Building the Business Capacity of Senior Nutrition Programs

Business Acumen Learning Collaborative

2016 - 2017
Network Profile: Twin Cities Care Partnership (MN)

Executive Summary – Healthcare Integration Approach/Goals:

Our project provides patients discharged from the hospital who have been diagnosed with diabetes, chronic obstructive pulmonary disease, or 

chronic kidney disease with nutrition services for 30 days, nutrition counseling for their disease, a medication review, and daily in-home safety 

checks. We will provide the patients with a simple in-home recovery plan to reduce readmissions to the hospital. Our goal with the project is to 

reduce the thirty day readmission rates in the three specific chronic diseases by 8% overall, increase patient self-management of disease in 

regards to nutrition, and increase patient assessed wellness and safety in the home.

Current Partners and Contract Prospects (e.g., name of potential integrated care entities – health plan, hospitals, ACO, MCO – 

being targeted for contracts)

HealthVisions Midwest, Vytos Phramacy, Methodist Hospital – Northlake Campus, Methodist Hospital – Southlake Campus, St. Catherine’s 

Hospital Franciscan Alliance ACO.

Potential Target Population (e.g., dual eligible, duals with multiple chronic diseases, EBP targets, high risk, vulnerable seniors, 

etc):

Recent hospital discharges, who have 1+ of the following conditions, chronic obstructive pulmonary disease, diabetes, and/or chronic kidney 

disease. The target population will also be Medicare or Dual-eligible – particularly those with little support systems in place.

Potential Services or service packages (types of services each Learning Collaborative Member will sell to contract prospects):

Our proposed service package will include 10 home-delivered meals (therapeutic if needed), an in- home, one hour nutrition consult and home 

safety check, and referrals to other programs as needs are identified. 

Collaborative partners (i.e., a list of all partners organizations in each Learning Collaborative Member’s network):

Community Emergency Services (CES), Senior Services

Consortium of Ramsey County (SSCRC) and Metro Meals on Wheels.

Learning Collaborative Member Contact(s)

Mike Krachmer, Director of Operations

1900 11th Avenue South 

Minneapolis, MN 55404

Email: mkrachmer@cesmn.org

Phone: 612-870-6121
Network Profile: Southern Maine Area Agency on Aging (ME)

Executive Summary – Healthcare Integration Approach/Goals:

The Southern Maine Agency on Aging (SMAA) will dedicate four hours a week of its Business Development Manager’s time to cultivating 

relationships, establishing a business model for marketing SMAA “service packages”, and ultimately developing financial contracts with 

healthcare partners to support its’ Simply Delivered for ME program. SMAA’s Simply Delivered for ME program provides home-delivered meals 

to high-risk Medicare patients who have been discharged from the hospital. Through extensive research, SMAA has proven that the provision of 

Simply Delivered meals reduces the risk of re-hospitalization within the subsequent 30 days after discharge. Through this grant opportunity, 

SMAA will improve on its knowledge of the healthcare arena, strengthen its’ business capacity and relationships with existing and potential 

partners, and will work collaboratively with other grantees to develop a replicable business model for establishing funding contracts in the 

future.

Current Partners and Contract Prospects (e.g., name of potential integrated care entities – health plan, hospitals, ACO, MCO – 

being targeted for contracts)

York Hospital, Martin’s Point Healthcare, Anthem BCBS of Maine

Potential Target Population (e.g., dual eligible, duals with multiple chronic diseases, EBP targets, high risk, vulnerable seniors, 

etc):

Older adult hospital discharges and those with chronic diseases, including hypertension, diabetes, osteoporosis, and heart disease, as well as 

stroke victims and those with dementia.

Potential Services or service packages (types of services each Learning Collaborative Member will sell to contract prospects): 

Service packages may include evidence-based falls prevention programs like Matter of Balance and Tai Chi; Medicare and insurance counseling; 

and other care transitions services.

Collaborative partners (i.e., a list of all partners organizations in each Learning Collaborative Member’s network):

NHCAS is comprised of 5 New Hampshire (NH) based nonprofit 501(c) (3) organizations that provide Meals on Wheels to older and disabled 

adults in their respective service areas; Ossipee Concerned Citizens

(OCC), Tri-County Community Action Program (TCCAP), Grafton County Senior Citizens Council (GCSCC), the Community Action Program of 

Belknap-Merrimack Counties, Inc. (CAPBMCI), and St. Joseph Community Services (SJCS).

Learning Collaborative Member Contact(s)

Nancy Connelly, Business Development Manager

136 U.S. Route One

Scarborough, ME 04074

Email: nconnelly@smaaa.org

Phone: 207-396-6591
Network Profile: Meals on Wheels of Northwest Indiana (IN)

Executive Summary – Healthcare Integration Approach/Goals:

Our project provides patients discharged from the hospital who have been diagnosed with diabetes, chronic obstructive pulmonary disease, or 

chronic kidney disease with nutrition services for 30 days, nutrition counseling for their disease, a medication review, and daily in-home safety 

checks. We will provide the patients with a simple in-home recovery plan to reduce readmissions to the hospital. Our goal with the project is to 

reduce the thirty day readmission rates in the three specific chronic diseases by 8% overall, increase patient self-management of disease in 

regards to nutrition, and increase patient assessed wellness and safety in the home.

Current Partners and Contract Prospects (e.g., name of potential integrated care entities – health plan, hospitals, ACO, MCO – 

being targeted for contracts)

HealthVisions Midwest, Vytos Phramacy, Methodist Hospital – Northlake Campus, Methodist Hospital – Southlake Campus, St. Catherine’s 

Hospital Franciscan Alliance ACO.

Potential Target Population (e.g., dual eligible, duals with multiple chronic diseases, EBP targets, high risk, vulnerable seniors, 

etc):

Recent hospital discharges, who have 1+ of the following conditions, chronic obstructive pulmonary disease, diabetes, and/or chronic kidney 

disease. The target population will also be Medicare or Dual-eligible – particularly those with little support systems in place.

Potential Services or service packages (types of services each Learning Collaborative Member will sell to contract prospects): 

Our proposed service package will include 10 home-delivered meals (therapeutic if needed), an in- home, one hour nutrition consult and home 

safety check, and referrals to other programs as needs are identified. 

Collaborative partners (i.e., a list of all partners organizations in each Learning Collaborative Member’s network):

N/A

Learning Collaborative Member Contact(s)

Jodi Bella, Business Development Manager

8446 Virginia Street

Merrillville, Indiana 46410

Email: jodi@mownwi.org

Phone: 219-756-3663
Network Profile: Minuteman Senior Services (MA)

Executive Summary – Healthcare Integration Approach/Goals:

Minuteman Senior Services has over 40 years of experience successfully delivering meals to seniors in their homes and has developed an 

expertise in providing other in-home services. We will leverage existing medical partnerships and utilize the expertise of a health care consultant 

to expand our nutrition program to a targeted population, through formal contracts with hospitals, accountable care organizations and others. 

Minuteman Senior Services will impact malnutrition and improve health outcomes by developing a business plan to contract with medical 

providers and offer therapeutic meals and community nutrition consults targeting patients with cardiac disease post hospital discharge. This fills 

an unmet need, as nutrition is a key factor in recovery and 70% of adults age 65 and up are at risk for malnutrition post hospitalization. Nutrition 

has proven efficacy to reduce readmissions regarding heart disease and other chronic conditions as well as post hospitalization.

Current Partners and Contract Prospects (e.g., name of potential integrated care entities – health plan, hospitals, ACO, MCO – 

being targeted for contracts)

Emerson Hospital,Healthcentric Advisors, (the New England QIN-QIO), Winchester Hospital, Lahey Health’s ACO, Commonwealth Care Alliance, 

NaviCare, Senior Whole Health, Tufts Health Plan, and United

Health Care.

Potential Target Population (e.g., dual eligible, duals with multiple chronic diseases, EBP targets, high risk, vulnerable seniors, 

etc):

Hospital discharged cardiac patients

Potential Services or service packages (types of services each Learning Collaborative Member will sell to contract prospects): 

Our proposed service package will include 10 home-delivered meals (therapeutic if needed), an in- home, one hour nutrition consult and home 

safety check, and referrals to other programs as needs are identified. 

Collaborative partners (i.e., a list of all partners organizations in each Learning Collaborative Member’s network):

See the above.

Learning Collaborative Member Contact(s)

Leslie May-Chibani, Assistant Director

26 Crosby Drive

Bedford, MA 01730

Email: l.may-chibani@minutemansenior.org

Phone: 781-221-7056

Jennifer Stiff, Nutrition Program Director

Email: j.stiff@minutemansenior.org 

Phone: 781-221-7056
Network Profile: Meals on Wheels Greater Pittsburg (PA)

Executive Summary – Healthcare Integration Approach/Goals:

The goal is to help Meals on Wheels Greater Pittsburg (MOWGP) develop contracts with health care providers including MLTSS contractors, 

hospitals/health systems, PACE replication programs, and Medicare Part C plans. Each MOWGP member is also a Meals on Wheels America 

member that operates a senior nutrition program currently receiving funds from the Older Americans Act. Project goals include: 1) Improve 

service packaging and service delivery options; 2) Prepare marketing plan for health plans, hospitals, and related health care providers; 3) Create 

simplified ordering system to better meet the needs of prospective purchasers; 4) Document impact of nutritional support services that support 

independence; 5) Implement cross agency Quality Assurance Performance Improvement (QAPI) program to meet\exceed MCO requirements; 

and 6) Execute a minimum of 3 contracts with MCOs to provide services prior to August, 2017.

Current Partners and Contract Prospects (e.g., name of potential integrated care entities – health plan, hospitals, ACO, MCO – 

being targeted for contracts)

Contract prospects include:

(1) MCOs, particularly those who will be implementing the new MLTSS system in southwestern Pennsylvania; (2) Stand-alone hospitals; (3) Area 

PACE replication projects, including Community Life and Life Pittsburgh; and (4) other healthcare providers (i.e., hospice).

Potential Target Population (e.g., dual eligible, duals with multiple chronic diseases, EBP targets, high risk, vulnerable seniors, 

etc):

Older adults “at-risk” of losing independence by virtue of their age, health, living situation, and other factors.

Potential Services or service packages (types of services Learning Collaborative Member will sell to contract prospects):

Traditional Meals on Wheels service plus a “safety check” (including change of condition monitoring) that takes place during each “delivery”. As 

needed an “alert” will be transmitted to an Intervention Specialist, who follows up on the report and takes appropriate action (referral, family 

notification, care management/care coordination, MD appointment).

Collaborative partners (i.e., a list of all partners organizations in each Learning Collaborative Member’s network):

Seven programs comprise Meals on Wheels of Greater Pittsburg (MOWGP): LifeSpan, Inc., Eastern Area Adult Services, Hill House Association, 

Plum Senior Community Center, Riverview Community Action Corporations and the Catholic Youth Association.

Learning Collaborative Member Contact(s)

Kimberly Delp, RN, BSN, Senior Director of Home Based Community Services

Landmark Home Healthcare Inc

Northern Area Multi-Service Center

Email: kimberly.delp@namsc.com

Phone: 724-444-6767
Network Profile: Southern Maine Area Agency on Aging (ME)

Executive Summary – Healthcare Integration Approach/Goals:

The Southern Maine Agency on Aging (SMAA) will dedicate four hours a week of its Business Development Manager’s time to cultivating 

relationships, establishing a business model for marketing SMAA “service packages”, and ultimately developing financial contracts with 

healthcare partners to support its’ Simply Delivered for ME program. SMAA’s Simply Delivered for ME program provides home-delivered meals 

to high-risk Medicare patients who have been discharged from the hospital. Through extensive research, SMAA has proven that the provision of 

Simply Delivered meals reduces the risk of re-hospitalization within the subsequent 30 days after discharge. Through this grant opportunity, 

SMAA will improve on its knowledge of the healthcare arena, strengthen its’ business capacity and relationships with existing and potential 

partners, and will work collaboratively with other grantees to develop a replicable business model for establishing funding contracts in the 

future.

Current Partners and Contract Prospects (e.g., name of potential integrated care entities – health plan, hospitals, ACO, MCO – 

being targeted for contracts)

York Hospital, Martin’s Point Healthcare, Anthem BCBS of Maine

Potential Services or service packages (types of services each Learning Collaborative Member will sell to contract prospects):

Service packages may include evidence-based falls prevention programs like Matter of Balance and Tai Chi; Medicare and insurance counseling; 

and other care transitions services.

Potential Target Population (e.g., dual eligible, duals with multiple chronic diseases, EBP targets, high risk, vulnerable seniors, 

etc):

Older adult hospital discharges and those with chronic diseases, including hypertension, diabetes, osteoporosis, and heart disease, as well as 

stroke victims and those with dementia.

Collaborative partners (i.e., a list of all partners organizations in each Learning Collaborative Member’s network):

NHCAS is comprised of 5 New Hampshire (NH) based nonprofit 501(c) (3) organizations that provide Meals on Wheels to older and disabled 

adults in their respective service areas; Ossipee Concerned Citizens

(OCC), Tri-County Community Action Program (TCCAP), Grafton County Senior Citizens Council (GCSCC), the Community Action Program of 

Belknap-Merrimack Counties, Inc. (CAPBMCI), and St. Joseph Community Services (SJCS).

Learning Collaborative Member Contact(s)

Nancy Connelly, Business Development Manager

136 U.S. Route One

Scarborough, ME 04074

Email: nconnelly@smaaa.org

Phone: 207-396-6591
Network Profile: New Hampshire Coalition of Aging Services (NH)

Executive Summary – Healthcare Integration Approach/Goals:

The New Hampshire Coalition of Aging Services (NHCAS) was formed in 2011 by five non-profit organizations that provide nutrition and other 

essential services to older and disabled adults in NH (St. Joseph Community Services is one of the 5). Members recognize that the current 

healthcare system is changing from a fee-for-service based system to one that is based on outcomes and improved care coordination that also 

results in reduced costs. NHCAS members seek to augment their skills, knowledge and business acumen in order to better position and integrate 

nutrition and other important services offered by their organizations into the healthcare market. Together, members will accomplish this by 

engaging in strategic planning, defining their value proposition to the healthcare system, enhancing the current system of data collection and 

documentation of service impact, effecting the necessary culture change within each organization, developing a business plan and contracting 

with at least one healthcare entity within the next year.

Current Partners and Contract Prospects (e.g., name of potential integrated care entities – health plan, hospitals, ACO, MCO – 

being targeted for contracts)

Ascentria Care Alliance, Catholic Charities, NH Healthy Families, and Easter Seals of NH

Potential Services or service packages (types of services each Learning Collaborative Member will sell to contract prospects):

The proposed service package includes home-delivered meals, nutrition assessment and education, in-home safety checks and tracking of 

necessary follow-up to any issues or concerns encountered during the home visit. This ‘basic’ package represents the core of services that every 

member of the NHCAS offers. This service package has proven value in improved customer outcomes with high satisfaction and is an extremely 

cost effective option, especially as it compares to any form of institutional care.

Potential Target Population (e.g., dual eligible, duals with multiple chronic diseases, EBP targets, high risk, vulnerable seniors, 

etc):

Older adult hospital discharges and those with chronic diseases, including hypertension, diabetes, osteoporosis, and heart disease, as well as 

stroke victims and those with dementia.

Collaborative partners (i.e., a list of all partners organizations in each Learning Collaborative Member’s network):

NHCAS is comprised of 5 New Hampshire (NH) based nonprofit 501(c) (3) organizations that provide Meals on Wheels to older and disabled 

adults in their respective service areas; Ossipee Concerned Citizens

(OCC), Tri-County Community Action Program (TCCAP), Grafton County Senior Citizens Council (GCSCC), the Community Action Program of 

Belknap-Merrimack Counties, Inc. (CAPBMCI), and St. Joseph Community Services (SJCS).

Learning Collaborative Member Contact(s)

Meghan Brady, President

395 Daniel Webster Highway, P. O. 910

Merrimack, NH 03054

Email: mbrady@sjcsinc.org

Phone: 603-424-9967
Network Profile: Elmview Senior Nutrition (WA)

Executive Summary – Healthcare Integration Approach/Goals:

HomeLinks expands services currently provided by Elmview Senior Nutrition contracting with community health partners for the following 

services: home-delivered meals. nutrition/wellness assessments, nutrition education, in-home safety checks, and information and referral so 

that people remain healthy and at home. Target populations are chronically ill, people transitioning from health care institutions to home, and 

people identified as at risk. The outcome will be contracts for services with two community health entities.

Current Partners and Contract Prospects (e.g., name of potential integrated care entities – health plan, hospitals, ACO, MCO – 

being targeted for contracts)

Kittitas Valley Healthcare, Community Health of Central Washington, MCOs, and healthcare companies-Community Health Plan of Washington, 

Coordinated Care Corporation, United Behavioral Health, and United Healthcare of Washington.

Potential Services or service packages (types of services each Learning Collaborative Member will sell to contract prospects): 

Current service package includes: home-delivered meal, nutrition and wellness assessments, nutrition education, in-home safety checks, and 

information and referrals as needed to needed long-term services and supports. 

Potential Target Population (e.g., dual eligible, duals with multiple chronic diseases, EBP targets, high risk, vulnerable seniors, 

etc):

Seniors over the age of 60, with chronic illness, people transitioning from hospitals or nursing facilities, and those identified by community 

partners as at risk and in need of in-home nutrition services.

Collaborative partners (i.e., a list of all partners organizations in each Learning Collaborative Member’s network):

N/A

Learning Collaborative Member Contact(s)

Bruce Tabb

Executive Director

P.O. Box 66

Ellensburg, WA 98926 

Email: bruce@elmview.org

Phone: 509-925-6688