Problem 10
Importance of a Promising Practice Project 11
Organizational Context and Mission 13
Organizational Performance Status 15
Organizational Performance Goal and Current Performance 15
Description of Stakeholder Groups 16
Stakeholder Group from the Study 17
Purpose of the Project and Questions 18
Conceptual and Methodological Framework 18
Definitions 19
Organization of the Project 20
Chapter Two: Review of the Literature 21
Malnutrition in Older Adults 21
Impact of Senior Nutrition Programs on Health Outcomes 22
Assessment of Senior Nutrition Programs 24
Sustainability of the Medicare Program 25
Benefits of Senior Nutrition Programs as a Cost Savings to Medicare 26
Explanation of the Clark and Estes Framework 27
Stakeholder Knowledge, Motivation, and Organizational Influences 28
Summary 44
Chapter Three: Methodology 46
Purpose of the Project 46
Research Questions 46
Conceptual Framework 47
Research Design 49
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Unit of Analysis 50
Participating Stakeholders, Criteria, and Rationale 50
Data Collection and Instrumentation 51
Data Analysis 54
Credibility and Trustworthiness 54
Ethics 55
Limitations and Delimitations 56
Chapter Four: Results and Findings 58
Participating Stakeholders 59
Knowledge Results 60
Motivation Results 64
Organization Results 66
Findings 70
Collecting Data on Senior Nutrition Program Participants 71
Utilizing Data for Program Innovation and Implementation 72
Summary 74
Chapter Five: Recommendations 77
Validated Knowledge, Motivation, and Organizational Influences 77
Integrated Implementation and Evaluation Plan 95
Recommendations for Future Research 110
Summary 111
References 113
Appendices 129
Appendix A: Survey Items 129
Appendix B: Interview Protocol 131
Appendix C: Informed Consent for Interview 132
Appendix D: Information Sheet for Survey 137
Appendix E: Recruitment E-mail for Survey 140
Appendix F: Recruitment E-mail for Interviews 141
Appendix G: Onboard Training Employee Evaluation 142
Appendix H: Comprehensive Geriatric Assessment Manager Observation Form 144
Appendix I: Professional Development Evaluation Form 146
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LIST OF TABLES
Table 1. Knowledge Influences, Knowledge Types, and Knowledge Assessment
Table 2. Assumed Motivation Influences and Motivational Influence Assessment
Table 3. Organizational Influences and Organizational Influence Assessment
Table 4. Summary of Assumed Knowledge, Motivational, and Organizational Influences
Table 5. Summary of Knowledge Influences and Recommendations
Table 6. Summary of Motivation Influences and Recommendations
Table 7. Summary of Organizational Influences and Recommendations
Table 8. Outcomes, Metrics, and Methods for External and Internal Outcomes
Table 9. Critical Behaviors, Metrics, Methods, and Timing for New Reviewers
Table 10. Required Drivers to Support New Reviewers’ Critical Behaviors
Table 11. Components of Learning for the Program
Table 12. Components to Measure Reactions to Learning Opportunities
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LIST OF FIGURES
Figure 1. Conceptual Framework
Figure 2. Visual representation of most used words in survey and interview data
Figure 3. Internal Outcomes Dashboard
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Abstract
The growing number of older adults threatens the sustainability of the Medicare program.
The purpose of this study was to use the Clark and Estes (2008) gap analysis framework to
understand the knowledge, motivation, and organizational influences among clinical staff that
impacts their ability to collect data on older adults participating in a senior nutrition program.
Assumed knowledge, motivation, and organizational influences, supported by a literature review,
were investigated through a qualitative data collection of interviews and surveys. The assumed
influences were validated through qualitative analysis and confirmed with an examination of
documents collected from the study setting. As a promising practice, this research study
demonstrates a strategy that has been implemented at an organization to solve a problem of
practice to inspire and advise similar organizations. The recommendations in Chapter Five are
based on the New World Kirkpatrick Model (Kirkpatrick & Kirkpatrick, 2016), and designed to
establish a standardized data collection process for senior nutrition program providers. The
purpose of collecting data is to advocate for increased federal funding for senior nutrition
programs. These programs increase quality of life for older adults by keeping them healthy and
independent, and therefore offer cost savings to the Medicare program.
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CHAPTER ONE: INTRODUCTION
Introduction to the Problem of Practice
It is estimated that 73 million people will be over the age of 65 in the United States by the
year 2030, up from 41 million people in 2011(United States Census Bureau, 2010). This 78
percent increase threatens the sustainability of Medicare, the federal health insurance program
for people who are 65 or older. According to research, Baby Boomers have a longer life
expectancy than previous generations despite higher rates of hypertension, high cholesterol,
diabetes, and obesity (Shankar, King, Broman-Fulks, Matheson, & Chirina, 2013). These chronic
conditions increase Medicare expenditures and highlight the need for innovative programs that
can prevent or delay symptoms. Senior nutrition programs are a cost-effective approach to
keeping older adults healthy and independent. The cost of one day in a hospital is roughly the
same amount as providing a patient with one year of meals through nutrition programs, and the
cost of one month in a nursing home is the same as providing lunch, five days per week, for
seven years (Colello, 2010). Investing in senior nutrition and wellness programs can potentially
reduce health care utilization and sustain the Medicare program for future generations.
Background of the Problem
When Medicare was first established in 1965, life expectancy for people born in the year
1900 was 50 years (National Institute on Aging, 2011). With remarkable increases in life
expectancy, older adults are expected to live nearly 20 more years after reaching Medicare
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eligibility. According to the Trustees of the Medicare program (2012), Medicare is expected to
remain solvent until 2024. The diverse aging population in the United States will need access to
quality healthcare services. Research has shown that symptoms of chronic conditions such as
diabetes, hypertension, or dyslipidemia can be reduced with appropriate nutrition intervention;
however, nutrition therapy, counseling, and health education are not covered supplemental
benefits for Medicare enrollees (Institute of Medicine, 2000). The United States Senate
Committee on Finance (2015) developed a subcommittee tasked with proposing policy that
delivers high-quality care, improves care transitions, produces stronger patient outcomes,
increased program efficiency, and contributes to an overall effect that will reduce the growth in
Medicare spending. One of the considerations is expanding supplemental benefits to meet the
needs of chronically ill Medicare Advantage enrollees to include nutrition.
Importance of a Promising Practice Project
The purpose of this promising practice research study is to understand the importance of
collecting data on senior nutrition program clients to document improved health outcomes. This
promising practice demonstrates a strategy that has been implemented at an organization to solve
a problem of practice. The problem of practice is a lack of data collection across all senior
nutrition program providers to document health outcomes for clients. Without evidence of
improved health outcomes, it is difficult to advocate for increased federal funding for senior
nutrition programs. Advocacy is critical because there is anecdotal evidence that senior nutrition
programs improve overall health outcomes for older adults and, therefore, could offer a
substantial cost-savings to Medicare. It is important to examine the organization’s performance
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in collecting data because it has the potential to inspire and advise similar organizations.
Collectively, senior nutrition program providers across the country have a unique opportunity to
establish a standardized data collection process, advocate for additional federal funding, and
expand nutrition programs that improve the quality of life for the growing elderly population.
This promising practice is important because the rising cost of Medicare is a burden on
all Americans and reform is needed for the program to remain viable. In 2012, Medicare
spending was $557 billion and is expected to nearly double by the year 2023 (Congressional
Budget Office, 2013). Without comprehensive reform and innovative solutions, there will have
to be an increase in taxes or a reduction in benefits for seniors to be covered by Medicare
expenses. An analysis of longitudinal data by Sheils, Rubin, and Stapleton (1999) found that
medical nutrition therapy, for people 55 years and older with diabetes or cardiovascular disease,
resulted in a net reduction of health services utilization and costs. The research concluded that
the savings in the utilization of hospital and other services will exceed the cost of providing the
medical nutrition therapy benefit.
Despite numerous studies showing that adequate nutrition is critical to health,
functioning, and quality of life, there is a lack of attention and adequate funding from policy
makers. For example, the Older Americans Act (OAA) was enacted into law in 1965 to improve
the well-being and quality of life for the most vulnerable seniors, and included funding for home-
delivered and congregate meals (Government Accountability Office, 2012). In 2006, Congress
voted to reauthorize the OAA which modernized and strengthened the original piece of
legislation. However, the OAA expired in 2011 and was not reauthorized until five years later in
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2016. Although funding continued through Congressional resolutions, it was not adjusted for
inflation or the growing number of older adults. Less money is being spent per capita on seniors
today than in 2006. This problem is important to address because malnourished seniors take
more medication, have higher rates of chronic medical conditions, and are more likely to fall and
break bones. Also, Medicare is the primary funding source for malnourished patients who have
hospital stays twice as long as well-nourished patients (Barker, Gout, & Crowe, 2011).
Studying this promising practice can help identify a strategy for reducing the cost of
health care services for older adults. Senior nutrition programs play a vital role in helping to
keep older adults healthy and independent. Successful programs offer more than just food for
low-income seniors. Socialization is an important factor in improving health outcomes for older
adults. According to a study by Holt-Lunstad, Smith, and Layton (2010), isolation among
seniors poses a substantial risk of death, similar to smoking 15 cigarettes a day. With adequate
funding and a trained and motivated workforce, senior nutrition programs increase health,
wellness, and socialization for a vulnerable population. These types of programs have a
profound impact on quality of life for older adults, but there needs to be a tool to measure the
impact adequately.
Organizational Context and Mission
Senior Support (pseudonym) is a non-profit organization in the western region of the
United States dedicated to improving the well-being of low-income seniors through innovative
programs and services. According to the Senior Support Annual Report (2016), the mission of
the organization is helping low-income older adults live a healthy, independent, and fulfilling
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lives. Senior Support opened nearly twenty years ago to serve meals to low-income senior adults
in the community. Within ten years, the organization recognized critical needs that were not
being met such as transportation, case management, and referral services to for physical and
mental health needs. The organization added senior affordable housing units to compliment the
full spectrum of services and nearly ten years ago, Senior Support opened the cornerstone of
their organization, an innovative and integrated Wellness Center to promote independence and
healthy living for seniors. Completing the full-service model was the addition of a senior dental
clinic, which provides access to high-quality, low-cost dental care coordinating with clinical and
social services (Senior Support, 2015).
The average income of Senior Support clients is $850 per month and 85% of all clients
live at or below the poverty level (Senior Support, 2016). The Elder Economic Security
Standard Index, an accurate measure of poverty utilizing data from the United States Census
Bureau and the United States Department of Housing and Urban Development, estimates this is
less than half of what is needed to ensure basic needs are met for a senior living in the area
(UCLA Health Center for Policy Research, 2013). Senior Support serves a diverse population
including 61 percent minority clients (Senior Support, 2015). Meals and supportive services are
provided 365 days per year to more than 2,000 clients per day. Senior Support has some
strategic partnerships with local universities, healthcare providers, advocacy groups, government
agencies, and other non-profit organizations to provide services. The organization leverages
more than $1 million annually by providing free space for partners in exchange for free services
for clients (Senior Support, 2015). The integration of services at the Wellness Center, including
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medical, dental, case management, mental health, and meals, helps seniors remain independent
and healthy. Programs that help older adults live independently in the community decrease the
costs of long-term supports and services (Thomas & Mor, 2013).
Organizational Performance Status
As the senior population grows, so does the need for services. According to the Elder
Economic Security Standard Index, 40% of seniors within the service boundaries of Senior
Support are low-income (UCLA Health for Policy Research, 2013). Based on the mission of the
organization, there is a desire by senior leadership for an open-door policy, helping all seniors in
need of services which requires a steady stream of income from varied sources. The majority of
funding comes from the OAA. The organization receives 6.5% of its funding from foundations
and 55% from corporate and individual donors (Senior Support, 2016). As the largest provider
of senior services in the county, Senior Support is recognized as a model organization from local,
state, and national aging organizations.
Organizational Performance Goal and Current Performance
One of the long-term performance goals of the organization is to increase governmental
funding and impactful legislation that benefits older adults, especially those living in poverty.
The organization believes that this can be achieved by utilizing data to show a decrease in
emergency room visits and hospital stays due to the nutrition and supportive services clients
receive at Senior Support. The nutrition program sets the foundation for all other service
offerings. Nutrition programs are integral to reducing the number of necessary medical
interventions and overall cost of care. While the staff at Senior Support recognizes that good
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nutrition, along with social engagement, supportive services, and lifelong learning, increase the
health and wellbeing of seniors, they understand the need for tracking data.
The organization implemented real-time electronic record keeping which monitors every
meal, activity, service, and intervention with clients. Clinical staff is trained to monitor
improved health outcomes for clients through a Comprehensive Geriatric Assessment (CGA)
tool. Through this data collection, the organization found that 80% of seniors utilizing services
for the first time were at moderate to high risk for malnutrition and 70% of seniors reported food
insecurity (Senior Support, 2015). The organization believes they implemented a replicable
model that offsets Medicare expenses by improving overall health, reducing hospital visits, and
increasing the length of time seniors can live healthily and independently outside of nursing
homes. Their clients are reassessed every six months, and more than 85 percent strongly agreed
that the assistance they receive at Senior Support helps them to remain independently at home
(Senior Support, 2015). This corroborates research conducted at Brown University, which found
that states that have invested in meal programs for older adults have fewer residents in nursing
homes (Thomas & Mor, 2013).
Description of Stakeholder Groups
There are several stakeholder groups that work in conjunction to achieve the performance
goal of the organization. The Senior Support clinical staff plays an integral role to ensure data is
tracked appropriately to monitor improved health outcomes for clients. This begins with a CGA
designed to collect data and establish a care coordination plan for each client. Every meal,
program, and service that a client receives is documented in Efforts to Outcomes, a software
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program specifically designed to track the efforts of social service organizations and accessible
by every staff member in the organization. The administrative staff at Senior Support is equally
as important. This includes management, finance, development, communications, and public
affairs. The administrative staff is responsible for the overall operations and funding of
programs and services. The most important stakeholders are the clients who directly benefit
from achieving the performance goal. After agreeing to participate in the initial assessment,
clients are provided with an identification card with a barcode to scan when they access meals or
services. This card is critical to documenting a correlation between investments in senior
wellness programs and reduced health care utilization and Medicare expenditures.
Stakeholder Group from the Study
While all the stakeholders play a critical role in the health and wellbeing of older adults,
it is important to understand the promising practices and data collection strategies used by Senior
Support clinical staff to show senior nutrition programs offset Medicare costs. The clinical staff
offers a unique perspective because they work directly with clients and witness the value of the
programs and services offered by the organization. They are responsible for accurately assessing
clients and documenting health improvements. This is a critical component to the promising
practice because their knowledge and motivation play an essential role in the success of the
organization. Also, clinical staff regularly meet with senior leadership to make
recommendations for new programs and services based on data collection and observations.
Therefore, the stakeholders of focus for this promising study are Senior Support clinical staff.
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Purpose of the Project and Questions
The purpose of this project was to study the organization’s performance related to a larger
problem of practice. The analysis focused on the assets in the area of knowledge and skills,
motivation, and organizational resources. While a complete study would have focused on all
stakeholders, for practical purposes the stakeholders focused on in this analysis was Senior
Support clinical staff. The analysis focused on the role that staff members have in administering
a nutrition program for seniors and collecting data to show that nutrition, health education, and
wellness programs decrease health services utilization.
As such, the questions that guided this promising practice study were the following:
1. What are the knowledge, motivation, and organizational assets in relation to the goal of
collecting data to support that senior nutrition programs improve health outcomes for
older adults and decrease emergency room visits and hospital stays?
2. What are the areas of knowledge, motivation, and organizational resources that are
needed to utilize data to create programs for older adults that are designed to improve
overall health outcomes?
3. What solutions and recommendations in the areas of knowledge, motivation, and
organizational resources may be appropriate for solving the problem of practice at
another organization?
Conceptual and Methodological Framework
This study utilized Clark and Estes’ (2008) gap analysis framework, a systematic,
analytical method that helps to understand organizational goal achievement. The researcher
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adapted the framework to a promising practice approach and implemented this as the conceptual
framework. Assumed knowledge, motivation, and organizational assets were generated by the
researcher based on personal knowledge and related literature. The researcher assessed these
influences through interviews, document analysis, surveys, literature review, and content
analysis. Research-based solutions have been recommended by the researcher and evaluated in a
comprehensive manner.
Definitions
The following definitions are federally accepted terms which are commonly used in social
service organizations working to improve the quality of life for older adults:
Clinical Staff: Licensed clinical social workers, nurses, geriatric care coordinators, psychiatrists,
and case managers (Senior Support, 2015).
Comprehensive Geriatric Assessment (CGA): A multidimensional, multidisciplinary diagnostic
instrument designed to collect data on the medical, psychosocial and functional capabilities and
limitations of elderly patients (Ellis, Whitehead, O’Neill, Langhorn, & Robinson, 2011).
Medicare: The United States federal health insurance program for people who are 65 and older
(Medicare.gov, 2017).
Older Adults: Men and women age 65 and older (Medicare.gov, 2017).
Senior Nutrition Program: Authorized under Title III, Grants for State and Community
Programs on Aging, and Title VI, Grants for Native Americans, under the Older Americans Act,
is intended to improve the dietary intakes of participants and offer opportunities to form new
friendships and to create informal support networks (National Council on Aging, 2017).
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Seniors: Men and women age 65 and older (Medicare.gov, 2017).
Organization of the Project
Five chapters are used to organize this study. This chapter provided the reader with the
key concepts and terminology commonly found in a discussion regarding senior nutrition
programs. The organization’s mission, goals, and stakeholders, as well as the initial concepts of
gap analysis, were introduced. Chapter Two provides a review of the current literature
surrounding the scope of the study. Topics of malnutrition in older adults, the importance of
senior nutrition programs to physical and mental health, and the CGA are addressed by the
researcher. Chapter Three details the assumed influences for this study, as well as the
methodology the researcher implemented regarding the choice of participants, data collection,
and analysis. In Chapter Four, the data and results are assessed and analyzed by the researcher.
The researcher provided a discussion on the findings in Chapter Five. Chapter Five also focuses
on the limitations of this study and the researcher provided recommendations for the
implementation of the promising practice at similar organizations based on a synthesis of the
literature and data results.
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CHAPTER TWO: REVIEW OF THE LITERATURE
This literature review examines the link between senior nutrition programs, improved
health outcomes, and the implications for cost savings to Medicare. The review begins with
general research on malnutrition in older adults. This is followed by an overview of research on
the importance of senior nutrition programs to physical and mental health. The review includes
an in-depth discussion on the CGA, a holistic assessment tool used to determine the medical,
psychological, and functional capabilities of older adults. The literature review will also discuss
the history and sustainability of the Medicare program and conclude with evidence on the cost
saving benefits of senior nutrition programs. Following the general research, the review turns to
the Clark and Estes (2008) Gap Analytic Conceptual Framework and, specifically, the
knowledge, motivation and organizational influences of clinical staff to improve health outcomes
for older adults.
Malnutrition in Older Adults
Malnutrition, insufficient food intake compared with nutrition requirements, is a serious
health problem for older adults. It is often caused by physical, social and psychological issues
such as restricted diets, limited income, and dental issues. Also, natural age-related changes in
appetite predispose older adults to a decrease in food intake. Despite the fact that effective
interventions are available, prevention and treatment of malnutrition do not receive appropriate
attention, especially in nursing homes where malnutrition rates range between 52 and 85%
compared to five to 12% of older adults who live independently (Isenring, Baker, & Kerr, 2013;
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Volkert, 2013). Malnutrition causes impaired recovery from injury and illness, impaired wound
healing, reduced muscle strength, and fatigue (Denny, 2007; Marshall, Bauer, & Isenring, 2014).
Malnutrition increases health care costs by delaying recovery, extending hospital stays, and
increased medical complications (Allaudeen, Vidyarthi, Maselli, & Auerbach, 2011; Kellett,
Kyle, Itsiopoulos, Naunton, & Luff, 2016; Norman, Pichard, Lochs, & Pirlich, 2008).
Research has found that at least one in three older adults admitted to hospitals are
malnourished, which increases health care costs by more than 300 percent (Correia & Waitzberg,
2003; Gamble Coats, Morgan, Bartolucci, & Weinsier, 1993; Giner, Laviano, Meguid, &
Gleason, 1996; Thomas, Zdrowski, Wilson, Conright, Lewis, Tariq, & Morley, 2002). Studies
have estimated that the cost of treating disease-associated malnutrition is $157 million per year
in the United States (Correia et al., 2003) and $3.5 trillion globally (Haddad, Achadi, Benedech,
Ahuja, Bhatia, Bhutta…Reddy, 2015). Addressing malnutrition in older adults improves health
outcomes and reduces health care expenditures (Elia, 2006; Lloyd & Wellman, 2005; Volkert,
2013).
Impact of Senior Nutrition Programs on Health Outcomes
The majority of older adults who participate in senior nutrition programs have the
greatest economic or social need and are at risk of institutionalization (Administration on Aging,
2009). Characteristics of those at the highest risk include older adults who lack familiar
caregivers, do not have children, and have one or more chronic health condition (Alshuler &
Schimmel, 2010; Porter & Cahill, 2005). A review of the literature suggests that senior nutrition
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programs can improve physical, mental, and social health in older adults. Congregate nutrition
program studies have found that older adults who eat at a nutrition program have a significantly
higher percentage of Recommended Dietary Allowances (RDA) for energy, protein, and calcium
that those who did not (Balsam & Rogers, 1991, Palamino & Colello, 2011), and a majority of
participants believe meal programs help them feel better, allow them to remain independent in
their own homes, and helps them eat healthier (Lloyd et al., 2015). A randomized clinical trial
conducted by the Institute of Medicine (2000) directly examined the impact of nutrition therapy
and found consistent evidence to indicate that nutrition therapy is effective as part of a
comprehensive approach to the management and treatment for conditions such as dyslipidemia,
hypertension, heart failure, diabetes, and kidney failure.
Senior nutrition programs can increase socialization and decrease isolation in older
adults. Older adults are at risk for social isolation due to declining health (Nicholson, 2012),
however, research suggests that individuals with adequate social relationships have a 50%
greater chance of survival compared to those with poor or insufficient social relationships (Holt-
Lunstad, Smith, & Layton, 2010). Senior nutrition programs increase self-reliance, confidence,
and dignity, provide community engagement and volunteer opportunities, and improve social
skills (Buehler Center on Aging of Northwestern University, 2000; Gergerich, Shobe, & Christy,
2015; Iacovou, Kirk, Waldrop, & Rittner, 2001; Patterson, Truby, & Palermo, 2012; Nicholson,
2012). Several studies have indicated evidence that congregate meal programs increase social
interaction. A study in California found that 87% of congregate meal participants identified
social interaction as their primary reason for attending senior nutrition programs with secondary
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benefits including social support, relief of loneliness and depression, stimulation, and self-
satisfaction (Neyman, Zidenberg-Cherr, & McDonald, 1996). Similarly, a study conducted in
suburban Chicago found that participants cited “socialization” as the primary reason for
attending congregate meals and a nationwide survey in 2013 found that 83% of participants “see
friends more often” because of congregate meals (Gergerich et al., 2015).
Assessment of Senior Nutrition Programs
Assessment models can be used to evaluate the effectiveness of senior nutrition
programs. Studies conducted to evaluate the nutritional status of older adults participating in
senior nutrition programs indicate improvements in physical and mental health (Beauchet,
Launay, Merjagnan, Kabeshova, & Annweiler, 2014; Joung, Ki, Yuan, & Huffman, 2011;
Wunderlich, Fodero, & McKinnon, 2007). However, it can be difficult to assess nutritional and
health status because few tools are designed specifically for the older adult population (Fodero,
Wunderlich, Shahla, 2008). Current funding for senior nutrition programs is insufficient for the
increasing older adult population (Lloyd et al., 2015). Therefore, it is critical that providers
utilize a standard measurement tool to assess clients and collect information on health
improvements to justify increases in funding for senior nutrition programs.
Comprehensive Geriatric Assessment
The CGA is a multidisciplinary, holistic approach to evaluating older adults’ health
needs, which leads to creating an overall plan with effective strategies for treatment and follow-
up (Caillet, Canoui-Poitrine, Vouriot, Berle, Reinald, Krypciak, . . . Paillaud, 2011; Ramani,
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Furmedge, & Reddy, 2014; Stuck & Illiffe, 2011). Although there is a lack of research on
utilizing the CGA specifically for assessing the outcomes of nutrition programs, previous studies
have found that the utilizing the CGA results in mortality decline, reduced length of
hospitalization, fall prevention, preservation of cognitive function, and reduced medical costs
(Caillet et al., 2011; Ellis, Whitehead, O’Neill, Langhorn, & Robinson, 2011; Scanlan, 2005).
Sustainability of the Medicare Program
The population increase of adults age 65 and older threatens the sustainability of the
Medicare program. In 2010, a typical Medicare beneficiary was estimated to have a total
lifetime Medicare spending worth $130,000 (Gaudette, Tysinget, Cassil, & Goldman, 2015).
Due to rising life expectancy, higher prevalence of chronic conditions and medical cost growth,
the total lifetime spending for Medicare beneficiaries in 2030 is estimated at $223,000, a 72
percent increase (Gaudette et al., 2015). Overall Medicare spending is projected to double
between and 2010 and 2030 to about $1.2 trillion annually in 2030 (Gaudette at al., 2015), due to
poorer health including increased rates of hypertension, high cholesterol, and diabetes, and
increases in health care costs (King, Matheson, Chirina, Shankar, & Broman-Fulks, 2013).
Alternative Medicare Payment Models
Alternative payment models are being explored for sustaining the Medicare program.
Alternative payment models reward quality over quantity and may prove to be a long-term
solution that fundamentally transforms the Medicare delivery system, including improved quality
and controlled costs (Clough, Richman, & Glickman, 2015; Nathan & Dimick, 2017). In 2015,
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the Department of Health and Human Services replaced 20% of Medicare fee-for-service
payments with alternative payment models, with goals of replacing 30% by the end of 2016, and
50% by 2018 (Clough et al., 2015). Additional research is required to understand the long-term
impact of alternative payment models.
Benefits of Senior Nutrition Programs as a Cost Savings to Medicare
Research shows there is a potential to save millions of dollars in Medicare expenditures
by using nutrition to keep seniors healthy and independent. According to the Institute of
Medicine (2000), expanded coverage for nutrition therapy will likely generate economically
significant benefits to the Medicare program. Estimates are $52 million to $167 million for
hypertension, $54 million to $164 million for those with elevated lipids, and $132 million to
$330 million for those with diabetes.
A randomized study by Parikh, Montgomery, and Lynn (2015) involving 625 older adults
who participated in a senior nutrition program found that recipients had fewer falls and
hospitalizations than their counterparts who did not receive a meal service. In 2015, over $31
billion was spent in Medicare expenses to treat falls (Burns, Stevens, & Lee, 2016) and is
expected to increase to $54.9 billion in 2020 (Englander, Hodson, & Terregrossa, 1996). Similar
research has found that if all states increased by one percent the number of adults aged 65 years
and older who participate in a senior nutrition program, total annual savings to states could
exceed $109 million due to individuals who were able to remain at home and not require nursing
home care (Lloyd et al., 2015). Providing nutrition has previously been viewed outside the scope
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of healthcare, however research shows positive health outcomes with health and social services
are a coordinated effort (Lloyd, 2013; Parikh et al., 2015).
Explanation of the Clark and Estes Framework
Clark and Estes (2008) provide a problem-solving framework which identifies the needs
between performance level and organizational goals. The purpose of utilizing the framework
was to analyze if stakeholders have the knowledge, motivation, and organizational support
needed to achieve performance goals. According to Krathwohl (2002), there are four types of
knowledge categories that lead to learning outcomes: factual, conceptual, procedural, and
metacognitive. In the Clark and Estes framework, these types of knowledge are assessed to better
understand stakeholder knowledge influences on performance. Also, research by Clark and Estes
(2008) suggests that failure to achieve goals often stems from stakeholder motivation influences.
The indicators that influence motivation include active choice, persistence, and mental effort.
Finally, organizational influences, such as work processes or inadequate resources, must also be
addressed as a barrier to achieving performance goals (Clark and Estes, 2008).
The researcher utilized elements from the Clark and Estes (2008) framework to determine
the clinical worker’s knowledge, motivation, and organizational needs to meet their performance
goal of collecting data to show health improvements of older adults utilizing senior nutrition
programs. The organizational goal is to use the data to advocate for increased federal funding
for senior nutrition programs. The first section is a discussion on assumed influences on the
stakeholder performance goal in the context of knowledge and skills. Clark and Estes (2008)
suggest that knowledge is the foundation for building a solid framework for improving
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performance. The next section focused on assumed influences on the attainment of the
stakeholder goal from the perspective of motivation. Finally, the researcher reviewed assumed
organizational influences on achievement of the stakeholder goal. The researcher, through the
methodology discussed in Chapter Three, examined each of these assumed stakeholder
knowledge, motivation, and organizational influences on performance.
Stakeholder Knowledge, Motivation, and Organizational Influences
Knowledge and Skills
The clinical staff at Senior Support is tasked with assessing clients on a regular basis to
monitor health outcomes assessed by the CGA. The data collected by the CGA is intended to
show that senior nutrition programs help keep seniors healthy and independent, offering a cost-
savings to Medicare. Clark and Estes (2008) suggest that knowledge is the foundation for
building a solid framework for improving performance. A lack of knowledge creates an
opportunity to learn and then contribute to the organization. At Senior Support, the mission is to
help seniors in poverty live healthy and fulfilling lives. Building a workforce of knowledgeable
clinical staff is conducive to achieving the stakeholder goal of implementing health improvement
programs based on data measured by the CGA. This review of literature will focus on the
knowledge and skills necessary to assess clients, implement health improvement programs, and
create a care plan to ensure health outcomes are achieved.
Knowledge influences. According to Krathwohl (2002), there are four types of
knowledge categories that lead to learning outcomes: factual, conceptual, procedural, and
metacognitive. Factual knowledge refers to the basic elements of a specific discipline such as
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terminology and specific details and elements (Krathwohl, 2002). Similarly, conceptual
knowledge also refers to basic elements, with the addition of how things function together. For
example, knowledge of classifications and categories, principles and generalizations, and
theories, models, and structures (Krathwohl, 2002). Providing services to older adults requires
specialized knowledge and skills. To be successful, the clinical staff needs a solid understanding
of the theories of aging, contextual factors such as race, ethnicity, and social class, and social
justice issues (Blando, 2011). Procedural knowledge is how to do something. Staff must feel
empowered to apply their knowledge, devote time to challenging tasks, and offer expertise to
colleagues lacking in skills (Markova & Ford, 2011). Colman (2015) categorizes procedural
knowledge as “knowing how” in contrast to “knowing that”. Metacognitive knowledge is having
the awareness and ability to self-assess (Reuda, 2011). Optimal performance takes place when
the Senior Support clinical staff demonstrates success in each of these categories.
Clinical staff knows the seven different social theories of aging. This declarative
(conceptual) knowledge gives staff the ability to observe the influences that society has on the
aging process. The literature suggests that understanding social theories of aging helps to
mediate relations between older people and care professionals (Powell, 2009). It is important to
have a solid grasp on all seven social theories of aging because aging is multi-dimensional;
therefore, it is impossible to develop one overarching theory (Kolb, 2004). When clinical staff
shows they understand the needs of older adults, they can establish trust. Using social theories of
aging during counseling sessions with older adults provides important clues to increase life
satisfaction (Fry, 1992) and examines the continuity of values, skills, and activities (Atchley,
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1992). This information is important because it allows clinical staff to create an appropriate care
coordination plan for each client to reach optimal health outcomes.
Clinical staff knows health promotion programs. Clinical staff knows cost-effective
health programs. This conceptual knowledge gives staff the ability to develop programs that
increase the quality of life and decrease health care costs. Every provider of senior services
needs to offer health promotion programs specific to a community to best meet their needs
(Koehn, Habib, & Bukhari, 2016). Effective senior centers offer health promotion programs
including recreation, health and nutrition, and education (Dal Santo, 2009), and serve as
community focal points for community-based services for older adults (Casteel, Nocera, &
Runyan, 2013). Research demonstrates that a healthy lifestyle is more influential in helping older
adults avoid the decline traditionally associated with aging than genetic factors (Nunez,
Armbruster, Philips, & Gale, 2003). Health promotion programs can alleviate or postpone health
declines associated with aging (Schuster, 1995). With the knowledge of programs that increase
health outcomes for older adults, clinical staff is empowered to implement new programs at
Senior Support.
Clinical staff needs to know how to assess clients effectively as measured by the CGA.
The CGA is a holistic assessment model to determine the medical, psychological and functional
capabilities of older adults (Rodgers, 2016; James, 2016), and used to develop an integrated plan
for treatment (Ellis, Whitehead, O’Neill, Langhorne, & Robinson, 2011). The CGA is also used
to detect limitations of social support (Overcash, Beckstead, Extermann, & Cobb, 2005), which
helps the clinical staff at Senior Support create an individualized plan for each client aimed at
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preventing malnutrition. Research found that the delivery and management of nutrition
interventions require a team approach (DiMaria-Ghalili, 2014). James (2016) researched case
studies in a clinical setting and found that using the CGA earlier in treatment would have
provided clients with a higher standard of care and possibly prevented the need for a higher level
of care. If clinical staff has the knowledge to effectively assess clients using the CGA, they can
successfully document positive health outcomes based on the senior nutrition program.
Clinical staff knows how to self-reflect on their knowledge of health promotion
programs in relation to each client. During this self-reflection, clinical staff tests their own
knowledge by creating a care coordination plan for each client that will improve overall health.
The more knowledge clinical staff can share with clients, the better the outcome will be.
Addressing these gaps will allow clinical staff to create more robust care coordination plans for
clients. A study by Sheng and Simpson (2013), found that providing health information to older
adults is crucial to empowering them to control their health better. Working with clients that
have diverse situations and emotions may invoke personal memories for clinical workers (Yip,
2006). If the clinical staff uses self-reflected personal stories to share with clients, they can
establish a relationship, making it easier to provide health advice and recommendations.
The literature shows that self-reflected insights, and drawing on past experiences, imply wisdom
and competence (Morrison, 1997; Ruch, 2000). Through self-reflection, the clinical staff can
assess their knowledge and find performance gaps. Table 1 reflects the knowledge influences
and related assessments.
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Table 1
Knowledge Influences, Knowledge Types, and Knowledge Assessment
Knowledge Influence Knowledge Type Knowledge Influence
Assessment
Clinical staff knows the seven different
Social Theories of Aging.
Declarative –
Conceptual
Clinical staff asked to
recall the components
of the seven different
Social Theories of
Aging.
Clinical staff knows health promotion
programs.
Declarative –
Conceptual
Clinical staff asked to
evaluate different
health promotion
programs and
categorize under
“possible programs to
implement” or
“programs to avoid”.
Clinical staff knows how to assess clients
effectively as measured by the CGA.
Procedural Clinical staff will be
monitored by the
Director of Clinical
Services to ensure data
is accurately collected
and analyzed.
Clinical staff needs to know how to self-
reflect on their knowledge of health
promotion programs in relation to each
client.
Metacognitive Clinical staff will be
required to create a
care coordination plan
for each client that will
improve overall health.
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Motivation
According to Clark and Estes (2008), the indicators that influence motivation are active
choice, persistence, and mental effort. Active choice is when someone chooses to pursue a goal
actively. Persistence is continuing to work toward that goal despite distractions. Clark and Estes
(2008) suggest that in addition to active choice and persistence, mental effort, mainly determined
by confidence level, is critical to motivating someone to achieve their goal. If a person has a
high-level of confidence, they can feel bored with tasks, exerting a small amount of mental
effort. Similarly, a person with a low-level of confidence also exerts small amounts of mental
effort because they tend to believe they may fail at reaching their goal. Research by Clark and
Estes (2008) found four factors that have a major influence on active choice, persistence, and
mental effort: (1) Personal and team confidence, (2) Beliefs about organizational and
environmental barriers to achieving goals, (3) The emotional climate people experience in their
work environment, and (4) The personal and team values for their performance goals. It is
important for organizations to address motivational issues because the failure to achieve goals
typically stems from motivation problems and not a lack of knowledge and skills (Clark and
Estes, 2008).
The Senior Support clinical staff actively chose to work for an organization with a
mission to improve health outcomes for seniors. They actively pursue the opportunity to work
with clients and help them live independently as long as possible. They persist in their role
despite numerous issues such as low wages, difficult clients, and a heavy workload. While staff
could become easily distracted, they persist because they are motivated by the health
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improvements they see in their clients. According to Clark and Estes (2008), mental effort
requires staff to develop novel solutions. One of these solutions is creating new health
improvement programs. The clinical staff must find the right balance of confidence while
working with clients. Creating a care coordination plan for each client takes a high level of
mental effort and the staff values this task because they feel efficacious that their efforts are
improving overall health outcomes. Motivation is enhanced when people value their tasks
(Eccles, 2006).
The literature review focuses on the ability for clinical workers to improve overall health
outcomes. This section will focus on two of the motivational influences that help clinical staff
implement health improvement programs. The first influence, based on the attribution theory, is
that clinical staff should feel that low level of improvements in health is due to their efforts
rather than the client’s lack of ability to change behaviors. The second influence, based on the
self-efficacy theory, is that clinical staff believes they are capable of improving the quality of life
of seniors by helping them to remain independent and healthy in their own homes.
Attribution Theory. The attribution theory, first proposed by Heider (1958), is
concerned with how individuals interpret events in relations to their thinking and behavior
(Snead, Magal, Christensen, & Ndede-Amadi, 2015). Heider’s study of attribution was
expanded by Bernard Weiner who suggested that the specific attribution, such as luck or effort,
was less important than three dimensions: locus, stability, and controllability (Anderman &
Anderman, 2006). Locus is whether an individual perceives the cause of an event as due to an
internal or external factor. Stability is whether the cause is stable or unstable across time and
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environment. Controllability is whether or not an individual believes they are in control of the
outcome. Sahar (2014) suggests that the attribution theory, originally applied in the context of
studying academic achievement, can also be applied to social, political, and policy issues.
Learning and motivation are enhanced when individuals attribute success or failures to effort
rather than ability (Anderman & Anderman, 2006). According to Borkowski and Allen (2003),
the attribution theory framework is beneficial in the healthcare field in changing behaviors.
Clinical Staff Attributions. The research suggests that the attributions clinical staff
makes can influence behaviors by their willingness to offer help or support (Dilworth, Phillips, &
Rose, 2011). The clinical staff at Senior Support believes they have the ability to change client
behaviors by making recommendations on health improvement programs and explaining the
benefits to achieving optimal health. A study by Hand, Cavanaugh, Forbes, Govern, and Cress
(2012) found that implementing a leadership training program to increase self-efficacy, self-
esteem, and initiative at a community senior center led to positive changes in health-related
quality of life and increased exercise training. Similar research by Haber (1996), found that
clinical staff promoting health activities among older adults at a senior center was a successful
model for improving overall health. The clinical staff at Senior Support is motivated by the fact
that they believe health improvements are strongly influenced by the amount of effort they put in
working with clients.
Self-Efficacy Theory. Positive self-efficacy is a motivator that leads to accomplishing
goals (Bandura, 2000). Pajares (2009) suggests that people must believe that their actions will
produce the desired outcome, or they will have little incentive to act or persevere when
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encountering difficulties accomplishing a task. The effectiveness of a team is determined by the
level of efficacy exerted by individuals (Bandura, 2000). In the context of social problems, a
collective effort of efficacy is most beneficial in achieving change. Bandura (2000) asserts that a
team’s accomplishments are not based on an individual’s self-efficacy, but rather the collective
efficacy of shared beliefs that influence the results they seek to achieve. People with high self-
efficacy approach difficult tasks and activities with ease and enjoyment (Pajares, 2009).
Clinical Staff Self-Efficacy. People with a high level of self-efficacy view difficult tasks
as something to be accomplished rather than avoided (Pedrazza, Trifiletti, Berlanda, & Gian,
2013). The clinical staff at Senior Support believes they can improve the quality of life of
seniors by helping them to remain independent and healthy. Since this is not an easy task,
exerting a high-level of self-efficacy motivates staff to achieve their goal. Consistent with
Bandura’s theory, research shows that clinical workers with high self-efficacy have the ability to
assess clients and provide intervention leading to positive outcomes (Simons & Bonifas, 2016).
It is important for clinical staff to feel confident that their work significantly improves the quality
of life for their clients. They have the ability to enhance the client’s self-efficacy and reinforce
the importance of personal accountability. Through high expectations and goal setting, clinical
workers generate feelings of optimism, possibility, and hope (Hopps, Pinderhughes, & Shanakar,
1995). Based on the self-efficacy theory, the clinical staff at Senior Support believe their high
self-efficacious efforts working with clients is the reason seniors are living healthy and fulfilling
lives. Table 2 reflects the motivational influences and motivational influence assessments.
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Table 2
Assumed Motivation Influences and Motivational Influence Assessment
Assumed Motivation Influences Motivational Influence Assessment
Attributions – Clinical staff should feel that low
level of improvements in health is due to their
own efforts rather than the clients’ lack of ability
to change behaviors.
Written survey item: “Improvements in
health are strongly influenced by the amount
of effort I put into working with seniors.”
(Strong disagree – strongly agree)
Interview prompt: “What are some of the
behaviors that hinder keeping seniors healthy
and independent in their homes?”
Self-Efficacy – Clinical staff believes they are
capable of improving the quality of life of seniors
by helping them to remain independent and
healthy in their own home.
Written survey item: “I feel confident that
working with clients is significantly
improving their quality of life.” (Strongly
disagree – strongly agree)
Interview prompt: “How do you feel about
your ability to improve the quality of life for
clients utilizing the senior nutrition
program?”
Organization
Knowledge and motivation are imperative to developing a competent workforce.
However, knowledge and motivation are not enough to accomplish organizational goals. It is the
responsibility of an organization to provide resources for the completion of tasks (Clark & Estes,
2008). This includes creating work processes, furnishing tangible supplies and equipment, and
creating a company culture. It is also incumbent on the organization to use a gap analysis to
identify performance gaps and implement organizational change.
Research by Clark and Estes (2008) found six types of support necessary for most
organizational change processes: (1) Have goals, a clear vision, and a way to measure progress,
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(2) Align the structures and the processes of the organization with goals, (3) Communicate
constantly and candidly to those involved about plans and progress, (4) Top management must
be continually involved in the improvement process, (5) Provide adequate knowledge, skills, and
motivational support for everyone, and (6) All change processes with the same name are not
equal. While implementing change can be difficult, it is a critical component, along with
knowledge and motivation, to achieve organizational goals.
The following literature review examines organizational influences pertinent to achieving
the Senior Support organizational goal of having data to advocate that senior nutrition programs
offset Medicare expenses by improving overall health, reducing emergency room visits, and
increasing the length of time seniors can live healthy and independent outside of nursing homes.
Specifically, the literature review focuses on the immediate goal of implementing health
improvement programs as measured by the CGA. The literature has been analyzed by the
researcher to identify specific organizational influences that may impact how clinical staff
achieves organizational goals.
Cultural Model and Cultural Settings
One of the most important aspects of an organization is the culture. The cultural model is
a shared understanding of how the organization works or ought to work and the cultural setting is
when two or more people come together to accomplish goals (Gallimore & Goldenberg, 2011).
The cultural model at Senior Support is based on the mission to improve the quality of life for
aging adults. The cultural model can be achieved by multiple instances of cultural settings where
staff collaborate and achieve performance goals. Goffee and Jones (1996) described
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organizational culture as the glue that holds organizations together. According to Schein (2004),
culture stems from shared assumptions created from group norms, values, habits, formal
philosophy, and formal rituals or celebrations. Research by Balthazard, Cooke, and Potter
(2006) found that expected behaviors and norms can explain why some organizational units
exhibit dysfunctional behaviors that are counter to the organization’s mission and hinder
efficiency and effectiveness. Successful organizations rely on values such as customer
orientation, concern for employees, transparency, openness to the community, innovation, and
respect for others (Tatarusanu & Onea, 2013).
Cultural Model: innovation. Innovation has a vital role in the growth of an
organization. Research by Parveen, Senin, and Umar (2015) found a significant positive
relationship between organizational culture and a commitment towards innovation. Despite
multiple viewpoints that culture can foster innovation, Dougherty and Heller (1994) found
evidence that innovations may fail because organizations prefer stability in systems of thought
and action. However, organizations are continually under competitive pressure and forced to
come up with innovations (Sadegh & Ataei, 2012), especially for providers working to influence
health outcomes for older adults positively. A study by Nimrod and Hutchinson (2010) found
that innovation in activities tended to protect a sense of internal continuity, which had a positive
effect on the well-being of older adults with chronic health conditions. Their findings suggest
that innovation plays a role in improving health outcomes and physical impairments.
Innovative clinical staff. One of Senior Support’s assumed organizational assets is an
organizational culture where clinical staff is involved in the innovation and implementation of
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new health improvement programs. Due to the diversity of clients with varying levels of health
needs, the organization has found that one-size-fits-all programs are not as effective in improving
overall health outcomes. According to Dyer, Gregersen, and Christensen (2011), innovators gain
a different perspective when they devote time and energy to finding and testing ideas through a
network of diverse individuals. Senior Support has created an organizational culture where the
clinical staff has a high degree of responsibility for achieving the overall organizational goals.
Goals are accomplished when staff develops a sense of ownership and control over their work
ideas, overcomes potential problems with persistence and determination, and produces more
creative and innovative outcomes (Hogan & Coote, 2014).
Cultural Model: communication. Organizational communication impacts the
effectiveness of an organization. Internal communication is cultivated by authentic leadership,
which includes supportiveness, emphasis on reward, and stability (Men & Jiang, 2016).
Research by Chen (2008) found a linkage between internal employee communication and
organizational effectiveness. Poor communication from organizational leadership can lead to
performance gaps and misalignment of goals. Bratton and Gold (1999) believe that there should
be a commitment from senior management to communication efforts. Specifically, a
combination of written and face-to-face channels work best, messages should be perceived to be
relevant to employees, messages should be consistent with actions, and the communication
system should be monitored and evaluated. Internal communication is a key factor in the survival
and growth of an organization (Kitchen & Daly, 2002).
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Internal communication. Preliminary observations suggest Senior Support uses internal
communication between clinical staff and leadership on the importance of using data from the
CGA to implement new health improvement programs. The organization has a multi-layer
approach to serving clients. Clinical staff works directly with clients and has the responsibility
of recording accurate data related to health outcomes. Administrative staff works in a separate
area that offers little direct interaction with clients. Therefore, the organization facilitates
strategies to ensure both clinical staff and administrative staff are constantly communicating.
According to Dixon, Arnold, Heineke, Kim, and Mulligan (1994), one aspect of improving
efficiency, service, and quality is the ability to communicate constantly and candidly. This
creates trust, which increases the commitment to achieve performance goals on all levels. Senior
Support has created a culture where staff is welcome to share opinions, ideas, and criticisms with
other staff. This type of open communication, as researched by Gordon and Hartman (2009),
leads to cohesion among teams, organizational commitment, and a lower level of stress in the
workplace.
Cultural Setting: workload. According to Bruggen (2015), a moderate employee workload
positively impacts performance while a high workload decreases staff productivity. Specifically,
when working in a healthcare setting, reductions in staffing levels mainly due to budgetary
constraints, diminish the commitment of staff (Burke, 2003; Rafferty, Clarke, & Coles, 2007).
Ultimately, this not only has a negative effect on teamwork, delegation, and trust, but an adverse
effect on patient outcomes (Thompson, 2012). Increasingly high demands on employee time,
effort, and cognitive processing negatively impact performance (Burke, 2003).
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Workload support in a clinical setting. The collection of data at Senior Support is a
relatively new endeavor. Previously, staff anecdotally believed their work was improving health
outcomes; however, there was a critical need to collect data to prove it. While collecting data is
a critical component of meeting the organization’s global goal, clinical staff worried that
completing the CGA would feel overwhelming when they were already working with a large
number of clients. Perceiving a high workload generates stress and cognitive fatigue, which
contributes to poor performance behaviors (Sutthiwan & Clinton, 2008). It is the responsibility
of an organization to create a work process that specifies how people, equipment, and materials
link and interact to produce results (Clark & Estes, 2008). Senior Support is assumed to have
created an organizational culture that provides the necessary resources to ensure clinical staff can
accurately collect data from the CGA.
Cultural Setting: policies, procedures, and processes. From an organizational culture
perspective, measurable outcomes are a result of strong policies, procedures, and processes.
According to Clark and Estes (2008), organizational processes have to support policies or there
is a great risk of failure. Research by Carthey, Walker, Deelchand, Vincent and Griffiths (2011),
found that policies which are overly complex, with a large number of guidelines, may be difficult
for staff to understand and comply. Carthey et al., (2011), recommends simplifying policy
development by reducing the number of organization-wide policies, consulting with industry
leaders when policies and guidelines are developed, and raising awareness among organizational
leadership to understand that simply writing a policy without explanation will not ensure
compliance. Identifying and fixing process impediments must be part of organizational culture.
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Translating data into new policy and programs. The organizational culture at Senior
Support includes a competent workforce that should be able to translate data into new health
improvement programs. However, prior to implementation, the organization is responsible for
ensuring there are policies, procedures, and processes in place to support new programs.
Evidence-based interventions can change organizational trajectories in positive ways (Berkel,
Mauricio, Schoenfelder, & Sandler, 2011). Frieden (2014) asserts there are six components
necessary for effective public health program implementation: (1) Innovation to develop the
evidence base for action; (2) a technical package of a limited number of high-priority, evidence-
based interventions that together will have a major impact; (3) effective performance
management, especially through rigorous, real-time monitoring, evaluation, and program
improvement; (4) partnerships and coalitions with public- and private-sector organizations; (5)
communication of accurate and timely information to the healthcare community, decision
makers, and the public to effect behavior change and engage civil society; and (6) political
commitment to obtain resources and support for effective action. Senior Support is assumed to
address these issues that result in successfully translating data into new policy and programs to
support improved health outcomes. Table 3 reflects the assumed organizational influences and
organizational influence assessments.
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Table 3
Organizational Influences and Organizational Influence Assessment
Assumed Organizational Influences Organization Influence Assessment
Cultural Model Influence 1:
The organization has a culture where the
clinical staff is involved in the innovation
and implementation of new health
improvement programs.
Survey or interview questions about interest
in implementing new health improvement
programs.
Cultural Model Influence 2:
The organization uses internal
communication between clinical staff and
leadership on the importance of using data
from the CGA for new health
improvement programs.
Survey or interview questions regarding the
level of internal communication.
Cultural Setting Influence 1:
The organization assists clinical support
staff in completing the CGA so it does not
feel overwhelming when they are already
working with a large number of clients.
Survey or interview questions regarding
feelings about the CGA.
Cultural Setting Influence 2:
The organization has a process in place for
translating data into new policy and health
improvement programs.
Survey or interview questions about knowing
how to implement new programs based on
data from the CGA.
Summary
This chapter examined the link between senior nutrition programs and improved health
outcomes and the implications for cost savings to Medicare. A review of the related literature
was conducted by the researcher to provide the reader with a general overview on malnutrition in
older adults, the importance of senior nutrition programs to physical and mental health, and the
CGA. Within this context was an in-depth analysis of programs that allow older adults to remain
healthy and independent in their own homes and communities, and the sustainability of the
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Medicare program. The literature review concluded with an explanation of the Clark and Estes
(2008) framework, which analyzed if the stakeholders have the knowledge, motivation, and
organizational support needed to achieve performance goals.
Specifically, the literature established that clinical staff needs a solid understanding of the
theories of aging to evaluate clients using the CGA. When clinical staff feel empowered to apply
their knowledge, they successfully create individualized care coordination plans for every client
to help them achieve optimal health outcomes. The research also shows that the delivery and
management of nutrition interventions require a team approach. There are two motivational
influences that help clinical staff utilize a team approach and implement health improvement
programs. The first is that clinical staff feel that low levels of improvement in health are due to
their own efforts rather than the client’s lack of ability to change behaviors. The second is that
clinical staff believes they can improve the quality of life for older adults by helping them to
remain independent and healthy.
Review of the knowledge, motivation, and organization literature suggest an
interconnectedness between all three areas to identify performance gaps and implement
organizational change. The following chapter discusses the assumed knowledge, motivation,
and organizational influences and links them with the research methodology utilized in this study
to better understand how senior nutrition programs seek to improve health outcomes and could
potentially offer cost savings to Medicare.
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CHAPTER THREE: METHODOLOGY
Purpose of the Project
The purpose of this project is to study the organization’s performance related to a larger
problem of practice. The analysis focused on the organization’s assets in the area of knowledge
and skills, motivation, and organizational resources. While a complete study would focus on all
stakeholders who play a critical role in the health and wellbeing of older adults, for practical
purposes, the stakeholder to be focused on in this analysis is Senior Support clinical staff. The
analysis will focus on the role that staff members have in administering a nutrition program for
seniors and collecting data to show that nutrition decreases health services utilization.
It is important to identify strategies for reducing the cost of health care services for older
adults. Senior nutrition programs play a vital role in helping to keep older adults healthy and
independent (Thomas & Mor, 2013). With adequate funding and a trained and motivated
workforce, senior nutrition programs increase health, wellness, and socialization for a vulnerable
population (Dal Santo, 2009; Gergerich et al., 2015). These programs have a profound impact
on the quality of life for older adults while saving taxpayer dollars (Thomas & Mor, 2013).
Research Questions
The three research questions that guided this promising practice study include the
following:
1. What are the knowledge, motivation, and organizational assets in relation to the
goal of collecting data to support that senior nutrition programs improve health outcomes for
older adults and decrease emergency room visits and hospital stays?
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2. What are the areas of knowledge, motivation, and organizational resources that
are needed to utilize data to create programs for older adults that are designed to improve
overall health outcomes?
3. What solutions and recommendations in the areas of knowledge, motivation, and
organizational resources may be appropriate for solving the problem of practice at another
organization?
Conceptual Framework
The purpose of a conceptual framework is to give readers a graphic or narrative
explanation of the focus of a study. According to Maxwell (2013), the conceptual framework
acts as a guide to the plan of study, helps to assess and refine goals, develops relevant research
questions, and helps to identify validity threats. The Clark and Estes (2008) gap analysis
framework was used as a guide to develop the framework, and the design builds upon research to
focus on a specific topic (Maxwell, 2013; Merrian & Tisdell, 2016).
Figure 1 begins with the problem of practice: Senior nutrition program providers lack
data to show health improvements in older adults utilizing congregate or home-delivered meal
programs. The majority of senior nutrition programs are funded through Congressional
authorization of the Older Americans Act (Government Accountability Office, 2012). However,
the federal government does not require that organizations collect data on clients utilizing their
congregate or home-delivered meal programs. This is a problem of practice because the majority
of senior nutrition program providers lack the knowledge, motivation, or organizational
resources to accurately collect data and advocate for additional funding based on the assumption
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that seniors participating in a nutrition program are healthier and more independent and therefore
decrease reliance on Medicare-funded services.
The conceptual framework demonstrates the scaffolding of the research study and
identifies how the problem of practice is influenced by knowledge and skills, motivation, and
organization. While these are represented as individual elements in Chapter Two, the
stakeholders collaborate and interact to address the problem of practice through a combination of
knowledge, motivation, and organizational influences.
Figure 1. Conceptual Framework
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Research Design
To assess the promising practice, it is important to utilize several different types of
approaches to gather and analyze data. According to Creswell (2014), there are six steps to
conduct a research study: (1) identification of a research problem, (2) review of the current
literature, (3) having a purpose for research, (4) collection of data, (5) analysis of data, and (6)
reporting the evaluation of the research. This research study was designed around these steps
using a qualitative methodology. Qualitative research is a method of inquiry that utilizes
interviews, focus groups, and observation to allow for more interaction between the researcher
and participants (Merriam & Tisdell, 2016).
A qualitative methodology was selected for this study with the understanding that survey
and interview protocol would uncover firsthand knowledge from clinical staff that work directly
with clients. Through surveys and interviews, the researcher sought to understand the
knowledge, motivation, and organizational assets that are critical to improving the quality of life
for older adults. To triangulate the data, the researcher collected documents from the
organization, including Comprehensive Geriatric Assessment data, which confirmed health
improvements in more than 85% of clients (Senior Support, 2016).
This qualitative research study provided the researcher with information to understand
the elements and program components that led to organizational success (Maxwell, 2013;
Merriam, 2016). The results were generalized by the researcher to highlight a promising practice
model that is easily replicated in other organizations. This model includes hiring qualified staff,
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an extensive training program to collect data by assessing clients accurately and efficiently, and
using the data to advocate for an increase in Older American Act funding.
Unit of Analysis
The unit of analysis is a non-profit organization located in the western region of the
United States that serves low-income seniors with innovative programs and services designed to
improve their quality of life. This particular unit of analysis was selected for the promising
practice research study for a number of reasons: (1) The researcher was a former staff member at
the organization with unique access to data, (2) The organization has been recognized by the
American Society on Aging for best practices in serving older adults, and (3) The organization
serves a diverse population of more than 2,000 clients per day, 365 days per year (Senior
Support, 2016). Due to the diverse population and the large number of clients, the research
collected from this study is generalizable to similar senior nutrition program providers in urban
communities.
Participating Stakeholders, Criteria, and Rationale
There are 65 staff members at Senior Support. The organization is structured with four
departments including health and clinical services, development, operations, and nutrition. Staff
across all departments work in conjunction to achieve organizational goals. The stakeholder
population this study focused on is clinical staff who are responsible for administering the CGA
and working directly with clients on a daily basis. The researcher used purposeful sampling to
interview and survey the stakeholder group at the organization who play an integral role in
ensuring data is tracked appropriately for all clients by establishing a care coordination plan.
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Purposeful sampling allows the researcher to discover, understand, and gain insight from a
population with the knowledge to answer the research questions (Maxwell, 2013; Merriam et al.,
2016).
The organization defines clinical staff as social workers, nurses, or case managers. There
is a total of 11 clinical staff members with social worker, nurse, or case manager in their job title.
All of these clinical staff members have a bachelor’s degree and more than half of the clinical
staff have a graduate degree in social work, gerontology, or nursing. Of the 11, more than half
worked for the organization for more than three years. In addition to clinical staff, the researcher
interviewed two members of the senior leadership team who oversee clinical services to gain a
higher-level perspective on the health outcomes of clients utilizing the senior nutrition program.
This was an appropriate sample population because it incorporated data from multiple levels of
staff at the organization who shared first-hand knowledge on improved health outcomes of older
adults utilizing the senior nutrition program.
Data Collection and Instrumentation
The researcher validated the knowledge, motivation, and organizational resources for this
promising practice through surveys, interviews, and document analysis. The researcher used
surveys to evaluate the knowledge and motivation that is critical to ensuring clients are assessed
appropriately through the CGA and to understand how clinical staff feel about the level of
support they receive from organizational leadership. The researcher also conducted interviews
with senior leaders to gain further insight into the success of the organization and to understand
aspects of the hiring process, professional development, and organizational support for clinical
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staff. Also, the researcher used document collection as a triangulation measure to confirm health
improvements in clients at the organization.
Surveys
The survey instrument (Appendix A) was developed by the researcher using Qualtrics
computer software. The survey, along with the informed consent statement, was distributed via
email to all 11 clinical staff workers at Senior Support. Respondents had 30 days to complete the
survey, and the researcher sent a follow up after two weeks in an effort to increase the
participation rate. Seven people completed the survey. The 13 questions on the survey instrument
include open-ended questions designed to undercover the knowledge, motivation, and
organizational elements of the conceptual framework based on the research questions. Open-
ended questions gave respondents the opportunity to share information in their own words,
adding depth and insight that cannot be captured in closed questions. The survey also included
three questions intended to gather demographic data regarding years of experience as subject
matter experts. The survey instrument did not include identifying information to ensure
anonymity of the participants. The researcher followed all policies and protocol set forth by the
University of Southern California to protect data collection.
Interviews
The researcher conducted one-hour interviews with two participants who oversee clinical
staff. The request for interviews was sent via e-mail by the researcher and confirmed with
follow-up phone calls. The interview consisted of a mixed informal and formal design with semi-
structured interview protocol and open-ended questions. (Appendix B). This approach was
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appropriate because it allowed the researcher the flexibility to alter questions or follow-up based
on answers provided by the respondent. The types of questions that were asked during the
interview helped the researcher uncover the knowledge, motivation, and organizational assets
necessary at the management level to assess the health outcomes of older adults utilizing the
nutrition program.
The interviews took place before survey collection. The participants were provided with
an informed consent document by the researcher. The participants were advised by the researcher
that the interview was being recorded and would be transcribed. The participants were notified
by the researcher that they could view the transcription two weeks following the interview.
Member checks were conducted to confirm the interpretation of data was accurate. The
researcher followed all University of Southern California policies and protocol including saving
the confidential recording on a password-protected laptop.
Document Analysis
For this study, the researcher collected documents from the organization. According to
Merriam and Tisdell (2016), documents can provide valuable information that is easier to gather
than interviews. The documents were selected by the organization to highlight health
improvements in older adults including Comprehensive Geriatric Assessment data. Additional
documents provided by the organization included the organization’s annual strategic plan and
strategies and objectives for achieving organizational goals. Documentation is important
because it can substantiate and supplement evidence from other sources (Yin, 2009). The
researcher used the documents to develop a deeper understanding of how the organization
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collects data on clients and confirmed that improved health outcomes for clients could be
attributed to how the clinical staff administer the senior nutrition program.
Data Analysis
According to Merriam (2009), qualitative research aims to produce understandings on the
basis of rich, contextual, and detailed data. The researcher focused on interpreting the data
collected by surveys and interviews to understand the promising practice and recommend how
similar organizations can emulate how Senior Support improves the quality of life for older
adults. To do this, the researcher analyzed the qualitative data using the software program,
Nvivo. This software program was designed to help organize, analyze, and find insights in
unstructured qualitative data such as interviews and surveys. The researcher transcribed the
survey and interview data and utilized Nvivo to assist with thematic coding of the data,
generating emerging themes, and discovering patterns. The themes and patterns were
synthesized in an effort to understand how the promising practice can be emulated by similar
organizations. The documents collected by the organization were used to confirm the emerging
themes and patterns.
Credibility and Trustworthiness
To ensure credibility and trustworthiness, the researcher used triangulation of the three
methods of data collection: survey, interviews, and organizational documents. Triangulation is
using multiple sources to cross-check data collected at different times from different people with
unique perspectives (Merriam & Tisdell, 2016). The researcher began with qualitative
interviews of clinical staff that resulted in answers to the research questions. The researcher
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recorded the interview and transcribed within 72 hours. To rule out any misunderstanding, the
researcher used respondent validation to solicit feedback on emerging findings (Merriam &
Tisdell, 2016). The researcher also used adequate engagement strategies while collecting data
during until saturation was reached. According to Merriam and Tisdell (2016), saturation occurs
when the researcher begins to see and hear the same information without any new information
surfacing. The utilization of all three methods (triangulation, respondent validation, and adequate
engagement strategies) established credibility and trustworthiness in the research study.
Ethics
According to Merriam and Tisdell (2016), producing valid and reliable knowledge in an
ethical manner is a critical component of research. To protect the rights and welfare of human
subjects, the researcher submitted the research study proposal to the University of Southern
California University Institutional Review Board (IRB), who made certain that all ethical
guidelines were closely followed. The IRB is responsible for confirming equitable subject
selection, adequate informed consent, assessment and minimization of risks, and privacy and
confidentiality. Also, the IRB reviews all human research protocols to ensure accordance with
federal regulations, state law, and university policies. Submitting this proposal to USC’s IRB
ensured the study met all ethical guidelines.
During qualitative research, the researcher conducted surveys and interviews that
produced valuable data. Before participating, each person was provided with a consent form that
explains in detail the purpose of the study, the study procedures, potential risks and discomforts,
potential benefits to society, and information on participation and withdrawal. The informed
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consent contained information including the following: (1) ensured that their participation is
voluntary, (2) clarified any aspects of the research that may affect their well-being, and (3)
reminded participants that they could withdraw from the study at any point (Glesne, 2011).
Before conducting interviews, the researcher asked for written consent to audio record and
placed the recorder in front of the participant as a visual reminder during the interview. The
researcher also verbally reminded the participant about their right to privacy and that
confidentiality will be respected by preserving anonymity.
Limitations and Delimitations
The purpose of this promising practice research study was to understand how senior
nutrition programs improve overall health outcomes for seniors, and therefore offer a cost-
savings to Medicare because older adults utilizing nutrition programs are healthier and remain
more independent. This promising practice study demonstrates a strategy that has been
implemented at Senior Support to improve a problem of practice with the potential to inspire and
assist similar organizations in collecting data to document health improvements in older adults.
Since the research is focused on one singular organization, there are limitations identified with
this study. First, it is difficult to determine whether the results at this organization can be
generalized or replicated at other organizations based on funding sources. Second, there is the
possibility of respondents providing inaccurate responses due to bias or selective memory.
Third, the sample size of this study was only nine individuals.
The researcher also identified delimitations to the study, which is a decision made by the
researcher that may affect data analysis. The researcher self-selected the site for this research
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study and has a direct relationship with the organization as a former staff member. Although the
researcher did not work in the same building as clinical staff, or have any oversight in a
managerial role, this could have potentially affected the survey and interview responses because
the respondents do not want to be seen in a negative manner (Weiss, 1994). Finally, the project
was also delimited due to clinical staff’s experience that may or may not be representative of
similar stakeholder groups at other organizations. While collecting data from clinical staff at
similar organizations would have provided a unique perspective, it was outside the scope of this
current research study.
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CHAPTER FOUR: RESULTS AND FINDINGS
The purpose of this research study was to understand how senior nutrition programs
improve overall health outcomes for seniors, and therefore offer a cost-savings to Medicare
because older adults utilizing nutrition programs are healthier and remain more independent.
Specifically, this promising practice study identified an organization that administered a senior
nutrition program and trained clinical staff to collect data to show health improvements in
clients. The organization uses the data to advocate for additional funding through the Older
Americans Act. This funding is used to pay for programs and services throughout the United
States that assist the rapidly growing number of low-income older adults. This study sought to
validate the knowledge, motivation, and organizational resources needed for clinical staff to
standardize data collection on clients to show the impact that senior nutrition programs have on
reducing overall Medicare expenses.
During this study, the researcher collected two forms of data to validate the assumed
knowledge, motivation, and organizational resources. Qualitative data were collected in the
form of interviews and surveys. The researcher also conducted a document analysis to
triangulate the data. The results were compared with the assumed knowledge, motivation, and
organizational resources described in Chapter Two to determine their validity. For assumed
needs that were validated, or partially validated, the researcher provides innovative
recommendations, based on literature, for similar organizations to utilize this promising practice.
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According to Winter (2000), validity in qualitative research is not a single concept, but a
construct grounded in particular research projects. Creswell and Miller (2000) suggest
researchers develop their own concepts of validity. The researcher determined that assumed
influences would be validated if there was consistency in responses from at least 60% of
respondents. This threshold was determined as the validity point as it represented more than a
majority of respondents. The researcher determined that assumed influences would be partially
validated if there was consistency in the survey and interview responses from at least 40% of
respondents and a second source (document analysis) confirmed the findings. If either of these
validity points was not met, the assumed influences were not validated.
Participating Stakeholders
Requests to participate in the voluntary survey for this research study were sent to 11
clinical staff members at Senior Support. There were seven total respondents and the researcher
did not attempt to collect additional surveys since saturation was reached. In addition, two
members of the clinical staff leadership team participated in one-hour interviews. Overall, there
was a 69.2% stakeholder response rate. 100% of the respondents have a bachelor’s degree and
55% of respondents have a graduate degree in either social work, business, or gerontology. The
average years of experience that participating stakeholders have working with older adults is 7.5
years and 88% of participating stakeholders have worked for the organization for more than three
years.
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Knowledge Results
Declarative Knowledge. Based on the literature review, the researcher identified the
declarative knowledge necessary to successfully assess clients utilizing the Comprehensive
Geriatric Assessment and to recommend a care coordination plan to improve overall health
outcomes. These influences included knowledge on the seven different Social Theories of Aging
and knowledge of health improvement programs. The results below are based on the analyzed
data collection.
Social Theories of Aging. Despite the vast amount of knowledge required for clinical
staff to be successful in their position, this assumed influence was not validated. Survey
question two stated, “Can you briefly describe the Social Theories of Aging?” The data showed
that only 42% of survey respondents could accurately recall the Social Theories of Aging.
Interview data confirmed that this was not a knowledge requirement for staff; however, there
was an opportunity to include this knowledge in future training. One participant explained, “It is
not a deal breaker if our staff has not completed gerontology coursework or internships working
with older adults where they may have learned that [Social Theories of Aging]. Instead, it is
more important to find staff that are comfortable working with older adults, who feel this is their
calling, and are active learners.” The participant continued, “This is an emerging field and we
are open to providing staff with knowledge.”
Health Improvement Programs. Based on the data collection and analysis, this assumed
influence was validated. There were two survey questions that resulted in confirming that the
respondents had declarative knowledge of health improvement programs. Question number three
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asked, “What are the pros and cons of a senior nutrition program?” and question number five
asked, “Can you provide an example of a client who has shown significant health improvements
based on the senior nutrition program?” There was also an interview question that confirmed
that clinical staff have knowledge of health improvement programs. Question number 10 asked,
“Do you have a personal story you would like to share about one of your clients that significantly
benefited from the senior nutrition program?”
The survey data showed that 100% of respondents could name at least three benefits
(pros) of a senior nutrition program. The data indicated that there is a correlation between senior
nutrition programs and health improvements programs. When asked about the benefits (pros) of
a senior nutrition program, 85% of survey respondents stated “exercise.” One respondent
elaborated, “Many seniors participate in a walking club. They meet before lunch and walk for
about an hour together. This, along with healthy meals, has greatly improved their health
outcomes.”
In addition, 100% of survey respondents provided detailed responses to question five
which highlighted the impact of health improvement programs to improved health outcomes.
While the answers were varied, all respondents were able to write about their knowledge of
health improvement programs and the benefits to clients.
We have a long-time client who has visited our center nearly every day for many years.
Previously, this client was a frequent user of emergency services, with numerous
medications, multiple medical conditions, and a near-fatal cancer diagnosis. Our team
helped the client receive a special home-delivered meal program that caters to older
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adults with specific dietary needs - in this case, celiac, cardiac disease, and diabetes. The
right programs and services were critical in transforming the client’s health.
Responses to interview question 10 confirmed the survey data. Both participants
provided multiple examples of the health improvement programs that clinical staff used to
improve overall health and wellbeing of clients. One participant stated, “Our staff are trained to
identify the issues a client is facing and refer them to the appropriate programs and services”. In
addition, document analysis also confirmed the findings. There is evidence that clinical staff are
trained on health improvement programs such as nutrition, health education, social services, case
management, affordable supportive housing, and lifelong learning opportunities. According to a
Strengths, Weaknesses, Opportunities, and Threats (SWOT) analysis conducted by the
organization in 2017, “experienced staff” is viewed by leadership as a strength of the
organization. Staff training includes a comprehensive onboarding program and ongoing
initiatives designed to provide effective and efficient delivery of care integration and social
services (Senior Support Strategic Plan, 2017).
Procedural Knowledge. The literature review determined that clinical staff need
procedural knowledge to assess clients effectively as measured by the CGA. Procedural
knowledge is an understanding of how to do something. Below are the results based on data
collection and analyzation.
Assessing clients utilizing the CGA. This assumed influence was validated. Survey
question 6 asked, “What training programs does your organization provide to increase your
knowledge working with the senior population?” 100% of respondents provided evidence to
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show their knowledge of assessing clients utilizing the CGA. In addition, survey question 4
asked, “What is the purpose of the Comprehensive Geriatric Assessment?” While 100% of
respondents shared a similar definition and purpose of the CGA, 71% of those respondents wrote
about the importance of accurate data collection as a resource for new program implementation.
The interview data confirmed these results through question 5, “What was the training
process like for introducing staff to the Comprehensive Geriatric Assessment?”
There is an extensive training process for staff. All staff involved with assessing clients
are provided with an assessment protocol and glossary of terms. Training includes
information of identifying common problems, active listening, and time to practice
assessing other staff members. During practice assessments, staff are provided with
immediate feedback. We occasionally observe staff as they work with clients and
continue to provide feedback to improve assessments of clients.
Metacognitive Knowledge. Based on the literature review, the researcher determined
that clinical staff need to know how to self-reflect on their knowledge of health promotion
programs in relation to each client to create individualized care coordination plans for each client
to improve overall health. Below are the results based on data collection and analyzation.
Self-reflect on knowledge of health improvement programs. This assumed influence
was partially validated based on data collection. Survey question number 10 was intended to
uncover if stakeholders self-reflected on their work. There was a follow-up to the question to
understand if stakeholders believed self-reflection was important. While 85% of respondents felt
self-reflection was important, only 42% of respondents self-reflect on their work. Of the 85% of
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survey respondents that felt self-reflection was important, 83% specifically wrote about lack of
time being the main reason they did not currently self-reflect on their work.
One Interview respondent reinforced these findings stating, “We do not provide training
or time for self-reflection.” However, the organization does provide time for team reflection.
Weekly team care coordination meetings were implemented to give “staff the time to discuss
unique or difficult cases.” Survey data confirmed the importance of weekly team collaboration
meetings. 42% of survey respondents specifically mentioned the care coordination meetings
despite not being asked directly about group reflection.
Motivation Results
Attributions. According to Anderman and Anderman (2006), motivation is enhanced
with individuals attribute success or failures to effort rather than ability. The following assumed
motivational influence was validated based on data collection.
Clinical staff should feel that low level of improvements in health is due to their own
efforts rather than the clients’ lack of ability to change behaviors. Survey and interview data
uncovered that employees feel strongly that they are instrumental in improving quality of life for
their clients. 100% of survey respondents acknowledged their own influence on clients.
According to one respondent, “I make a difference in people’s lives every single day.” Another
respondent shared, “I know I make life easier for my clients.” The data produced overwhelming
evidence that 100% of respondents felt responsible for improving their client’s health. Figure 2
provides a visual representation of the most used words in the collected survey and interview
data. The size of the word is determined by the number of times it was referenced by
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participants. The word “client” was used 4.42% more than any other word, suggesting the
importance of the client to each stakeholder.
Figure 2. Visual representation of most used words in survey and interview data
Self-Efficacy. According to Bandura (2000), positive self-efficacy is a motivator that
leads to accomplishing goals. The following assumed motivational influence was validated based
on data collection.
Clinical staff believes they are capable of improving the quality of life of seniors by
helping them to remain independent and healthy in their own home. Survey question number
8, “Your organization has been recognized as a national model for delivering high impact
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programs and services to older adults. What makes it unique?” revealed that stakeholders
believe they are capable of improving the quality of life for their clients. 85% made specific
mention of experience being the main factor in their ability to serve clients effectively. One
respondent wrote, “We have a supportive staff with many years of experience working with
seniors.” Another respondent wrote, “We provide immediate help for clients based on our
experience.”
There was also evidence to validate the assumed influence in the data provided by survey
question number 1, “Describe your interest and experience working with seniors.” 71% of
survey respondents referred to motivation as one of their interests for working with older adults.
One respondent shared, “When I see improvements in our clients, I am more motivated to help
others.” Similarly, another respondent wrote, “Working with seniors is rewarding and seeing the
direct impact of my work motivates me to work even harder.” Document analysis confirmed
these findings. According to the Senior Support Strategic Plan (2017), clinical staff “Plays a
critical role in the survival, health, and independence of seniors in need.” Also, document
analysis found that specific and measurable key performance indicators for staff are based on the
five brand pillars for the organization: (1) Respect, (2) Advocacy, (3) Holistic, (4) Impact, and
(5) Leadership. Success in each of these areas is tied to a clinical staff member’s ability to
improve health outcomes and quality of life for their clients.
Organization Results
Cultural Model. According to Gallimore and Goldenberg (2011), a cultural model is a
shared understanding of how an organization works or ought to work. This research project
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sought to understand how clinical staff work with organizational leaders to implement programs
to improve overall health of clients. The following assumed organizational influences were
validated based on data collection.
The organization has a culture where clinical staff is involved in the innovation and
implementation of new health improvement programs. Survey data uncovered that 85% of
respondents feel the organization values their opinion in creating new programs and services for
clients to improve health outcomes. One survey respondent shared, “We are given opportunities
to share ideas for improving or creating programs.” A second respondent wrote, “They value my
opinion and ideas.”
The interview data confirmed this finding. Interview question number 7, “Does staff
have the ability to provide input and improve the process?” confirmed that staff are included in
both improvement of current programs and the creation of new programs and services. One
interview participant stated, “We routinely ask about common problems or issues that staff are
experiencing. We actively listen and use the information to improve our process.” In addition,
document analysis uncovered one of the organizational goals is to “Cultivate and enthusiastically
support an empowering agency culture that values employee learning, growth, innovation, and
purpose.”
The organization uses internal communication between clinical staff and leadership on
the importance of using data from the CGA for new health improvement programs. Survey
and interview data, along with document analysis, overwhelmingly validated this assumed
organizational influence. 100% of survey respondents and interview participants confirmed the
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collaboration that exists, both cross-departmentally and between clinical staff and leadership.
77% of survey responses included “strong internal communication” as one of the answers to
question number 8, “Your organization has been recognized as a national model for delivering
high impact programs and services to older adults. What makes it unique?”
Document analysis confirmed these findings. The organization’s “Overarching
Performance Vision” document includes a list of goals and key performance indicators designed
to “Lead a motivated, highly performing team that consistently exceeds expectations and fully
embraces the tenants of the growth initiative.” One of the measurements is the development of
“Cohesive and consistent internal communication tools to connect the various departments,”
including an opportunity to “Allow employees a venue for communicating their thoughts and
concerns with management.” This confirms that value that the organization places on creating a
cultural model built around internal communication.
Cultural Setting. Measurable outcomes are a result of strong policies, procedures, and
processes. If organizational processes do not support policies, there is a great risk of failure
(Clark & Estes, 2008). The following assumed organizational influences were validated based
on data collection.
The organization assists clinical support staff in completing the CGA so it does not feel
overwhelming when they are already working with a large number of clients. Survey and
interview data show that the staff feel supported in completing assessments despite the growing
number of clients. While 57% of survey respondents provided ways to improve the assessment
process, such as additional staff and additional space, 100% of survey respondents felt they had
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sufficient training and support to effectively and efficiently assess clients. Interview question
number 8 asked, “With the growing number of seniors needing services, how do you assess the
number of clinical staff you need to effectively serve a large number of clients?” One participant
shared, “We use productivity standards and monitor our number of clients per staff. We ask that
clinical staff spends 50% of their day with clients, but do not limit the amount of time spent per
client. This ensures they receive the assistance they need.” Document analysis found that a
social work consultant was hired to assess the clinical staff workload and identify issues that may
affect their ability to serve clients effectively (Senior Support Strategic Plan, 2017). Based on
industry trends, organizational leadership created standardized caseload and productivity
standards which states that staff must spend 50% of their day with clients and the other 50%
creating programs, completing paperwork, and attending training programs. In addition, the
organization disseminates an annual employee survey to inform departments and make
recommendations for improvement.
The organization has a process in place for translating data into new policy and health
improvement programs. Interview question number 2 asked, “Why do you feel it was important
to start assessing clients and tracking health outcomes?”
We started assessing clients because it was important to understand what issues they are
facing and recommend the appropriate staff and program interventions. If we see a
trending need, and do not have a program in place, we work collaboratively with staff
and collaborative partners to create new programs and services.
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The survey data found that that 85% of respondents were familiar with the process of
translating data into new policy or health improvement programs. In addition, working directly
with clients gives clinical staff first-hand knowledge of programs that interest clients. For
example, one respondent wrote, “We help facilitate client-led programs such as the walking
group.” Another respondent shared, “We work directly with the development team to
demonstrate issues the seniors are facing and request funding for new programs or services.”
Findings
The purpose of this promising practice research study was to answer the following
questions:
1. What are the knowledge, motivation, and organizational assets in relation to the goal of
collecting data to support that senior nutrition programs improve health outcomes for
older adults and decrease emergency room visits and hospital stays?
2. What are the areas of knowledge, motivation, and organizational resources that are
needed to utilize data to create programs for older adults that are designed to improve
overall health outcomes?
3. What solutions and recommendations in the areas of knowledge, motivation, and
organizational resources may be appropriate for solving the problem of practice at
another organization?
The following themes provide answers to the first two questions. Question number 3 will
be answered in the recommendations sections in Chapter Five.
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Collecting Data on Senior Nutrition Program Participants
The first question for this research project was designed to uncover a promising practice
for collecting data that documents the benefits of senior nutrition programs including improved
health outcomes for clients. Survey and interview data, triangulated with document analysis,
identified the knowledge, motivation, and organizational assets necessary to support data
collection on clients, specific to Senior Support. However, the researcher believes the results
could be generalized to support similar organizations seeking to collect data on their own clients.
Motivated Workforce
To create an organizational culture that values data collection, there must be buy-in from
all levels of the organization. This begins with hiring a motivated workforce. While it is
important for employees to have the knowledge and skills necessary to complete their work,
motivation to improve the quality of life for older adults is more important. Through
professional development and training opportunities, organizations can offer employees the
support they need to accurately and effectively assess clients. However, employees must hire
motivated staff who believe they are capable of improved health outcomes for their clients. A
motivated worker is not someone who improves job performance based on monetary value.
Instead, they are motivated by the success of their clients and are passionate about helping other
people.
Extensive Knowledge of the Comprehensive Geriatric Assessment
Prior to collecting data on clients, staff need to be trained on how to administer the CGA.
It is important for an organization to create and implement a training program to include a basic
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overview, practice assessments, and ongoing professional development opportunities to ensure
best practices are being followed. It should be noted that the CGA is not the only assessment
tool available for assessing clients; however, it is recommended that organizations across the
country establish a standardized data collection process to collectively show improved health
outcomes for clients and advocate for additional federal funding for senior nutrition programs.
Utilizing Data for Program Innovation and Implementation
The second question for this research project was designed to uncover a promising
practice for utilizing data collected from the CGA to create programs for older adults to improve
overall health outcomes. Survey and interview data, triangulated with document analysis,
identified the knowledge, motivation, and organizational assets necessary to support the creation
and implementation of new programs based on data collection specific to Senior Support.
However, the researcher believes the results could be generalized to support similar
organizations seeking to assess clients and create new programs and services based on client
need.
Internal Communication and Collaboration
An organization needs to have a strong internal communication and collaboration plan in
place to effectively use data from assessments to create new programs and services. There are a
number of reasons this is important. First, the clinical team must communicate the results of the
CGA assessments with other departments to create an implementation plan for new programs.
Internal buy-in is critical to the success of a new program. Second, the clinical team must
collaborate with other departments to ensure funding of a new program. The survey and
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interview data suggested that working with the development team to talk about client needs
could lead to applying to new grants or seeking program-specific funding from a donor. Finally,
communication and collaboration ensure staff are working together to implement programs that
are based not only on client need, but on best practices for improving the quality of life for older
adults.
Professional Development
The population of clients at senior nutrition programs are majority low-income and
struggling with a diverse set of issues including homelessness, mental and physical health issues,
and lack of familial support. While the survey and interview data showed that 100% of clinical
staff feel that working with older adults is rewarding, it was evident through interview data that
the challenges of working with a diverse population of clients is often stressful. One way to
increase knowledge and more importantly, motivation, is to develop a professional development
program. As a promising practice, Senior Support has developed an internal professional
development program that includes weekly care coordination meetings to discuss difficult cases
and to collaborate on potential solutions.
In addition, 71% of survey respondents suggested that additional external professional
development programs would increase their knowledge and motivation. For example, attending
conferences would give clinical staff additional knowledge on best practices as well as a break
from the day-to-day challenges of working with clients. The researcher suggests creating a
professional development plan that improves daily work through internal collaboration and
training opportunities, as well as through external opportunities such as conferences, webinars,
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seminars, and tours of similar organizations to increase knowledge of best practices. The
information could be gathered onto an internal, web-based collaborative platform and shared
with colleagues, creating an organizational culture of collaboration.
Summary
This chapter presented the findings based on survey data, interviews, and document
analysis. Out of the four assumed knowledge influences, two were validated, one was not
validated and one was partially validated. All of the motivation and organizational assumed
influences were validated. The validation of these assumed influences, visually represented in
Table 4, suggests that the data collection process in place by Senior Support to assess clients is a
promising practice that could be implemented by similar organizations.
The findings suggest that Senior Support has created a model organization for similar
organizations seeking to collect data, to implement new programs and services to improve health
outcomes, and to retain a knowledgeable and motivated workforce. The data showed less of a
need to hire staff with specific aging-related knowledge, but more of a need to hire motivated
staff who find their job rewarding and who have the support of their organization to innovate
new programs and services that lead to improved health outcomes for older adults.
As a promising practice, the next chapter presents potential solutions and
recommendations in the areas of knowledge, motivation, and organizational resources which
may be appropriate for similar organizations seeking to emulate the Senior Support model. All of
the solutions and recommendations are evidence-based and suggested from relevant research.
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Table 4
Summary of Assumed Knowledge, Motivational, and Organizational Influences
Assumed Influences Validated
Not
Validated
Partially
Validated
Knowledge
Clinical staff has knowledge of the seven
different Social Theories of Aging.
√
Clinical staff has knowledge of health
promotion programs.
√
Clinical staff knows how to assess clients
effectively as measured by the CGA.
√
Clinical staff needs to know how to self-
reflect on their knowledge of health
promotion programs in relation to each client.
√
Motivation
Clinical staff should feel that low level of
improvements in health are due to their own
efforts rather than the clients’ lack of ability
to change behaviors.
√
Clinical staff believes they are capable of
improving the quality of life of seniors by
helping them to remain independent and
healthy in their own home.
√
Organization
The organization has a culture where clinical
staff is involved in the innovation and
implementation of new health improvement
programs.
√
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The organization uses internal
communication between clinical staff and
leadership on the importance of using data
from the CGA for new health improvement
programs.
√
The organization assists clinical support staff
in completing the CGA so it does not feel
overwhelming when they are already
working with a large number of clients.
√
The organization has a process in place for
translating data into new policy and health
improvement programs.
√
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CHAPTER FIVE: RECOMMENDATIONS
The purpose of this promising practice research study was to understand the importance
of collecting data on senior nutrition program clients to document improved health outcomes.
To inspire and advise similar organizations, this research study validated the assumed
knowledge, motivation, and organizational resources that clinical staff need to accurately assess
older adults and document improved health outcomes. This data can be used to show that senior
nutrition programs keep older adults healthy and independent, and therefore offer a cost savings
to the Medicare program. This chapter addresses each of the validated findings from Chapter
Four and offers recommendations to similar organizations who seek to establish a standardized
data collection process and advocate for additional federal funding to increase the number of
older adults being served by a senior nutrition program. These recommendations are based on a
synthesis of the literature review and data results.
Validated Knowledge, Motivation, and Organizational Influences
Knowledge
The knowledge influences in Table 5 represent stakeholder knowledge influences based
on informal interviews, literature review, and research by Clark and Estes (2008), who suggest
that knowledge is the foundation to building a solid framework for improving performance.
While not all of these knowledge influences have been validated through research at Senior
Support, there was evidence that each of these assumed influences could help to achieve a
similar organization’s goal of using data to show a decrease in emergency room visits and
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hospital stays due to a senior nutrition program. Table 5 also provides recommendations for
these influences based on theoretical principles.
Table 5
Summary of Knowledge Influences and Recommendations
Assumed
Knowledge
Influence: Cause,
Need, or Asset*
Validated
Yes, No,
Partially
Validated
(Y, N,
PV)
Priorit
y
Yes,
No
(Y, N)
Principle and
Citation
Context-Specific
Recommendation
Clinical staff has
knowledge of the
seven different
Social Theories of
Aging. (D)
N N Knowledge helps
people accomplish
performance goals
and assist with
problem solving
(Clark et al.,
2008).
Understanding
social theories of
aging helps to
mediate relations
between older
people are care
professionals
(Powell, 2009).
Create a training
program to ensure staff
has knowledge of the
seven different Social
Theories of Aging.
Provide clinical staff
workers with a job aid
that includes a brief
summary of each
theory. This can be
used to create an
appropriate care
coordination plan for
each client to reach
optimal health
outcomes.
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Clinical staff has
knowledge of
health promotion
programs. (D)
Y Y Declarative
knowledge
increases
procedural
knowledge (Clark
et al., 2008).
Every provider of
senior services
needs to offer
health promotion
programs specific
to a community to
best meet their
needs (Koehn,
Habib, & Bukhari,
2016).
Provide job aids and
professional growth
opportunities for staff
to attend trainings,
workshops, webinars,
and conferences
designed to advance
knowledge on best
practices for aging-
related issues.
Clinical staff needs
to know how to
effectively assess
clients as measured
by the
Comprehensive
Geriatric
Assessment (P).
Y Y To master skills,
individuals must
acquire, integrate,
and apply skills
(Schraw &
McCrudden,
2006).
The
Comprehensive
Geriatric
Assessment is
successful in
developing an
integrated plan for
treatment (Ellis et
al., 2011).
Provide training and job
aids to staff with
detailed steps on
assessing clients.
Monitor clinical staff to
ensure data is
accurately collected and
analyzed.
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Clinical staff needs
to know how to
self-reflect on their
knowledge of
health promotion
programs in
relation to each
client. (M)
PV Y Self-regulation
skills help increase
performance
(Clark & Estes,
2008).
Self-reflected
insights and
drawing in past
experiences imply
wisdom and
competence
(Morrison, 1997;
Ruch, 2000).
Provide training on the
self-reflection process
and opportunities for
professional growth to
close knowledge gaps.
Declarative knowledge. The two declarative knowledge influences are:
1. Understanding the seven different Social Theories of Aging
2. Knowing health promotion program best practices
Clinical staff at Senior Support are not currently trained or required to understand the
seven different Social Theories of Aging. However, the research shows that this knowledge
could increase skills to observe the influences that society has on the aging process.
According to Clark and Estes (2008), possessing adequate knowledge is important for
gaining additional knowledge. The literature suggests that understanding social theories of
aging helps to mediate relations between older people and care professionals (Powell, 2009).
Implementing a training program and providing a job aid to clinical staff with a brief
summary of each theory would be useful in creating appropriate care coordination plans for
each client to reach optimal health outcomes. Interview data suggests that this would be
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beneficial to staff; therefore, even though it was not validated as a current knowledge
influence at the organization, it is recommended that additional research be conducted to see
if this knowledge influence would be beneficial to similar organizations interested in solving
the problem of practice.
To effectively serve clients, clinical staff must have knowledge of cost-effective health
promotion programs. Every provider of senior services needs to offer health promotion
programs specific to a community to best meet their needs (Koehn, Habib, & Bukhari, 2016).
Research demonstrates that a healthy lifestyle is more influential in helping older adults avoid
the decline traditionally associated with aging than genetic factors (Nunez, Armbruster, Philips,
& Gale, 2003). Providing job aids and professional growth opportunities for staff to attend
trainings, workshops, webinars, and conferences designed to advance knowledge on best
practices for aging-related issues will increase health outcomes for older adults.
Knowledge of classifications and categories, principles and generalizations, and theories,
models, and structures allow staff to understand how programs function together (Krathwohl,
2002). The most effective senior centers offer health promotion programs including recreation,
health and nutrition, and education (Dal Santo, 2009), and serve as community focal points for
community-based services for older adults (Casteel, Nocera, & Runyan, 2013). Clinical staff
play a role in ensuring the health programs are based on best practices to improve overall health,
wellness, and socialization. The effectiveness of the programs increase when staff are
encouraged to attend professional growth trainings that allow them the flexibility to implement
the programs they believe will be the most impactful. According to Fidishun (2000), staff resist
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learning when they feel others are imposing information, ideas or actions; therefore it is
recommended that staff are able to select their own professional development opportunities.
Procedural knowledge. Clinical staff must know how to effectively assess clients as
measured by the Comprehensive Geriatric Assessment (CGA). Lack of this procedural
knowledge may prevent goal achievement of collecting data to show improvements in health
outcomes (Clark & Estes, 2008). The CGA is a holistic assessment model to determine the
medical, psychological and functional capabilities of older adults (Rodgers, 2016; James, 2016),
and used to develop an integrated plan for treatment (Ellis, Whitehead, O’Neill, Langhorne, &
Robinson, 2011). Developing an ongoing training program and presenting job aids to staff with
detailed steps on assessing clients will ensure accurate and effective data collection.
James (2016) researched case studies in a clinical setting and found that using the CGA earlier in
treatment would have provided clients with a higher standard of care and possibly prevented the
need for a higher level of care. If clinical staff has the knowledge to effectively assess clients
using the CGA, they can successfully document positive health outcomes based on the senior
nutrition program. Due to the diverse nature of clients, ongoing trainings allow staff the
opportunity to gain knowledge from each other while providing input to improve the assessment
process. Providing immediate feedback and reinforcement during training (Tuckman, 2009) will
strengthen staff knowledge to effectively assess clients and collect accurate data on health
outcomes.
Metacognitive knowledge. When clinical staff know how to self-reflect on their
knowledge of health promotion programs in relation to each client, they are more likely to create
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effective care coordination plans for each client that will improve overall health. According to
Clark and Estes (2008), self-regulation skills help increase performance. The more knowledge
clinical staff can share with clients, the better the outcome will be. Addressing these gaps will
allow clinical staff to create more robust care coordination plans for clients. Through self-
reflection, the clinical staff can assess their knowledge and find performance gaps in which they
can seek additional training. The organization needs to provide training of the self-reflection
process and opportunities for professional growth to close any knowledge gaps.
A study by Sheng and Simpson (2013), found that providing health information to older
adults is crucial to empowering them to better control their health. Working with clients that
have diverse situations and emotions may invoke personal memories for clinical workers (Yip,
2006). If the clinical staff uses self-reflected personal stories to share with clients, they can
establish a relationship, making it easier to provide health advice and recommendations.
According to literature, self-reflected insights, and drawing on past experiences, implies wisdom
and competence (Morrison, 1997; Ruch, 2000). Assessing a population of vulnerable clients
who are experiencing issues such as homelessness, poverty, and mental health problems, can be
draining on staff. Therefore, providing training on self-reflection and developing job aids will
help staff persist in a complex environment that presents significant challenges to cognitive
learning ability and learner motivation (Elen & Clark, 2006).
Motivation Recommendations
Introduction. According to Clark and Estes (2008), the indicators that influence
motivation are active choice, persistence, and mental effort. Active choice is when someone
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chooses to actively pursue a goal. Persistence is continuing to work toward that goal despite
distractions. Clark and Estes (2008) suggest that in addition to active choice and persistence,
mental effort, mainly determined by confidence level, is critical to motivating someone to
achieve their goal. If a person has a high-level of confidence, they can feel bored with tasks,
exerting a small amount of mental effort. Similarly, a person with a low-level of confidence also
exerts small amounts of mental effort because they tend to believe they may fail at reaching their
goal. It is important for organizations to address motivational issues because the failure to
achieve goals typically stem from motivation problems and not a lack of knowledge and skills
(Clark & Estes, 2008). Table 6 indicates the motivational influences, which have all be validated
based on survey data, interviews, document analysis, and literature review and provides
recommendations for these influences based on theoretical principles.
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SENIOR NUTRITION PROGRAMS
Table 6
Summary of Motivation Influences and Recommendations
Assumed
Motivation
Influence: Cause,
Need, or Asset*
Validated
Yes, No,
Partially
Validated
(Y, N, PV)
Priori
ty
Yes,
No
(Y, N)
Principle and Citation Context-Specific
Recommendation
Clinical staff should
feel that low level of
improvements in
health is due to their
own efforts rather
than the client's’
lack of ability to
change behaviors.
(Attribution Theory)
Y
Y
The attribution theory
framework is beneficial
in the healthcare field in
changing behaviors
(Borkowski & Allen,
2003).
Implementing a
leadership training
program to increase self-
efficacy, self-esteem, and
initiative at a community
service center led to
positive changes in
health-related quality of
life and increased
exercise training (Hand,
Cavanaugh, Forbes,
Govern, & Cress, 2012).
Implement a leadership
training program giving
clinical staff the
opportunity to focus on
self-improvement by
addressing issues,
collaborating, and
learning best practices for
improving health in older
adults.
Clinical staff
believes they are
capable of
improving the
quality of life of
seniors by helping
them to remain
independent and
healthy in their own
home. (Self-
Efficacy)
Y Y Positive self-efficacy is a
motivator that leads to
accomplishing goals
(Bandura, 2000).
Clinical staff workers
with high self-efficacy
have the ability to assess
clients and provide
intervention leading to
positive outcomes
(Simons & Bonifas,
2016).
Provide recognition in the
form of senior success
stories in internal and
external communication
pieces highlighting the
efforts of clinical staff.
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Attribution Theory. The attribution theory first proposed by Heider (1958) is concerned
with how individuals interpret events in relations to their thinking and behavior (Snead, Magal,
Christensen, & Ndede-Amadi, 2015). According to Anderman and Anderman (2006), Heider’s
study of attribution was expanded by Bernard Weiner who suggested that the specific attribution,
such as luck or effort, was less important than three dimensions: locus, stability, and
controllability. Sahar (2014) suggests that the attribution theory, originally applied in the context
of studying academic achievement, can also be applied to social, political, and policy
issues. Therefore, it is recommended that organizations interested in this promising practice
implement a leadership training program that demonstrates focus on the employee’s ability to
improve the quality of life of older adults. A leadership training program would give clinical
staff the opportunity to focus on self-improvement by addressing issues, collaborating, and
learning best practices for improving health in older adults. Similar research by Haber (1996)
found that clinical staff promoting health activities among older adults at a senior center was a
successful model for improving overall health. The clinical staff at Senior Support is motivated
by the fact that they believe health improvements are strongly influenced by the amount of effort
they put in working with clients.
Self-Efficacy. Positive self-efficacy is a motivator that leads to accomplishing goals
(Bandura, 2000). Pajares (2009) suggests that people must believe that their actions will produce
the desired outcome or they will have little incentive to act or persevere when encountering
difficulties accomplishing a task. The effectiveness of a team is determined by the level of
efficacy exerted by individuals (Bandura, 2000). In the context of social problems, a collective
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effort of efficacy is most beneficial in achieving change. Bandura (2000) asserts that a team’s
accomplishments are not based on an individual’s self-efficacy, but rather the collective efficacy
of shared beliefs that influence the results they seek to achieve. Therefore, it is recommended
that similar organizations seeking to implement this promising practice provide recognition to
clinical staff by highlighting their efforts in the form of senior success stories published in
internal and external communication pieces to demonstrate collective effort. The clinical staff at
Senior Support believe they can improve the quality of life of seniors by helping them to remain
independent and healthy. Since this is not an easy task, exerting a high-level of self-efficacy
motivates staff to achieve their goal. Consistent with Bandura’s theory, research shows that
clinical workers with high self-efficacy have the ability to assess clients and provide intervention
leading to positive outcomes (Simons & Bonifas, 2016). When staff are recognized for their
efforts in internal and external communication pieces, they feel valued for their work and believe
their high self-efficacious efforts working with clients is the reason seniors are living healthy and
fulfilling lives.
Organization Recommendations
Introduction. Table 7 represents the organizational influences which have all be
validated based on survey data, interviews, literature review, and research by Clark and Estes
(2008), who suggest it is the responsibility of an organization to provide resources for the
completion of tasks. This includes creating work processes, furnishing tangible supplies and
equipment, and creating an organizational culture. It is also incumbent on the organization to
use a gap analysis to identify performance gaps and implement organizational change. Research
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by Clark and Estes (2008) found six types of support necessary for most organizational change
processes: (1) Have goals, a clear vision, and a way to measure progress, (2) Align the structures
and the processes of the organization with goals, (3) Communicate constantly and candidly to
those involved about plans and progress, (4) Top management must be continually involved in
the improvement process, (5) Provide adequate knowledge, skills, and motivational support for
everyone, and (6) All change processes with the same name are not equal.
While implementing change can be difficult, it is a critical component, along with
knowledge and motivation, to achieve organizational goals. As indicated in Table 7, these
organizational influences have a high priority of achieving the goal of using data to show a
decrease in emergency room visits and hospital stays due to the nutrition and supportive services
that clients are receiving at Senior Support. Table 7 also provides recommendations for these
influences based on theoretical principles for similar organizations wishing to implement this
promising practice.
Table 7
Summary of Organization Influences and Recommendations
Assumed
Organization
Influence: Cause,
Need, or Asset*
Validated
Yes, No,
Partially
Validated
(Y, N, PV)
Priori
ty
Yes,
No
(Y, N)
Principle and
Citation
Context-Specific
Recommendation
The organization has
a culture where
clinical staff is
involved in the
innovation and
implementation of
Y
Y
Effective
organizational change
efforts ensure all key
stakeholders
collaborate during the
design and decision-
Conduct cross-
departmental team
meetings to discuss
shared resources and
organizational goals for
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SENIOR NUTRITION PROGRAMS
new health
improvement
programs.
making process
(Clark & Estes,
2008).
There is a significant
positive relationship
between
organizational culture
and a commitment
towards innovation
(Parveen, Senin, &
Umar, 2015).
improving health
outcomes.
The organization uses
internal
communication
between clinical staff
and leadership on the
importance of using
data from the CGA
for new health
improvement
programs.
Y Y Change efforts are
communicated
frequently to all key
stakeholders (Clark &
Estes, 2008).
There is a linkage
between internal
employee
communication and
organizational
effectiveness (Chen,
2008).
Facilitate strategies to
ensure both clinical staff
and administrative staff
are constantly
communicating
including monthly
updates, quarterly all-
staff meetings, and
annual staff retreat.
The organization
assists clinical
support staff in
completing the CGA
so it does not feel
overwhelming when
they are already
working with a large
number of clients.
Y Y It is the responsibility
of an organization to
create a work process
that specifies how
people, equipment,
and materials link and
interact to produce
results (Clark &
Estes, 2008).
When working in a
healthcare setting,
reductions in staffing
levels diminish the
commitment of staff
(Burke, 2003;
Routinely conduct one-
on-one meetings with
clinical staff to
determine if staff has the
resources and time to
complete work.
Ensure staff-client ratio
is based on best practices
and reviewed on a
quarterly basis.
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Rafferty, Clark &
Coles, 2007).
The organization has
a process in place for
translating data into
new policy and health
improvement
programs.
Y Y Organizational
change efforts require
evidence-based
solutions adapted to
organizational culture
(Clark & Estes,
2008).
Evidence-based
interventions can
change organizational
trajectories in positive
ways (Berkel,
Mauricio,
Schoenfelder, &
Sandler, 2011).
Ensure there are policies
and procedures in place
to support new
programs.
Conduct staff meetings
to refine the process of
using data and best
practices to create
innovative health
improvement programs.
Cultural Model. The cultural model at Senior Support is based on the mission of
improving the quality of life for older adults. One pillar of the organizational cultural model is
innovation. According to Parveen, Senin, and Umar (2015), there is a significant positive
relationship between organizational culture and a commitment towards innovation. With a
diverse aging population, it is important to come up with new programs and services that
positively influence health outcomes for older adults. Every clinical staff worker is supported in
sharing ideas and best practices designed to improve health outcomes and physical
impairments. Effective organizational change efforts ensure all key stakeholders collaborate
during the design and decision-making process (Clark & Estes, 2008). According to Nimrod and
Hutchinson (2010), innovation protects a sense of internal continuity which has a positive effect
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on the well-being of older adults with chronic health conditions. While innovative ideas lead to
program development, it is critical that organizations develop rigorous monitoring and evaluation
to ensure program effectiveness for progress and sustainability (Frieden, 2014). As a promising
practice, Senior Support has created an efficient data collection model that can be shared with
similar organizations seeking to document improved health outcomes for clients.
To foster innovative ideas, it is recommended that similar organizations seeking to
implement this promising practice conduct cross-departmental team meetings to discuss shared
resources and goals for improving health outcomes. Innovators gain a new perspective when they
devote time and energy to finding and testing ideas through a network of diverse individuals
(Dyer et al., 2011). According to Frieden (2014), there are key areas that must be addressed in
order for an organization to create successful and sustainable health improvement programs
including evidence-based interventions, effective program management, partnerships with public
and private sector organizations, communication, and commitment to obtain resources and
support for effective action. Senior Support has created an organizational culture where the
clinical staff has a high degree of responsibility for achieving the organizational goals. It is
recommended that similar organizations ensure staff has the time to innovate and are provided
with the resources to execute the innovation.
Cultural Model. To meet the organizational goal of using data to show improved health
outcomes for clients based on the programs and support provided by the organization, it is
critical that clinical staff understand the importance of collecting accurate data. Lack of
communication from leaders in an organization can lead to performance gaps and misalignment
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of goals. According to Chen (2008), there is a linkage between internal employee
communication and organizational effectiveness. The responsibility for internal communication
stems from senior management (Bratton & Gold, 1999). Internal communication channels
should be used on a regular basis to ensure staff recognizes the importance of using data from the
CGA for new health improvement programs.
Based on the successful internal communication programs at Senior Support, it is
recommended that similar organization seeking to implement this promising practice facilitate
strategies to ensure both clinical staff and administrative staff are constantly
communicating. This includes developing new communication programs such as a monthly
update from senior leadership expanding on current internal communication efforts including the
quarterly all-staff meeting. One way to improve efficiency and quality is the ability to
communicate constantly and candidly (Dixon et al., 1994). It is recommended that internal
communication programs be top-down and bottom-up to allow lower levels of staff multiple
opportunities to share knowledge and ideas with senior leadership. It is also recommended that
organizations develop an annual retreat focusing on communication. Research by Richardson
and Nassar (1995), found that annual retreats for clinical staff increased productivity levels
ranging from 1.7 to 9.3 percent despite an 18.75 percent staff reduction. Despite the growing
number of older adults needing support and services, the data showed that the organization has
not been able to increase staff due to budgetary restraints. Therefore, an annual retreat that seeks
to increase communication and productivity is worth the organizational investment for any
organization seeking to implement this promising practice.
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Cultural Setting. According to Burke (2003), increasingly high demands on employee
time, effort, and cognitive processing negatively affect performance. Specifically, in a
healthcare setting, reductions in staffing levels diminish the commitment of staff (Rafferty,
Clark, & Coles, 2007). Working with a diverse older adult population creates unique challenges
for clinical staff; however, it is the responsibility of an organization to create a work process that
specifies how people, equipment, and materials link and interact to produce results (Clark &
Estes, 2008). The Senior Support clinical team works with a large number of clients on a daily
basis. Since each case is unique dealing individualized issues such as homelessness, mental
health issues, financial constraints, and physical ailments, the time to complete a CGA varies
from 30 to 90 minutes per client. The large variation is time to complete the CGA is due to the
unique issues that pertain to each client including malnutrition, homelessness, mental health, and
physical ailments. To ensure accurate data collection, the organization monitors staff workload
and makes formative adjustments so they do not feel overwhelmed working with clients. Failure
to do so has a negative effect on teamwork, delegation, trust, and patient outcomes (Thompson,
2012).
It is recommended that organizations seeking to implement this promising practice ensure
senior management routinely conducts one-on-one meetings with clinical staff to determine if
staff has the resources and time to complete their work. According to Sutthiwan and Clinton
(2008), a high workload generates stress, fatigue, and poor performance behaviors. One-on-one
meetings will keep employees engaged with the organization. Rice, Marlow, and Masarech
(2012) found that engaged employees are the top performers and contribute fully to an
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organization. However, this relies on the theory that they are getting what they need from work
including satisfaction of their personal values and aspirations, emotional connection to the
organization and their colleagues, and the ability to use their talents to make a difference (Rice et
al., 2012). The second recommendation is for management to utilize the information from one-
on-one meetings and ensure the client-staff ratio is based on best practices. According to data
collection, the current client to staff ratio at Senior Support is 100 to four. It is recommended
this ratio be reviewed every quarter based on one-on-one meetings and best practices.
Culture Setting. Measurable outcomes are a result of strong policies, procedures, and
processes. According to Clark and Estes (2008), organizational processes have to support
policies or there is a great risk of failure. To implement change for the growth and improvement
of the organization, it is critical that identifying and fixing process impediments are another
pillar of the organizational culture. The implementation process for these new programs requires
procedures and procedures to be clear and concise for staff. Carthey et al., (2011) suggests
simplifying policy development by reducing the number of organization-wide policies, using
best practices when guidelines are developed, and raising awareness that written policies without
explanation will not ensure compliance. Based on data collection, Senior Support has a process
in place for translating data into new policy and health improvement programs.
It is recommended that similar organizations seeking to implement this promising
practice ensure that policies and procedures are in place before implementation of new
programs. This can vary from organization to organization, therefore, it is recommended that
senior leadership conduct staff meetings to refine the process of using data and best practices to
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create innovative health improvement programs. Evidence-based interventions can change
organizational trajectories in positive ways (Berkel, Mauricio, Schoenfelder, & Sandler,
2011). This allows clinical staff to have a stake in the change process from innovation to
implementation. According to Clark and Estes (2008), organizational change efforts required
evidence-based solutions adapted to organizational culture. Addressing these issues with
evidence-based solutions will result in successfully translating data into new policies, programs,
and improved health outcomes.
Integrated Implementation and Evaluation Plan
Implementation and Evaluation Framework
The recommended implementation and evaluation plan for this research study is the New
World Kirkpatrick Model (Kirkpatrick & Kirkpatrick, 2016), which is based on the Kirkpatrick
Four Level Model of Evaluation which include Level 1: reaction, Level 2: behavior, Level 3:
learning, and Level 4: results (Kirkpatrick & Kirkpatrick, 2006). The New World Kirkpatrick
Model suggests that evaluation plans must start with the end in mind. This reverses the order of
the original Kirkpatrick Four Level Model of Evaluation and begins with looking at the expected
results. With the results in mind, it becomes easier to determine the job behaviors that are
required to accomplish those results and determine the type of learning interventions and culture
that is necessary to achieve the desired results. Based on the framework, the implementation and
evaluation framework for this research study will begin with Level 4, to determine the desired
indicators and outcomes. The next step is to focus on Level 3 which identifies behavior through
on-the-job training, monitoring, reinforcement, encouragement, and rewards (Kirkpatrick &
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Kirkpatrick 2016). According to Kirkpatrick and Kirkpatrick (2016), Levels 1 and 2 can occur
simultaneously. The learning evaluation in Level 2: Learning includes evaluating the knowledge,
skills, attitude, confidence, and commitment. This has a strong correlation with Level 1:
Reaction. The original Kirkpatrick Four Level Model of Evaluation focused on customer
satisfaction as the measure of success but has been evolved to include engagement and
relevance, two powerful components of effectively measuring reaction. This implementation and
evaluation plan provides immediate solutions to ensure success of the organizational goal.
Organizational Purpose, Need and Expectations
The purpose of Senior Support is to improve the well-being of low-income seniors
through innovative programs and services which is evident in their mission to help low-income
seniors live healthy and fulfilling lives. As the senior population grows, so does the need for
services. According to the Elder Economic Security Standard Index, 40 percent of seniors within
the service boundaries of Senior Support are low-income (UCLA Healthy for Policy Research,
2013). The long-term performance goal of the organization is to utilize data to show a decrease
in emergency room visits and hospital stays due to the nutrition and supportive services that
clients are receiving at Senior Support. This research study examined the knowledge and skills,
motivational, and organizational resources that are needed to accurately and efficiently collect
data to document health improvements in older adults. The proposed solution is to improve data
collection efforts through training, job aids, an internal and external communication strategy, and
staff meetings. As a promising practice, the goal is to share these solutions with similar
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organizations to collectively measure improved health outcomes and advocate for increased
federal funding for senior nutrition programs.
Level 4: Results and Leading Indicators
Table 8 shows the proposed Level 4: Results and Leading Indicators in the form of
outcomes, metrics and methods for both external and internal outcomes for Senior Support. If
the internal outcomes are met as expected as a result of the training and organizational support
for utilizing data to show a decrease in emergency room visits and hospital stays due to the
nutrition and supportive services that clients are receiving at Senior Support, then the external
outcomes should also be met.
Table 8
Outcomes, Metrics, and Methods for External and Internal Outcomes
Outcome Metric(s) Method(s)
External Outcomes
1. Increase federal funding
and enactment of impactful
legislation that benefits older
adults living in poverty
through targeted advocacy
strategies.
Authorization of the Older
Americans Act with
increased funding year-
over-year.
Identify and track the number of
key legislation year-over-year.
2. Serve as the thought-leader
on aging issues for
government entities.
Known as the leading
expert on aging issues in
the state, providing input
on legislation and
testimony at government
hearings.
Track number of relationships
with elected officials and their
staff and compare year-over-year.
3. Replicate the Senior
Support nutrition and
supportive services model at
similar organizations across
the United States.
Increase the number of
organizations that tour
Senior Support or request
speakers to present on the
Compare number of requests
year-over-year.
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nutrition and supportive
services model.
4. Empower older adults to
become involved in diverse
community groups to bring
overall awareness to Senior
Support services.
Increase the number of
Senior Support clients that
are involved in volunteer
opportunities or engaged in
community and civic
groups.
Track the number of older adults
that are engaged in volunteerism
and compare number year-over-
year.
5. Increased media attention
highlighting the programs and
services at Senior Support.
The frequency of Senior
Support mentions in radio,
television, blogs,
newspapers, and social
media.
Track frequency of Senior
Support mentions and compare
year-over-year.
Internal Outcomes
6. Increase participation in
the senior nutrition program
by improving the client
experience through
innovative programs and
services.
Development of a customer
service training curriculum
focused on enhancing the
client experience at all
congregate dining facilities.
Track number of senior nutrition
programs participants and
compare year-over-year.
7. Ensure all clinical staff are
effectively trained to assess
clients with the
Comprehensive Geriatric
Assessment tool.
Quarterly manager
observation to ensure data
is collected efficiently and
accurately.
Utilize a metric based progress
report during manager
observations, ensure time to
review results, and provide
positive feedback and
recommendations for
improvement.
8. Clinical staff are able to
translate data from CGA into
new policy and health
improvement programs.
Increase the number of
health improvement
programs designed to
improve the quality of life
for older adults.
Track the number of health
improvement programs that are
implemented and remain
successful after six months and
compare year-over-year.
Level 3: Behavior
Critical behaviors. The stakeholders of focus are the Senior Support clinical staff that
are assessing clients with the Comprehensive Geriatric Assessment tool. The first critical
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behavior is that clinical staff must believe they are capable of improving the quality of life of
older adults by helping them to remain independent and health in their own home. The second
critical behavior is the ability to assess clients in an appropriate matter of time to accurately
document unmet needs in new clients and their health improvements over time. The third critical
behavior is the ability to utilize data, research, and best practices to design and implement health
improvement programs that improve quality of life for Senior Support clients. The specific
metrics, methods, and timing for each of these outcome behaviors are detailed in Table 9.
Table 9
Critical Behaviors, Metrics, Methods, and Timing for New Reviewers
Critical Behavior Metric(s) Method(s) Timing
1. Clinical staff must believe
they are capable of improving
the quality of life of older
adults by providing programs
and services to help them
remain independent and
healthy in their own home.
One-on-one meetings
between clinical staff
and their manager.
During one-on-one
meetings, discuss
motivation issues that may
be preventing clinical staff
from providing best in
class services to clients.
Monthly
one hour
meetings.
2. Clinical staff have the
ability to assess clients in an
appropriate matter of time to
accurately document unmet
needs in new clients and their
health improvements over
time.
Manager observation
during the assessment
and one-on-one
meetings between
clinical staff and their
manager.
Manager completes
progress report during
observation to provide
positive and negative
feedback.
Quarterly.
3. Clinical staff have the
ability to utilize data, research,
and best practices to design
and implement health
improvement programs that
improve quality of life for
Senior Support clients.
The number of health
improvement
programs
recommended by
clinical staff.
Conduct care coordination
meetings to discuss best
practices, new research,
and suggestions for
improving current health
improvement programs
and services.
Monthly
team
meetings.
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Required drivers. To achieve the stakeholder goal, the leadership at Senior Support
must provide support in the form of reinforcement, encouragement, rewards, and
monitoring. The organizational goal is dependent on clinical staff effectively assessing
clients. Without accurate data, it would be difficult to implement new programs and services
based on the needs of clients. In addition, collecting and analyzing data is critical to showing
improved health outcomes for clients, which is the basis for advocating for additional funding for
senior nutrition programs. Table 10 shows the recommended drivers to support critical behaviors
of clinical staff.
Table 10
Required Drivers to Support New Reviewers’ Critical Behaviors
Method(s) Timing
Critical
Behaviors
Supported
1, 2, 3 Etc.
Reinforcing
Job Aid including brief summary of the 7 Theories of Aging to
create an appropriate care coordination plan for each client to reach
optimal health outcomes.
Ongoing 1, 2, 3
Provide staff with a list of approved professional development
opportunities designed to advance knowledge on best practices for
aging-related issues.
Quarterly 1, 2, 3
Job aid including detailed steps on assessing clients utilizing the
Comprehensive Geriatric Assessment.
Ongoing 1, 2
Provide training to clinical staff on how to self-reflect on their
knowledge of health promotion programs in relation to each client
in an effort to improve and close the knowledge gap.
Annual 1, 2
Implement an annual leadership training program to give clinical
staff the tools to collaborate and innovate based on best practices
for improving health in older adults.
Annual 1, 2, 3
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Encouraging
Conduct cross-departmental team meetings to discuss shared
resources and organizational goals for improving health
outcomes.
Quarterly 1, 2, 3
Designate time during one-on-one meetings with clinical staff and
their manager to discuss motivation issues that may be preventing
clinical staff from providing best in class services to clients.
Monthly 1, 2, 3
Rewarding
Highlight the work of clinical staff in success stories published in
external media pieces.
Quarterly 1, 2
Recognize an employee of the quarter and reward them with a paid
day off.
Quarterly 1, 2, 3
Monitoring
Observe clinical staff during Comprehensive Geriatric Assessment
evaluation of client and provide feedback.
Quarterly 1, 2
Manager participates in care coordination meetings led by clinical
staff discussing difficult or complex cases.
Monthly 1, 2, 3
Routinely conduct one-on-one meetings with clinical staff to
determine if staff has the resources and time to complete their work
and ensure client-staff ratio is based on best practices.
Quarterly 1, 2, 3
Organizational support. It is the responsibility of Senior Support to ensure that clinical
staff are supported to meet their stakeholder goal. First, the appropriate training for new
employees is a critical element in addressing the need for collecting accurate data on
clients. Managers must monitor new staff to immediately address concerns and make
adjustments to improve performance. Ongoing training, job aids, and external professional
development opportunities will provide best practices and knowledge to continuously improve
their ability to work with clients. The organization must encourage employees to take advantage
of these training opportunities and provide time for the employees to self-reflect on how their
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impact on serving the low-income, older adult population. The organization must also recognize
staff through positive reinforcement and rewards. This will increase staff longevity and give the
organization the benefit of institutional knowledge. Finally, the organization needs to monitor
clinical staff through observations and meetings. This will ensure staff has the appropriate tools
and knowledge to complete their job and the motivation to improve the quality of life of older
adults.
Level 2: Learning
Learning goals. Following completion of the recommended solutions, most notably
ongoing training to ensure staff are effectively trained to assess clients with the Comprehensive
Geriatric Assessment, the stakeholders will be able to:
1. Explain the seven different Social Theories of Aging and how they can be used to
create appropriate care coordination plans for each client to reach optimal health
outcomes, (D)
2. Recognize best practices in community health programs designed to improve health
outcomes for older adults, (D)
3. Assess clients accurately and efficiently using the Comprehensive Geriatric
Assessment tool, (P)
4. Utilize data from the Comprehensive Geriatric Assessment to suggest improvements to
the current senior nutrition program, (P)
5. Translate data from the Comprehensive Geriatric Assessment into new policy and
health improvement programs, (P)
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6. Apply feedback from manager observations to ensure accurate data collection and
client satisfaction, (P)
7. Create appropriate care coordination plans for each client based on their individual
needs, (P)
8. Self-reflect on their knowledge of health promotion programs in relation to each client,
(M)
9. Indicate with confidence that they have the resources and time to complete their work
or that they need additional resources, (Confidence) and
10. Value their ability to improve health outcomes for older adults (Value).
Program. The learning goals will be achieved with an ongoing training program for
clinical staff that ensures staff are effectively trained to assess clients using the Comprehensive
Geriatric Assessment tool. The training program begins with onboarding of new staff and
continues with a variety of monthly, quarterly, and annual professional growth opportunities,
one-on-one and team meetings, and consistent feedback. During the ongoing training, clinical
staff will study a broad range of aging-related topics and best practices to improve and innovate
programs and services designed to improve the quality of life for older adults. The internal
ongoing training program is enhanced with external learning opportunities including professional
development conferences, seminars, meetings, and webinars. It is recommended that the
organization offer at least two mandatory internal training opportunities and select a minimum of
four approved external training opportunities per year.
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During the onboard training for new staff, it is recommended that job aids be provided
and explained to ensure clinical staff understand key terminology and aging theories. There will
also be an in-depth training on how to assess new clients and the process for reassessing clients
after six months. During the first three months of employment, managers will observe at least
one assessment per week and provide immediate feedback designed to improve efficiency,
accuracy, and confidence. New staff will also be provided with a mentor to provide extra
support. Research shows that staff who receive intensive mentoring increase performance
(Strong, Fletcher, & Villar, 2008).
The ongoing training program for clinical staff is critical for achieving the learning goals.
Professional growth enables clinical staff to develop the knowledge and skills necessary to
improve the quality of life for aging adults. Each client has diverse and varied needs, and it is
important that staff are effectively trained to understand their unique situation and create
appropriate and individualized care coordination plans. With the number of older adults growing
at a substantial rate year-over-year, it becomes increasingly important for clinical staff to be
knowledgeable in best practices to be able to serve a larger population without additional
resources.
In addition to internal and external training opportunities, clinical staff need time for one-
on-one meetings with their manager, team meetings within each department, and all-staff
meetings and retreats. This gives clinical staff the opportunity to ask questions, share best
practices learned from external learning opportunities, and work directly with organizational
leaders. This type of collaborative environment will foster communication and the creation of
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innovative programs. It is also important that managers train staff on the self-reflection process
and allow time for clinical staff to self-reflect on how they are improving health outcomes for
older adults. Investing in staff will produce a motivated workforce and lower staff
turnover. According to Mcmahon (2017), leaders who recognize the strategic value of education
and engage their staff in training can expect a meaningful return on their investment.
Components of learning. Declarative knowledge increases procedural knowledge and
therefore demonstrating proficiency often shows how the knowledge can be used to
improve problems (Clark et al., 2008). To assess whether the training programs are successful, it
is important to evaluate learning for both declarative and procedural knowledge. The evaluation
process should demonstrate that training participants retain declarative knowledge, can utilize the
knowledge to perform tasks, value the training as imperative to increasing job performance,
confident that they can succeed in applying the knowledge, and committed to applying the
knowledge to their work. As such, Table 11 lists the evaluation methods and timing for these
components of learning.
Table 11
Components of Learning for the Program.
Method(s) or Activity(ies) Timing
Declarative Knowledge “I know it.”
Knowledge checks using multiple choice. Immediately following new
employee onboard training.
Knowledge checks through one-on-one meetings with
managers.
Monthly.
Procedural Skills “I can do it right now.”
Report out during team care coordination meetings. Quarterly.
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Demonstrate knowledge through scenario situations
presented during new employee onboard training.
Immediately following new
employee onboard training.
Demonstrate knowledge during care coordination
meetings which include mock scenario cases and new or
worked solutions.
Quarterly.
Demonstrate knowledge of assessing clients during a
workshop where clinical staff have the opportunity to
assess each other in teams.
During the training.
Retrospective pre- and post-test assessment survey
asking participants about their level of proficiency
assessing clients before and after the training.
Before and after the training.
Attitude “I believe this is worthwhile.”
Manager’s observation of clinical staff during the
assessment training.
During the training.
Discussions of the value of what they are being asked to
do on the job during one-on-one meetings.
Monthly.
Confidence “I think I can do it on the job.”
One-on-one formal discussions with manager. Immediately following training
workshops or professional
development opportunities.
Discussions following mock assessment with staff. After the training.
Commitment “I will do it on the job.”
Discussion following observation of clinical staff
assessing clients.
Quarterly.
Manager review care coordination plans created by
clinical staff.
Quarterly.
Team meetings to discuss case outcomes. Monthly.
Level 1: Reaction
Due to the amount of training that is required for clinical staff to ensure they are
assessing clients appropriately and creating innovative programs to improve quality of life for
aging adults, it is important to determine how they react to new employee training, ongoing
workshops, seminars, and external professional development opportunities. This will ensure the
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organization is investing in training opportunities that improve quality of work and enhance the
employee’s confidence, motivation, reaction, and value. As such, Table 12 lists the components
to measure reactions to learning opportunities.
Table 12
Components to Measure Reactions to Learning Opportunities
Method(s) or Tool(s) Timing
Engagement
Observation by managers during new employee onboard
training.
During training.
Completion of at least two external professional development
training opportunities per year.
Ongoing.
Share information on what was learned during training
programs with other staff members.
Quarterly.
Relevance
One-on-one meetings with managers to share information about
the training.
At monthly meeting
immediately following the
training.
Share relevant information during care coordination meetings to
enhance the quality of care provided to clients.
Monthly.
Customer Satisfaction
Require form after the training to report on the knowledge and
best practices learned as well as a recommendation for other
staff.
Immediately following
training.
Add a section on the employee’s self-evaluation to discuss how
the training has improved job performance.
Annually.
Evaluation Tools
Immediately following the program implementation. The new employee onboard
training program is a critical component in developing clinical staff with the knowledge and
motivation to effectively assess clients, collect data, and implement health improvement
programs. To assess the effectiveness of the onboard training program, new employees will be
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asked to complete an onboard training evaluation form (Appendix G). This will indicate new
employee satisfaction, knowledge, and confidence in applying the training to their work. It will
also give managers the opportunity to address concerns or provide additional training to ensure
clinical staff feel comfortable assessing clients.
For Level 1, managers will be present for various portions of the onboard training to
observe new staff. Specifically, managers will be actively engaged during the mock
Comprehensive Geriatric Assessment training sessions to ask periodic questions and provide
immediate feedback. This also helps foster a collaborative environment between new employees
and their managers.
Level 2 checks for understanding by monitoring new clinical staff during their first three
months of employment. Once a week, for the first three months of employment, managers will
observe new staff as they assess clients. During the assessment, managers will use an
observation form (Appendix H) to provide feedback on targeted behaviors including
engagement, inclusivity, interaction, knowledge, assessment, time management, and
organizational policies. This immediate feedback allows managers to provide an improvement
plan and additional training to ensure accurate data collection of clients is not compromised by
incorrect assessments.
Delayed for a period after the program implementation. It is recommended that after
employees are on the job for at least six months, they are required to participate in at least two
external professional training opportunities per year. This will ensure employees have access to
best practices and emerging research in the field of aging. Allowing employees to select from
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approved training programs gives them the opportunity to strengthen their own weaknesses to
provide the highest quality of service to clients. Each clinical staff worker has a unique
educational or professional background, and therefore they need diverse training opportunities,
rather than a one-size-fits-all training approach, to improve their work. Within one week of
completing a professional development training, employees are required to submit an evaluation
form (Appendix I). One of the goals of the professional development training program will be
for employees to attend different programs and present the information to their colleagues as part
of the internal training program. This strengthens collaboration and ensures each employee can
exhibit knowledge on best practices (Level 3) and can utilize the information to create
meaningful health programs that improve the quality of life for older adults (Level 4).
Data Analysis and Reporting
The level 4 goal of collecting data on health outcomes for older adults is measured by the
ability of clinical staff to assess clients accurately and efficiently. Clinical staff must have the
knowledge, skills, and motivation to improve health outcomes for older adults by establishing a
care coordination plan for each client. This is critical to meeting the long-term performance goal
of the organization to use data to show a decrease in emergency room and hospital visits due to
the nutrition and supportive services that clients receive at Senior Support.
The Chief Administrative Officer will use the dashboard below (Figure 3) to monitor
Level 4 internal outcomes. Analyzing the data to see if it meets expectations and evaluating why
it does or does not meet expectations is a critical component to evaluating the program. The
dashboard, which tracks how efficiently and accurately clinical staff are completing
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Comprehensive Geriatric Assessments, shows organizational leadership that the training
programs are meeting expectations because more than 90 percent of assessments are completed
on time, without errors. Similar dashboards will be created to monitor Levels 1, 2, 3, and
external outcomes for Level 4.
Figure 3: Internal Outcomes Dashboard
Recommendations for Future Research
As a promising practice, this research study was limited to understanding the knowledge,
motivation, and organizational resources at a singular organization. This particular organization
has been successful in providing programs and services to low-income seniors in the community
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for nearly 50 years. While the organization’s model can be replicated, it is unknown whether
similar organizations can attain the level of success without similar funding sources. It is
particularly important to explore organizations that solely offer a senior nutrition program
without additional programs and services, such as housing assistance, to understand the value
that comprehensive programs bring to improve health outcomes and reduce overall Medicare
expenses. It is recommended that future research explore similar organizations with varied
budgets and program offerings to fully assess this promising practice. It is also recommended
that future research explore the benefits of training staff on specific gerontology topics such as
the 7 Social Theories of Aging.
Summary
The recommended implementation and evaluation plan for this research study is based on
the New World Kirkpatrick Model. Based on the model, there are four levels of training and
evaluation that ensure clinical staff have the knowledge, motivation, and organizational support
to improve health outcomes for older adults. The model suggests that evaluation plans must start
with the end in mind, reversing the order of the original Kirkpatrick Four Level Model of
Evaluation (Kirkpatrick & Kirkpatrick, 2016).
This evaluation plan begins with Level 4, establishing the outcomes, metrics, and
methods to measure the targeted outcomes that meet the organization’s goal of using data to
show a decrease in emergency room visits and hospital stays due to the nutrition and supportive
services that clients receive. Next, the plan outlines the critical behaviors (Level 3) that are
necessary for clinical staff to achieve their goals. Finally, learning and reaction (Levels 1 and 2),
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are expected to occur simultaneously. Learning includes evaluating the knowledge, skills,
attitude, confidence, and commitment that is necessary for assessing clients accurately and
efficiently and creating individualized care plans to improve health outcomes. Reaction
evaluates the training program for clinical staff to ensure the organization is investing in
meaningful and worthwhile professional development that increases job performance and
motivation.
According to Kirkpatrick and Kirkpatrick (2016), organizational support is critical to the
success of any training program. Annually, the Chief Administrative Officer will use dashboards
to measure success. In addition, managers will test knowledge throughout the year through
observation, progress reports, and feedback. This will allow clinical staff to continuously
improve on how they assess clients and ensure the data collected is accurate. This data can be
used by the organization to advocate for additional senior nutrition funding, which ultimately
offers a cost savings to Medicare.
The recommendations made in this Chapter will help improve the data collection process
at Senior Support. More importantly, the model used at Senior Support can be used at similar
organizations seeking to implement this promising practice to start collecting data or clients, or
improve their current process. Collectively, senior nutrition program providers have a unique
opportunity to standardize the data collection process which will show improved health
outcomes for clients based on their programs and services. This evidence can be used to advocate
for additional funding because it will show that older adults are healthier, more independent, and
less reliant on Medicare-funded services.
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APPENDIX A
Survey Items
Open-Ended Questions
1. Describe your interest and experience working with seniors.
2. Can you briefly describe the Social Theories of Aging?
3. What are the pros and cons of a senior nutrition program?
4. What is the purpose of the Comprehensive Geriatric Assessment?
5. Can you provide an example of a client who has shown significant health improvements
based on the senior nutrition program?
6. What training programs does your organization provide to increase your knowledge
working with the senior population?
7. What does your organization do to increase awareness of the senior nutrition program?
8. Your organization has been recognized as a national model for delivering high impact
programs and services to older adults. What makes it unique?
9. What improvements would you make to the current process of assessing the health of
new clients?
10. What are some of the obstacles to serving more clients in the community?
11. Give an example of how you collaborate with other departments in the organization to
improve the quality of life for seniors.
12. Do you self-reflect on your work? If so, why do you believe that is important?
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Demographic Questions
13. What is your highest level of education?
14. How many years have you worked for your organization?
15. How many years have you been working with older adults?
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APPENDIX B
Interview Protocol
Interview Questions
1. Can you give me a general overview on the process for a new client who would like to
participate in the senior nutrition program?
2. Why did you feel it was important to start assessing clients and tracking health outcomes?
3. Why did you decide to use the Comprehensive Geriatric Assessment as the standardized
tool to assess clients?
4. How often do you assess clients after the initial assessment?
5. What does the training process include for introducing staff to the Comprehensive
Geriatric Assessment?
6. What is the reaction of clients when they realized they have to be assessed to participate
in the nutrition program?
7. Could you explain how your data collection efforts be easily implemented by other senior
nutrition program providers?
8. With the growing number of seniors needing services, how do you assess the number of
clinical staff you need to effectively serve a large number of clients?
9. How would additional funding enhance your current senior nutrition program?
10. Do you have a personal story you would like to share about one of your clients that
significantly benefited from the senior nutrition program?
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APPENDIX C
Informed Consent for Interview
University of Southern California
Rossier School of Education
Los Angeles, CA 90089
INFORMED CONSENT FOR NON-MEDICAL RESEARCH
Examining the Benefits of Senior Nutrition Programs as a Cost Savings to Medicare:
A Promising Practice Study
You are invited to participate in a research study conducted by a doctoral student at the University
of Southern California, because you are a clinical staff worker at Senior Support. Your
participation is voluntary. You should read the information below, and ask questions about
anything you do not understand, before deciding whether to participate. Please take as much time
as you need to read the consent form. You may also decide to discuss participation with your
family or friends. If you decide to participate, you will be asked to sign this form. You will be
given a copy of this form.
PURPOSE OF THE STUDY
The purpose of this research study is to understand how senior nutrition programs improve overall
health outcomes for seniors and therefore offer a cost-savings to Medicare because older adults
utilizing nutrition programs are healthier and remain more independent. As a clinical staff worker
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in one of the few organizations in the United States that is collecting data on improved health
outcomes for seniors participating in congregate or home delivered meal programs, your
knowledge will help contribute to similar organizations who only have anecdotal stories of health
improvements rather than data. If multiple organizations collect data showing improved health
outcomes, it will be easier to advocate for increased federal funding to support senior nutrition
programs.
STUDY PROCEDURES
If you volunteer to participate in this study, you will be asked to complete a one-time online
survey which is anticipated to take between 25-30 minutes. The survey will have multiple
choice and open-ended questions. You can choose to answer all questions or skip questions if
you do not feel comfortable answering.
POTENTIAL RISKS AND DISCOMFORTS
There are no anticipated risks or discomforts associated with this research study.
POTENTIAL BENEFITS TO PARTICIPANTS AND/OR TO SOCIETY
This research study is being conducted to enrich the literature on the benefits of senior nutrition
programs. Findings from this study can be used to create a standardized data collection for similar
organizations. This study will offer solutions and recommendations in the areas of knowledge,
motivation, and organizational resources that may be appropriate for other senior nutrition program
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providers who wish to provide data highlighting their role in improving health outcomes for older
adults.
CONFIDENTIALITY
We will keep your records for this study confidential as far as permitted by law. However, if we
are required to do so by law, we will disclose confidential information about you. The members
of the research team and the University of Southern California’s Human Subjects Protection
Program (HSPP) may access the data. The HSPP reviews and monitors research studies to protect
the rights and welfare of research subjects. The data will be stored on a password protected laptop
owned by the researcher and be kept indefinitely. The data will not be released to any other party
for any reason. Any identifiable information obtained in connection with this study will remain
confidential. Your responses will be coded with a false name (pseudonym) and maintained in a
separate location. When the research study is published or discussed in any manner, no identifiable
information will be used.
PARTICIPATION AND WITHDRAWAL
Your participation is voluntary. Your refusal to participate will involve no penalty or loss of
benefits to which you are otherwise entitled. You may withdraw your consent at any time and
discontinue participation without penalty. You are not waiving any legal claims, rights or remedies
because of your participation in this research study.
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INVESTIGATOR’S CONTACT INFORMATION
If you have any questions or concerns about the research, please feel free to email the Principal
Investigator at: mmatter@usc.edu.
RIGHTS OF RESEARCH PARTICIPANT – IRB CONTACT INFORMATION
If you have questions, concerns, or complaints about your rights as a research participant or the
research in general and are unable to contact the research team, or if you want to talk to someone
independent of the research team, please contact the University Park Institutional Review Board
(UPIRB), 3720 South Flower Street #301, Los Angeles, CA 90089-0702, (213) 821-5272 or
upirb@usc.edu.
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SIGNATURE OF RESEARCH PARTICIPANT
I have read the information provided above. I have been given a chance to ask questions. My
questions have been answered to my satisfaction, and I agree to participate in this study. I have
been given a copy of this form.
__________________________________
Name of Participant
__________________________________ ____________________
Signature of Participant Date
SIGNATURE OF INVESTIGATOR
I have explained the research to the participant and answered all of his/her questions. I believe
that he/she understands the information described in this document and freely consents to
participate.
__________________________________
Name of Person Obtaining Consent
__________________________________ ____________________
Signature of Person Obtaining Consent Date
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APPENDIX D
Information Sheet for Survey
University of Southern California
Rossier School of Education
Los Angeles, CA 90089
INFORMATION/FACTS SHEET FOR EXEMPT NON-MEDICAL RESEARCH
Examining the Benefits of Senior Nutrition Programs as a Cost Savings to Medicare:
A Promising Practice Study
You are invited to participate in a research study. Research studies include only people who
voluntarily choose to take part. This document explains information about this study. You should
ask questions about anything that is unclear to you.
PURPOSE OF THE STUDY
The purpose of this research study is to understand how senior nutrition programs improve overall
health outcomes for seniors and therefore offer a cost-savings to Medicare because older adults
utilizing nutrition programs are healthier and remain more independent. As a clinical staff worker
in one of the few organizations in the United States that is collecting data on improved health
outcomes for seniors participating in congregate or home delivered meal programs, your
knowledge will help contribute to similar organizations who only have anecdotal stories of health
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improvements rather than data. If multiple organizations collect data showing improved health
outcomes, it will be easier to advocate for increased federal funding to support senior nutrition
programs.
PARTICIPANT INVOLVEMENT
If you volunteer to participate in this study, you will be asked to complete a one-time online
survey which is anticipated to take between 25-30 minutes. The survey will have multiple
choice and open-ended questions. You can choose to answer all questions or skip questions if
you do not feel comfortable answering.
CONFIDENTIALITY
We will keep your records for this study confidential as far as permitted by law. However, if we
are required to do so by law, we will disclose confidential information about you. The members
of the research team and the University of Southern California’s Human Subjects Protection
Program (HSPP) may access the data. The HSPP reviews and monitors research studies to protect
the rights and welfare of research subjects. The data will be stored on a password protected laptop
owned by the researcher and be kept indefinitely. The data will not be released to any other party
for any reason. Any identifiable information obtained in connection with this study will remain
confidential. Your responses will be coded with a false name (pseudonym) and maintained in a
separate location. When the research study is published or discussed in any manner, no identifiable
information will be used.
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INVESTIGATOR CONTACT INFORMATION
Principal Investigator: Michelle Matter via email at mmatter@usc.edu or Faculty Advisory Dr.
Corinne Hyde via email at chyde@usc.edu.
IRB CONTACT INFORMATION
University Park Institutional Review Board (UPIRB), 3720 South Flower Street #301, Los
Angeles, CA 90089-0702, (213) 821-5272 or upirb@usc.edu
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SENIOR NUTRITION PROGRAMS
APPENDIX E
Recruitment E-mail for Survey
Dear (First Name),
My name is Michelle Matter and I am a doctoral student at the University of Southern California.
I am conducting a research study about how senior nutrition programs improve overall health for
older adults and therefore offer a cost savings benefit to Medicare. Specifically, I am interested
in researching best practices for collecting data on clients, moving away from anecdotal stories
highlight health improvements to a standardized data collection method across all organizations
providing congregate and home-delivered meal programs to seniors.
I am writing to ask if you would be willing to participate in my research study by completing a
survey. The survey is anticipated to take no more than 30 minutes of your time. Participation is
completely voluntary and your answers will remain confidential and anonymous.
If you are interested in participating, please click on the link below for additional information
and the survey: www.qualtrics.com/[link]. If you have any questions or need additional
information, please feel free to contact me.
Thank you,
Michelle Matter
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APPENDIX F
Recruitment E-mail for Interviews
Dear (First Name),
My name is Michelle Matter and I am a doctoral student at the University of Southern California.
I am conducting a research study about how senior nutrition programs improve overall health for
older adults and therefore offer a cost savings benefit to Medicare. Specifically, I am interested
in researching best practices for collecting data on clients, moving away from anecdotal stories
highlight health improvements to a standardized data collection method across all organizations
providing congregate and home-delivered meal programs to seniors.
I am writing to ask if you would be willing to participate in my research study by participating in
a one-hour interview. Participation is completely voluntary and your answers will be kept
confidential.
If you have any questions or need additional information, please feel free to contact me.
Thank you,
Michelle Matter
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APPENDIX G
Onboard Training Employee Evaluation
Please rate the following on a scale of 1 to 5:
1= Strongly Disagree 2= Disagree 3=Neutral 4=Agree 5=Strongly Agree
The orientation session provided clear information about:
Organization mission 1 2 3 4 5
Organizational goals 1 2 3 4 5
Ethics 1 2 3 4 5
Training requirements 1 2 3 4 5
The Comprehensive Geriatric Assessment (CGA) Training provided sufficient information on the following:
Importance of assessing clients 1 2 3 4 5
How to engage with clients 1 2 3 4 5
The diversity of client needs 1 2 3 4 5
Explanation of each question on the assessment 1 2 3 4 5
Time management during assessments 1 2 3 4 5
Programs and services available to clients 1 2 3 4 5
Referral information and process 1 2 3 4 5
Dealing with difficult clients 1 2 3 4 5
Weekly manager observations 1 2 3 4 5
I feel confident in assessing clients in two weeks 1 2 3 4 5
I feel comfortable asking my manager questions 1 2 3 4 5
I need additional training before I can assess clients 1 2 3 4 5
I feel comfortable with my assigned staff mentor 1 2 3 4 5
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The mock CGA assessment was helpful 1 2 3 4 5
What did you like best about your onboard training experience?
_____________________________________________________________________________________________
_____________________________________________________________________________________________
_____________________________________________________________________________________________
What would you like to see improved in the onboard training experience?
_____________________________________________________________________________________________
_____________________________________________________________________________________________
_____________________________________________________________________________________________
Please provide any additional comments about your onboard training experience.
_____________________________________________________________________________________________
_____________________________________________________________________________________________
_____________________________________________________________________________________________
_____________________________________________________________________________________________
_____________________________________________________________________________________________
_____________________________________________________________________________________________
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APPENDIX H
Comprehensive Geriatric Assessment Manager Observation Form
Name of Employee:_______________________________________Date:__________________
Name of Evaluator: _______________________________________________
Rating Scale
5 = Exceeds criteria of assessing the client accurately and efficiently
4 = Meets criteria of assessing the client accurately and efficiently
3 = Needs improvement in assessing the client accurately and efficiently
2 = Makes major mistakes in assessing the client accurately
1 = Fails to assess clients accurately and/or efficiently
Target Behavior Rating Comments of Examples
of Behavior
ENGAGEMENT
Clinical staff member makes eye contact, greets and welcomes the client
sincerely, speaks in a friendly manner, explains the CGA process.
INCLUSIVITY
Clinical staff serves without regard to national origin, religion, gender, sexual
orientation, medical condition, disability, or economic status.
INTERACTION
Asks questions in a clear and consistent manner and provides explanations for
questions that are not clear to the client.
KNOWLEDGE
Provides information to the client including questions regarding programs and
services offered at the organization as well as referrals.
ASSESSMENT
Provides accurate assessment of the client’s health status and needs.
TIME MANAGEMENT
Spends appropriate amount of time assessing the client based on individual
health issues and needs.
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POLICIES
Demonstrates and upholds organizational policies and procedures.
OVERALL PERFORMANCE RATING (check one)
_____ Exceeds expectations
_____Meets expectations
_____Needs improvement - improvement plan required
_____Unsatisfactory - additional training needed before staff can continue assessing clients
ADDITIONAL COMMENTS
_____________________________________________________________________________________________
_____________________________________________________________________________________________
_____________________________________________________________________________________________
_____________________________________________________________________________________________
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APPENDIX I
Professional Development Evaluation Form
Name:____________________________________
Professional Development Title:_________________________________________________
Brief Description of the Conference/Training/Webinar/Workshop:
______________________________________________________________________________
______________________________________________________________________________
______________________________________________________________________________
Date of Training:___________________________
Please rate the following on a scale of 1 to 5:
1= Strongly Disagree 2= Disagree 3=Neutral 4=Agree 5=Strongly Agree
The objectives of the training were clearly communicated. 1 2 3 4 5
The objectives of the training were relevant to my learning. 1 2 3 4 5
The training met my learning style as an adult learner. 1 2 3 4 5
The presenter was effective. 1 2 3 4 5
The training opportunity was worth my time. 1 2 3 4 5
I plan to use what I learned at the training to improve my work. 1 2 3 4 5
I can present what I learned today to my colleagues. 1 2 3 4 5
I would recommend this training to my colleagues. 1 3 3 4 5
Please comment:
What was the most significant thing you learned today?
_____________________________________________________________________________________________
_____________________________________________________________________________________________
_____________________________________________________________________________________________
What support do you need to implement what you learned?
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_____________________________________________________________________________________________
_____________________________________________________________________________________________
_____________________________________________________________________________________________
How will you apply what you learned at the training program to your work?
_____________________________________________________________________________________________
_____________________________________________________________________________________________
_____________________________________________________________________________________________
If you weren’t satisfied with the training, please explain why.
_____________________________________________________________________________________________
_____________________________________________________________________________________________
_____________________________________________________________________________________________
Additional comments:
_____________________________________________________________________________________________
_____________________________________________________________________________________________
_____________________________________________________________________________________________
_____________________________________________________________________________________________
_____________________________________________________________________________________________
Abstract (if available)
Abstract
The growing number of older adults threatens the sustainability of the Medicare program. The purpose of this study was to use the Clark and Estes (2008) gap analysis framework to understand the knowledge, motivation, and organizational influences among clinical staff that impact their ability to collect data on older adults participating in a senior nutrition program. Assumed knowledge, motivation, and organizational influences, supported by a literature review, were investigated through a qualitative data collection of interviews and surveys. The assumed influences were validated through qualitative analysis and confirmed with an examination of documents collected from the study setting. As a promising practice, this research study demonstrates a strategy that has been implemented at an organization to solve a problem of practice in an effort to inspire and advise similar organizations. The recommendations in Chapter Five are based on the New World Kirkpatrick Model (Kirkpatrick & Kirkpatrick, 2016), and designed to establish a standardized data collection process for senior nutrition program providers. The purpose of collecting data is to advocate for increased federal funding for senior nutrition programs. These programs increase quality of life for older adults by keeping them healthy and independent, and therefore offer a cost savings to the Medicare program.
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Asset Metadata
Creator
Matter, Michelle L.
(author)
Core Title
Examining the benefits of senior nutrition programs as a cost savings to Medicare: a promising practice study
School
Rossier School of Education
Degree
Doctor of Education
Degree Program
Organizational Change and Leadership (On Line)
Publication Date
04/09/2018
Defense Date
04/09/2018
Publisher
University of Southern California
(original),
University of Southern California. Libraries
(digital)
Tag
comprehensive geriatric assessment,Gerontology,Medicare,OAI-PMH Harvest,older adults,senior nutrition,senior nutrition programs,seniors
Language
English
Contributor
Electronically uploaded by the author
(provenance)
Advisor
Hyde, Corinne (
committee chair
), Crispen, Patrick (
committee member
), Krop, Cathy (
committee member
)
Creator Email
michellematter22@gmail.com,mmatter@usc.edu
Permanent Link (DOI)
https://doi.org/10.25549/usctheses-c89-11426
Unique identifier
UC11670945
Identifier
etd-MatterMich-6179.pdf (filename),usctheses-c89-11426 (legacy record id)
Legacy Identifier
etd-MatterMich-6179.pdf
Dmrecord
11426
Document Type
Dissertation
Rights
Matter, Michelle L.
Type
texts
Source
University of Southern California
(contributing entity),
University of Southern California Dissertations and Theses
(collection)
Access Conditions
The author retains rights to his/her dissertation, thesis or other graduate work according to U.S. copyright law. Electronic access is being provided by the USC Libraries in agreement with the a...
Repository Name
University of Southern California Digital Library
Repository Location
USC Digital Library, University of Southern California, University Park Campus MC 2810, 3434 South Grand Avenue, 2nd Floor, Los Angeles, California 90089-2810, USA
Tags
comprehensive geriatric assessment
Medicare
older adults
senior nutrition
senior nutrition programs
seniors