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Meals on Wheels and Rural Communities, with Carter Florence and Shon Gress

Date: August 1, 2023
Duration: 36 minutes

Shon Gress Carter Florence An interview with Carter Florence, DrPH, MPH, Vice President of Programs with Meals on Wheels America, and Shon Gress, CEO and Executive Director of Meals on Wheels Guernsey County, headquartered in Cambridge, Ohio. We discuss the myriad benefits Meals on Wheels can provide in rural areas, and the ways in which stakeholders can get involved.

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Organizations and resources mentioned in this episode:


Andrew Nelson: Welcome to Exploring Rural Health, a podcast from the Rural Health Information Hub. My name is Andrew Nelson. In this podcast, we'll be talking with a variety of experts about providing rural healthcare, problems they've encountered, and ways in which those problems can be solved. This is an episode about the Meals on Wheels program.

I'm talking today with Dr. Carter Florence, Vice President of Programs with Meals on Wheels America, as well as Shon Gress, CEO and Executive Director of Meals on Wheels Guernsey County, headquartered in Cambridge, Ohio. Thank you both for joining us.

Shon Gress: Thank you.

Carter Florence: Thanks for having us.

Andrew Nelson: To get started, can you tell me a little bit about the mission and the history of Meals on Wheels?

Carter Florence: Sure. Andrew, I can start. Meals On Wheels America is the national organization, and then Shon is [with] a local Meals on Wheels program. So I can talk a little bit nationally about the history of Meals on Wheels, and then maybe Shon can talk about how he fits into that as well. Meals on Wheels started as a compassionate idea: neighbors helping neighbors, and it really was a groundswell of a grassroots movement that started in the United States in the 1950s. The first known delivery was in Philadelphia in the early 1950s, but it spread widely there, throughout the U.S., and actually other countries as well.

And we really talk about the meal being the entree to enabling so much more being delivered. And that was true from the conception in the early '50s. And so much of how we're continued to be supported and be the network that we are was through the addition of Title IIIC of the Older Americans Act in the '70s, which codified Meals on Wheels as a public-private partnership — so leveraging those federal dollars to be able to bring to bear. And so Meals On Wheels America came shortly after that as a national leadership organization to support advocacy and continued research and support of Meals on Wheels nationally. And Shon, I'd love to know how Guernsey County got started.

Shon Gress: Well, we are a private nonprofit organization. We've been in operation for over 51 years. Back in 1972 we formed the Guernsey County Senior Citizens Center, and Meals on Wheels Guernsey County really falls under that larger umbrella of the senior center. We have a very detailed mission statement, but what it really comes down to is just being able to ensure seniors can live independently for as long and as safely as possible in the comfort of their own homes, and to really engage them in all aspects of community life. So for us, nutrition has been a big key component of maintaining that independence we've seen for a long time. Meals on Wheels just continues to grow. In our rural community, we actually have a Meals on Wheels levy and a senior services tax levy as well to support those programs.

Carter Florence: As Shon mentioned, thinking about supporting independence and supporting living at home or living in community with independence and dignity, that's core to Meals on Wheels.

It's the meal that creates the opportunities for additional tailoring of nutrition, social connection, safety, and resources and referrals.

We could spend an entire podcast just talking about the food of Meals on Wheels, and it would be pretty fabulous. It has a nutritional standard that it meets, and it's delivered in both home and community settings. So, senior centers, congregate dining sites, as well as through the home delivered work. But that meal enables so much more, and that really comes into advanced tailoring of the nutrition for some older adults. Some folks need a little bit more help. They might need a meal that has a different texture that can help them swallow and eat it. So we're able to provide that kind of work.

You also look at the social connection aspect of Meals on Wheels. That relationship that develops between folks who are receiving the meals and those delivering the meals is pretty tremendous. And there's a true trust that's established there, as well as a connection to the broader community that's established. Beyond that, many of our Meals on Wheels programs offer dedicated programming for social connection whether that is through pet food assistance or whether that is through friendly visiting and calling programs to just provide a little extra support and care and connection to older adults who may have more difficulty getting out into the community and building those connections on their own.

The third major component that we see through that meal delivery is our safety work. And so much of what's happening when we're going to the home setting to deliver a meal is we're noticing what is happening in that home environment. We may see a concern about a broken step or a loose rail or a door that's not locking properly. So, the home environment, as well as just the individual work that the nutrition aspects play to keep the older adult healthy and safe at home. There is also the physical environment that we're able to notice and address either directly or through referrals to other community-based partners.

And then the last aspect of the work that Meals and Wheels truly does at its core is make those community connections, those resources and referral connections. So bringing to bear programs like LIHEAP which is an energy efficiency support, or I believe Shon's program does a lot with transportation, chore programs to help support the older adults and then other community organizations that may need to be brought to bear and support an older adult to live at home.

But it truly is about the meal, creating those opportunities for tailored nutrition, social connection, safety, and resources and referrals that create the whole service model that enables elder adults to stay at home through our work.

Shon Gress: For us in rural Ohio, especially in Appalachia, food has always been the core, that social connectedness, especially, you know, with families and get-togethers and that sort of thing. So Meals on Wheels really just kind of goes and expands beyond that when a lot of those support systems no longer exist. Being able to provide someone with a hot meal every day, especially in areas where there may be what they refer to as food deserts, that there are no grocery stores, there's no longer any restaurants or mom-and-pop diners on the corner. As the world just continues to grow and expand and people are more mobile, we're fortunate that we can actually make referrals within our own agency through those relationships and the rapport that we have with our clients that we're providing hot, nutritious meals to every day. We're going in and we're looking for changes of condition and those social determinants of health to determine, is there anything else that we could be doing that could expand their independence or their quality of life?

If they live 25, 30 minutes away from the nearest town, our transportation can be really essential to going and picking them up, taking them to doctor's appointments, to care appointments, to the grocery store, and even visiting congregate dining sites if they choose or are not eligible to receive meals within their homes. Looking at the health concerns of rural isolated older adults, nutrition obviously is key. Looking at transportation and access, affordability of transportation and some of those other multi community-based services and just connecting people to the resources that we may have in our communities. I find rural communities have done more with less throughout history. We've had to be creative.

We try to be nice. We try to help each other. We try to work together as communities. But where a lot of our churches in small rural areas used to provide these services, we find they're struggling. You know the churches and the pews are not as full as they once were; socioeconomically they're struggling. So there continues to be a growing need and demand, and I think it's part of why we are so proud and honored to work with Meals on Wheels America. It's all about partnerships and collaboration. If you're sitting on an island thinking that you're going to solve everybody's problems by yourself, it's going to be a challenge and a struggle. So having that national partnership that parlays into networking with people locally and on a regional level, [is] so beneficial to addressing the needs of older adults. I think regardless if you're urban, rural, or where you're located in America, I think, you know, there's certainly benefits.

Andrew Nelson: How do people that could benefit from Meals on Wheels make the initial connection with the service?

Shon Gress: A lot of times it's the individual themselves who reaches out. Sometimes it's a concerned neighbor or friend or family member. And sometimes it's just our presence within a particular community. They see that vehicle, they see that logo, there's that curiosity. “What is that service? What do they do?” And as we always say, it's more than a meal. It's that daily wellness check, it's that connectedness. And so, you know, I think by and large, we always have other nonprofits that make referrals. We have hospitals that we partner with, different civic clubs and, and community organizations.

Carter Florence: Absolutely. And if folks are looking for service in their own communities, Meals on Wheels America manages a website called Find Meals where you can literally search by zip code to find Meals on Wheels providers in your community. And it talks a little bit about typical eligibility criteria, payments, other services that folks might be able to access there, but then reaching out to your local provider to make that connection.

Shon Gress: We're constantly surveying our clients to figure out the flavor, the quality of the food, the portions of the food, the different varieties and options of how we prepare those meals. Be it diabetic, pureed, chopped, all those different things that can address individual very specific needs, but keeping it locally flavored within our local culture as well.

Andrew Nelson: Certainly. Who are the people who run Meals on Wheels programs in rural areas, and how do they get funding?

Carter Florence: So Meals on Wheels programs are very much a local institution. So every Meals on Wheels program has their own governance. They may show up in various organizations, so they might be a standalone community-based organization. They can also be embedded within a local government or other entity within the organization. And some of that does have to do with the funding mix. Each program's mixes of funding is going to look a little different. On average, about 40% of overall budget for senior nutrition program comes through the federal dollars of the Older Americans Act. And then the other 60% is made up of client contributions, grants, and donations. Shon mentioned the levies that they have in Ohio, which is a really unique additional funding source for them. You'll find them in Parks and Recs departments. You'll find them embedded in senior centers. You'll find them as standalone community-based organizations.

Andrew Nelson: What are some examples of people that would especially benefit from meals on Wheels in rural communities?

Shon Gress: I know I can speak for our community, we usually see it's that, typically that single widow/widower who lives alone more often than not. So I think when we start looking at different people that benefit from the Meals on Wheels, each has their own unique varied story. And we're obviously looking at those independent living skills that they have. Is it for medical reasons that they would benefit? Is it for loneliness and isolation? Is it for just improved wellness? Is it some other type of ability or inability that keeps them in their home that would prevent them from being able to cook for themselves, go to a local restaurant or really fend for themselves nutritionally? So I think it really is kind of a wide range.

Carter Florence: And while this is not a wellness issue, I do want to point out that what we know about the Meals and Wheels client population at large is that we're routinely serving some of the oldest old, so kind of 75 and up and 85 and up, and just kind of the support systems that are available for individuals of that age. I think it's just a really, that is something we see as a common demographic factor of Meals on Wheels clients nationally. Shon, anything you'd add about your specific rural community makeup?

Shon Gress: I had here in my notes, diabetes, heart pulmonary disease, loneliness, you know, and then I think just again, those chronic conditions, multiple chronic conditions sometimes paired with obesity, physical limitations. So I think, again, there's often what we find some of those most common is probably in our area, the heart disease, pulmonary, diabetes.

Carter Florence: We are crossing their thresholds. We are creating an intimate relationship with older adults to be able to bring to bear ideas or opportunities that might help them; may not. And to keep their dignity, you know, top of mind. And to keep the individual's autonomy is really critical. So volunteers can come in all shapes and sizes. I'm sure Shon can go into some of his specific volunteers, but we also have additional standalone programming, or maybe you can't make that mealtime, lunchtime delivery, but you could help with delivering pet food on a Saturday, or be able to be a friendly visiting caller or a volunteer to help replace or build a ramp for someone to be able to get in and out of their home more easily. And Shon, I'll let you talk about locally in your program.

Shon Gress: I really support the tailored nutrition, the social connectedness, the safety resources and referrals, making those connections. Having that established rapport and relationship with our clients is so important. You know, more often than not in most states, people that work with older adults are also mandated reporters. And I think one of the key elements with Meals on Wheels that really makes us unique, we're not just popping in once a month or on the holidays to check in on someone. We're there every day, and sometimes it's five days a week, some days it's seven days a week, but to really identify if there are situations of elder abuse, neglect, financial exploitation, those are all things that volunteers and paid staff that work as home delivered meal drivers are exposed to or privy to, because we have that unique ability that we're there every day.

So we can sometimes see with consistency those changes that might be happening, maybe unexpected bruises that, you know send up a red flag. So I think, you know, there's that social and ethical part of what we do of protecting our elderly, and again, making those referrals and connections with other agencies and entities that might go above and beyond, some type of case management where there might need to be family intervention or individual support put in place. So I think, you know, from that very fundamental core, we're advocates for older adults. And so I think part of that responsibility is looking at every aspect that we can look at to try to protect them, to keep them safe, to keep them healthy and well. And I think too, very simply, to put a smile on their face, to make a difference in somebody's day, that pat on the back, that tap on the shoulder, just making eye contact or having somebody to talk to can make all the difference in somebody who may be lonely or isolated. So, makes a huge difference.

Andrew Nelson: Outside of delivering food to individuals' homes, what are some other ways that Meals on Wheels can help to ensure that rural residents that are in need of food get it?

Carter Florence: This goes back to what Shon mentioned earlier about partnership and collaboration. Meals on Wheels programs are not a silo. They're connected; they know other folks. And there are many other nutrition programs that they can make referrals to, like SNAP or the Farmer's Market Senior Nutrition Program and other federal programs as well as other local programs. A lot of our Meals on Wheels programs, if they do have a food bank within their communities, are also connected there. And so really there are a tremendous number of partners that communities take, and it's going to depend on the rural community.

Shon Gress: You're exactly right, Carter. When we look at the senior supplemental food commodities programs, the Farmers Market programs, working with food banks you know, at the state or regional level, what I find is in my 23 years of being the CEO I have never met a Meals on Wheels program that just dabbles in providing Meals on Wheels. They're all in. So they're always looking for those other food and nutrition partners that they can partner with, always have the capacity or the ability to try to do more, be more, meet all of those different needs. But I think the daily wellness check is so key and so important. I can't even begin to probably quote numbers of how many times a home delivered meal driver has gone into a home to find somebody unresponsive on the floor that has truly saved their life.

We saw during COVID the grab-and-gos which continue to be very popular for a lot of people. We know that there are some people that will never go back into a group setting to dine. And so it's been a great option to be able to provide grab-and-go meals to expand congregate meals within local communities. You know, we partner with a variety of churches to open up their churches and their facilities as congregate dining sites. And that has worked really well for us in some of our very small rural communities where they don't have access to restaurants or grocery stores.

Andrew Nelson: Yeah. You mentioned how a volunteer might be able to help someone with an accessibility ramp or something, depending on their abilities. What are some what are some different types of training that Meals on Wheels makes available for volunteers?

Carter Florence: So it may be something like data entry or calling people for surveys. That's something that we do regularly to make sure that folks are satisfied with the services that we're delivering. And to also kind of understand a little bit more about what other opportunities might be of interest or support. So, I mean, it's everything from data entry to literally packaging the food. Many Meals on Wheels programs use volunteers for that aspect. Not all. When you become a volunteer, there's a background check and then training will be dependent upon what role you're playing within the organization. Now there are some things, like perhaps a ramp, that would be maybe not as much training for or formal training for that, but more of those kind of community engagement opportunities that you may be able to have as well.

Shon Gress: And, I think for us, especially as we hire staff in things like sensitivity to aging, CPR, first aid training, key elements of being unofficial first responders in a lot of situations. And so I think also focusing on some of the sensitivity to trauma, be it socially induced or, you know, life experience and learning those familiarities and trying to educate our staff or volunteers that go out to provide meals that they have to be sensitive to each individual. And a lot of times that's part of building that trust and that relationship. If there is a female that does not feel comfortable with a male delivering a meal in her home alone you know, looking at the core of what can we do to adjust and modify, reasonably accommodate those individuals to be sensitive to those needs.

Not everybody just wants someone to come in and plop a meal down on their table and turn around and walk out and leave. Manners, I think, are also a real key to little things that we can train or educate our home deliver meal staff. Do you wipe your feet on the welcome mat before you walk in the house? You know, do you have to take your shoes off? All those things that when we're looking at somebody's opening up their home for you to provide a service, there are those little attention to detail things that can make all the difference to a satisfied customer or person that we're providing a meal to. So I think that's key.

Andrew Nelson: Yeah. Can you talk just a little bit about the flexibility that allows volunteers to adjust the amount of social interaction they have with clients, depending on what the client wants?

Carter Florence: Folks can adjust their route, kind of who they're delivering to. So if they know that their client who slated for their fifth delivery of 12 really likes to talk and they've got extra time, they may deliver to them last so that they can spend a little extra time with them or deliver to them first because, you know, because client number seven always wants their food right at X number of time or as much as close to it as possible. So making sure that they're there and have that consistency.

Shon Gress: There's some clients that you can move rather quickly in an out of the home, you know, to deliver a meal. On average, we find it's probably three minutes, but we have some clients that we can spend as much as probably 5 to 10, 15 minutes in their home. So, and especially if they need help with something and it's something that we can easily do to help them, I would want my staff to take the time to do that.

Andrew Nelson: Certainly. What are some of the distinct challenges that can exist for Meals on Wheels programs that are located in rural areas?

Shon Gress: A lot of the civic clubs and churches and small rural communities are struggling where they used to maybe give as part of their community outreach, they used to give donations. We're finding some of that has changed over the years. We're also finding that, at the core, volunteerism is changing. So what we're finding as people are having to work longer, which means they have less time to volunteer, we're also finding that individuals that want to give of their time, or at least want to give back to their community, also are looking to be supplemented or paid.

I think a lot of that could be geographical, depending on where you are in the country as well. I think for rural partners, when you look at how far we have to drive to deliver a meal, so you look at things like the cost of gas, the wear and tear on tires, some of the roads that we travel down. If I were to take some of my urban counterparts, they would probably question if this is even defined as a road, or is it more of a cow path? And so, you know that takes a beating on those vehicles and we don't have the large economic structure to really keep good condition of township roads and back roads and things like that to get to where we need to deliver that meal.

We are resourceful, if nothing else. We've had to do more with less. You know, where collaboration and partnership may be a buzzword in some communities. For us, it's been out of necessity, something that we've always had to do to sustain our program.

We are also facing a change where a lot of rural communities cannot retain young people because the jobs just aren't there. So the younger generation is maybe moving away to some of the more urban areas in search of work and to find jobs. It's a challenge when a nonprofit organization is trying to compete with the Burger Kings and, you know, other restaurants that may be paying 15, $18 an hour. And when you look at unit rates of reimbursement that have not been increased or really measure up to what is the cost to provide a service, these are all challenges that I think for us in rural areas has been especially difficult.

Andrew Nelson: Can you talk about what the process is for somebody that wants to become a volunteer for Meals on Wheels?

Carter Florence: Sure. So it's really about connecting with your local organization. And then from there kind of determining the interest and level of involvement that can be made, and if the fit's right, a background check and training to get y'all started. I think our greatest need is a consistent volunteer who can be a part of that delivery of meals. But we are able to accommodate, in some cases, more episodic volunteer opportunities as well. But we do have a website that you can fill out a quick form and that will be connected to a local program in your service area.

Shon Gress: One of the things that I think is so essential for people to understand is if you're interested in helping with a Meals and Wheels program, you don't just have to be a home delivered meal driver. There are cooks, there are assistant cooks, there are assessors, program planners, developers, care navigators — there's so many different positions under that larger umbrella of Meals on Wheels. So I often tell people, you know, if you're looking to connect a skill there's, that is such a huge department of different positions that are available out there.

Andrew Nelson: Certainly. During the COVID-19 pandemic, additional government funding actually helped to increase Meals on Wheels outreach. Since the end of the public health emergency, what's changed?

Carter Florence: Yeah. This has been a very timely question. I think we're continuing to see financial strains to Meals on Wheels programs to meet the sustained demand for services. COVID-19 really created significant demand. But it's not gone away and it's not going to. So programs are making difficult decisions to meet the need. And this may include reducing the amount of service delivered or maintaining wait lists for services. Meals on Wheels America conducted a survey this spring and found that 99% of our members are facing challenges to serving meals to all seniors in the community who need them. And most frequently those challenges include high food prices, funding to pay for the meals, recruiting and retaining enough volunteers, and gas prices. And so to put it simply, rising costs and declining funding — both federal through the public health emergency and others, and philanthropic just through this tremendous outpouring of support we saw throughout COVID, but through corporate partners as well as funder philanthropic entities — has really led to fewer meals and seniors being served. And the need and demand is continuing to grow. So we're going in the wrong direction here.

Shon Gress: Yeah, I agree, Carter. I think we're really in that rebuilding and recovery mode at this point. You know, a lot of Meals on Wheels programs really you know, stepped up to the task during COVID and did things even then that they couldn't afford, with the hopes of, kind of in our philosophies that we do the good and hopefully something will come that will offset what it cost us to do that so that we can fill those gaps. And I think a lot of programs, especially smaller rural programs, are still trying to heal those wounds. Because, you know, oftentimes those numbers increased dramatically during COVID. For us, we went from right around 500, 600 meals a day to averaging 2000 meals a day. We never stopped during COVID.

We didn't get to stay at home or work from home. We were still putting ourselves at risk and going out there and, and doing the work and doing what needed to be done to keep seniors in their homes and to keep them safe. ARPA [American Rescue Plan Act] funding has been dispersed to some programs. Even times where we're struggling with the high costs of food, some of our equipment is worn out. We did such volume and such production during those times. Even some of the commercial equipment that we have in our kitchens wasn't equipped to handle that kind of an influx on a routine daily basis. So just finding and getting the help and assistance through grants and through Meals on Wheels America and some of their grant opportunities to replace some of that equipment, to meet those unmet needs or to do some type of community expansion to help us sustain our programs has really been essential.

But I think, you know, we learned here personally, like the grab-and-gos was a great thing that came out of the COVID pandemic because, to me, it's a great option and a great alternative. So I think we're still trying to look for ways that I think some of the federal funding is probably going to be tapping off here, you know soon or if it hasn't already with some of the COVID relief funding and that sort of thing. But I think, again, for a lot of programs, it's a time of just that rebuilding and recovery. We thought we knew a lot before COVID, but we learned a lot. And so now I think it's also having the funding to build for what's next or what could potentially happen that we need to be better prepared for the next time or if and when something like that ever occurs again.

Andrew Nelson: For sure. Any final thoughts you'd like to share with our audience today?

Shon Gress: I would just say if you're a small rural program that is out there struggling and you don't know where to go, I know we've had a lot of new directors that have come in. We've had a lot of people that, as a result of COVID, retired and there's been a change in leadership. I would just suggest if you're out there, you're struggling, you don't know where to go to connect with the advocacy, to connect with grant opportunities, to connect with networking with your peers and people of programs all over the country, check into the membership of Meals on Wheels America, become a member of Meals on Wheels America. The opportunities that are out there to partner with group purchasing consortiums that can help save your program money and help you do more. And all of those different opportunities. I think we are blessed to have a national organization that has the care and compassion that they do. And to be able to reach out to bigger, smaller, programs of all sizes and try to identify very consistently, “What do you need? What can we do for you and what can we do together to make a difference?” And I think that's really at the core of the benefits of being a member of the Meals on Wheels network.

Carter Florence: Meals On Wheels is truly a unique entity that is a tremendous asset in rural communities. And you may not always know that it's there. But reach out to your senior center, reach out to us, and get connected in your community locally. And if you're interested and able, I would highly encourage you to volunteer. It's incredibly rewarding.

Andrew Nelson: You've been listening to Exploring Rural Health, a podcast from RHIhub. In this episode, we spoke to Dr. Carter Florence, Vice President of Programs with Meals on Wheels America, as well as Shon Gress, CEO and Executive Director of Meals on Wheels Guernsey County. Look in our show notes for more information about their work and visit for all things rural health.