1

2017 Grantee 

Tackling Malnutrition 

Through a Statewide 

Delivery System in Maryland

Summary: 

To transform their senior nutrition program, the Maryland 

Department of Aging used the epidemic of older adult 

malnutrition as the catalyst to introduce evidence-based 

practices, cost-cutting measures, innovative meal products, 

and efficient service delivery methods to forge new health care 

linkages and expand service to older adults in the community.
2 

Table of Contents

AAA Malnutrition Pathway Presentation ..................................... 3

AAA Malnutrition Pathway Site Visit Agenda .......................... 4

AAA Malnutrition Pathway Survey ................................................... 5

Addressing Malnutrition in Community Living Older 

Adults: A Toolkit for AAAs ....................................................................... 6

Expanded Food Security Screener: Home Delivered 

Meals Prioritization Tool ........................................................................... 7

Maryland Discharge Meal Program Materials....................... 8

Post-Discharge Meal Distribution Programs Report ......... 9

Summary Brief .............................................................................................. 10
3 

AAA Malnutrition Pathway 

Presentation

Presentation slides. 
AAAs: Hub for Community Supports 

Addressing Social Determinants of Health

The case for effective identification and treatment of Malnutrition Risk

Presenter: Livleen Gill, MBA RDN LDN

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AGENDA

• Payment frameworks now target Social Determinants of

Health (SDOH)

• Current and changing health care landscape in Maryland

• Malnutrition’s impact on healthcare cost

• How do AAAs own the mission of being the community

hub – tools we will provide you to take charge

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Social Determinants of Health

• Definition of SDOH/HRSN

• SDOH screening and coding

• ICD-10 SDOH codes - Z55-z65

• Screening tools

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Federal Legislation

& Social Determinants of Health

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Chronic Care Act 2018

• Bipartisan Act that Congress passed On February 11, 2018

• New federal law advancing integrated, person-centered care

for Medicare & dually-eligible beneficiaries

• Medicare Advantage Plans and their role

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Key Medicare Advantage & SNP* Provisions

• Expands supplemental benefits & continues VBID

demonstration for chronically ill MA enrollees

• Permanently authorizes D-SNP, C-SNP, & I-SNP

• Promotes additional integrated care in D-SNPs

• Updates C-SNPs care management requirements &

condition list (e.g., HIV/AIDS, ESRD, & mental illness)

• Expands tele-health access

*SNP = Special Needs Plans

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Types of Covered Services

• Adult Day Services

• In-Home Support Services

• Support for Caregivers of Enrollees

• Home and Bathroom Safety Devices and Modifications

• Transportation

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Opportunities

• Focus on health beyond medical care

• Craft new partnerships to address SDOH

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Centers for Medicare and Medicaid

• HHS spends over $1 trillion a year on healthcare for the elderly and

vulnerable through Medicare and Medicaid

• In 2018 CMMI launched the Accountable Health Communities model to

address the human needs that may be impacting high utilizers of

healthcare

• Screenings for

Food insecurity

Domestic violence risk

Transportation

Housing and utility needs

Needs assessed : connect with community resources- pay for services

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Healthcare Influencers

& Social Determinants of Health

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American Medical Association

• Integrating training on SDOH in undergraduate medical school education

• Incorporating lifestyle medicine in medical school adopted by AMA house of

delegates (USC Greenville)

• Implemented training module for providers in addressing SDOH in their

practices (Steps Forward)

• Six common domains

• Economic stability

• Neighborhood

• Food

• Education

• Community/social support

• Healthcare system

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American Hospital Association

• Task force to improve access and delivery of care to address

SDOH (www.aha.org/ensuringaccess)

• Identified 3 ways for hospitals to engage

• Screening and information

• Navigation

• Alignment

• Community conversations Toolkit for hospitals

• CMS 10 question screening tool for SDOH across 5 key 

domains

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Maryland Healthcare

Current and changing health care landscape

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State of Maryland Landscape

• Medicaid Service delivery (MCOs)

• Medicaid community services

• Role of Maryland Access Point (MAP)

• Maryland Primary Care Program (MDPCP)

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Medicaid

Maryland Medicaid’s high cost areas 

(FY2017):

• Institutional LTSS (7.8% of enrollees)

Hospital

Home and community based LTSS

•

•

• In 2018, approx. 1.3 million people

enrolled in Medicaid (including CHIP)

• 81.5% of enrolled beneficiaries are in

Managed Care Organizations (MCOs)

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Other

Medicaid - Federal

Medicaid - State
Maryland Access Point (MAP)

• Single point of entry for access to services of state agencies

(https://md.getcare.com)

• 20 MAP sites in Maryland

• Funding sources are Title II and Title III

• Title III funding is for all persons 60 years and over and means testing is

prohibited

• MAP is the Aging and Disability Resource Program in Maryland. The ADRC initiative is sponsored by

the federal Administration for Community Living, the Centers for Medicare and Medicaid Services and

the Department of Veterans Affairs, and involves a national network operating in 54 states and

territories

• MAP is a centralized, single point of entry for anyone – individuals, concerned families or friends, or

professionals – to access aging and disability programs and services provided by state agencies and

private, public and community-based organizations

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Major MAP Funding Sources

Medicaid FFP

State, Local 

Funds, Grants, 

Contracts

Older Americans Act:

Title IIIB

I & A

Supportive Services:

Case Management

Chore Services

Personal Care

Homemaker
MDPCP

• Supports overall health care transformation process.

• Allows primary care providers to play an increased role

in prevention, management of chronic disease, and

preventing unnecessary hospital utilization.

• Voluntary program and open to all eligible primary care

providers.

• Practices enrolled in the program are supported by

Care Transformation (CTO) organizations and state

practice coaches.

• Practices and CTO are provided additional $$ per

beneficiary attributed in addition to fee for service

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$$
MDPCP

• Five Pillars of MDPCP

• Use of CRISP is

mandatory

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Beneficiary & 

Caregiver 

Experience

Comprehensivenes

s & Coordination

Care 

Management
Malnutrition

Impact on healthcare cost

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Malnutrition

What is Malnutrition?

• Malnutrition is the inadequate intake

of nutrients, particularly protein, over

time and may contribute to chronic

illness and acute disease or illness and

infection

Impact of Malnutrition

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• Frailty

• Disability

Loss of independence

Increased risk for falls

•

•

• Increased risk for infections

Delayed wound healing

Increased medical complications for other

other diseases

Hospital readmissions

•

•

•

• Increased length of stay

• Decreased effectiveness of medical

treatment
Prevalence of Malnutrition in Care Settings

• Acute care

• 20-50% of all patients are at risk for or are malnourished at the time of hospital admission (1)

• Only 7% of patients are typically diagnosed with malnutrition during their hospital stay (2)

• Post-Acute care

• 14- 51% of seniors are malnourished

• Community

• Estimated 6-30% of seniors are malnourished

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1 Barker LA, Gout BS, Crowe TC. Hospital malnutrition: Prevalence, identification, and impact on patients and the healthcare system. Int J Environ Res Public Health. 2011;8:514-527. 

2 Weiss AJ, Fingar KR, Barrett ML, Elixhauser A, Steiner CA, Guenter P, Brown MH. Characteristics of hospital stays involving malnutrition, 2013. HCUP Statistical Brief #210. Rockville, MD: Agency for Healthcare Research and Quality. 

Available at: http://www.hcup-us.ahrq. gov/reports/statbriefs/sb210-MalnutritionHospital-Stays-2013.pdf.
Local Prevalence of Malnutrition

Maryland Malnutrition Data

Maryland Statewide Malnutrition Data

Timeframe: Q2 2015- Q1 2018

County Specific Malnutrition Data

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Maryland County Data Malnutrition Data

Timeframe: Q2 2015- Q1 2018 

*

 * *

* *

*

*

*

 * *
Malnutrition Risk Factors

• Clinical- Diagnosed by physicians, NPs and PAs

• Social- Diagnosed by care managers, nurses, support care personnel

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The Role of the AAA

Own the mission of being the community hub – tools we will provide you to 

take charge

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Aging Network 

Overview 

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Screening for SDOH at MAC

Chronic Disease Assessment: 1) Do you have 2 or more chronic 

medical conditions? 2) Are you taking more than 5 medications? 3) Do you 

have difficulty managing your condition(s)? 

REFER TO LIVING WELL, COMMUNITY RESOURCES, HEALTHCARE

Falls Risk Assessment for patients over 65: 1) Have you fallen in the 

past year? 2) Do you feel unsteady when standing or walking? 3) Do you 

worry about falling? 

REFER TO FALLS PREVENTION WORKSHOPS, EXERCISE PROGRAMS, 

COMMUNITY RESOURCES

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Screening for SDOH at MAC

Depression Screen: Over the past two weeks, how often have 

you been bothered by any of the following problems? 1) Little 

interest or pleasure in doing things? 2) Feeling down, depressed or 

hopeless? 

REFER TO PEARLS, COMMUNITY RESOURCES, ATTEND SENIOR CENTERS/

CONGREGATE MEALS

Malnutrition: 1) Have you recently lost weight without trying? 2) If yes, 

how much weight have you lost? (MST – Malnutrition Screening Tool)

REFER TO STEPPING UP YOUR NUTRITION, FALLS PREVENTION, LIVING 

WELL, MEALS PROGRAMS, EXERCISE PROGRAMS AS APPROPRIATE. IF 

FOOD INSECURE, FOOD PANTRIES AND OTHER RESOURCES.

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Multi-Disciplinary Approach

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MAP

Type of intervention Action 

Screening • Malnutrition Screen

• Falls Screen

• Depression Screen

Client Support Care Plan • Enroll/refer to Nutrition, HP and/or SHIP

• Transportation to healthcare appointments and referral sites

Address Root Cause • Program Eligibility

• Refer to Behavioral Health, caregiver support, Physician, CHW

• Grocery program, pet food, call reassurance, etc

Communicate Progress • Track Referrals

• Incorporate client Options Counseling goals

• Assist with hospital messages and progress
Multi-Disciplinary Approach

Nutrition Program 

Type of Intervention Action 

Screening • Malnutrition Screen

• Food Insecurity Priority Screen

Client Support Care Plan • Person- centered service/meal plan

• Provide Social Interaction

• Nutrition education

Address Root Cause • Nutritionally balanced food

• Social isolation

Hydration

Manage chronic conditions

•

•

Communicate Progress • Track Participation

• Assist with hospital messages and progress

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Multi-Disciplinary Approach

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Health Promotion 

Type of Intervention Action

Screening • Varies based on program and staff certifications

Client Support Plan •Exercise

Strength

Nutrition

Chronic Disease Management

•

•

•

Address Root Cause (s) • Social isolation

• Manage chronic conditions

• Falls risk

Communicate Progress • Track Referrals

• Share Client goals with healthcare team

• Assist with hospital messages and progress
Multi-Disciplinary Approach

SHIP

Type of Intervention Action

Screening • Benefits Check-up

Client Support Care • Identify & assist with medical insurance gaps

Addressing Root Cause (s) • Address gaps in insurance coverage (income)

Communicate Progress • Regular follow-up for high risk clients

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Case Study

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Case Study

• B.B. is an 85 year old woman who was referred to our

practice in early February 2018. She presented socially well

and was always well groomed.

• She had 42 ER visits to the local hospital in 2018

• She had two mini fires in her apartment

• She had not filled medications at the pharmacy since late

2017

• Calls would average between 2-8 times in a given day

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Case Study

• Our practice provided telephonic touch points, office visits,

home visits, information to EMS, hospital SW, contacted family

• We provided food items, supplements

Finally reported to APS as things kept escalating after 3 months

APS kept an eye on her but could not really do much

•

•

• In January 2019 was delirious and admitted to hospital psych

unit

• APS filed for temporary guardianship

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SDOH & ICD-10 Codes 

SDOH Domains ICD-10 codes for SDOH

Living Situation 

including housing 

and utilities

Z59 – Problems related to housing and economic circumstances

Z60 – Problems related to social environment 

• Z60.2 – Problems related to living alone

Food Z59 – Problems related to housing and economic circumstances

• Z59.4 – Lack of adequate food and safe drinking water

Safety Z60 Problems related to social environment

Financial Strain Z59 – Problems related to housing and economic circumstances

Employment Z56 – Problems related to employment and unemployment

Family and 

Community Support

Z63 – Other problems related to primary support group, including family circumstances

Z60 – Problems related to social environment

Education Z55 – Problems related to education and literacy

Mental Health Z64 – Problems related to certain psychosocial circumstances

Z65 – Problems related to other psychosocial circumstances

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Case Study

• Ideal Pathway for B.B.

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Next Steps: Tools to Take Charge

• Malnutrition Toolkit draft one week before in person meeting:

• Rationale for community-based interventions

• Community-based Malnutrition care pathway

• Professional role delineation

• Template presentations

Billing codes to match interventions

In person meetings to solicit feedback on feasibility of draft

•

•

toolkit (February)incorporate feedback in toolkit (March)

• Web meeting to disseminate toolkit (March/April)

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Thank you!

Livleen Gill, MBA RDN LDN

CEO of Bethesda NEWtrition and Wellness Solutions

Camalier Building

10215 Fernwood Road, Suite 630

Bethesda, MD 20817

Tel: (240) 449-3094

Fax: (240) 489-4415

www.bnws.co
4 

AAA Malnutrition Pathway 

Site Visit Agenda

Sample schedule for Malnutrition Pathway site visit. 
Malnutrition Pathway Site Visit 

Washington County Commission on Aging

535 E. Franklin Street, Hagerstown, MD 21740

Friday, April 12th, 11:00-12:15PM

Attendees: 

Washington County Commission on Aging

Maryland Department of Aging

Bethesda NEWtrition & Wellness Solutions

Agenda: 

11:00-11:05pm: Introductions 

11:05-11:10pm: Overview of Grant Goals and Purpose of Today’s 

Meeting 

11:10-11:15pm: Malnutrition Video

11:15-11:30pm: Interdisciplinary Role Activity 

11:30-11:45pm: Healthcare Partnerships and Billing 

11:45- 12:05pm: Community Care Plans 

12:05-12:15pm: Summarize Next Steps 
5 

AAA Malnutrition Pathway 

Survey

Survey for AAAs to provide feedback on their 

understanding of malnutrition and the malnutrition 

toolkit. 
Malnutrition Toolkit Survey 

Carroll

MAC

Baltimore

Washington

INTRO: Please review the Malnutrition Toolkit prior to filling out this survey. You should also 

have the toolkit available and be able to reference it section-by- section as you respond to this 

survey. 

1) Your name

2) Select your AAA

a) Baltimore City

b) Carroll County

c) MAC

d) Washington County

3) Select your position/role in your AAA? (select all that apply)

a) Executive Director

b) MAP

c) Nutrition

d) Health Promotion

e) SHIP

f) Senior Care

g) Other

Rationale for Community-Based Interventions (pages 3-5)

4) Please review the risk factors for malnutrition listed in this section. How often do you interact 

with individuals who have one or more risk factors for malnutrition? 

a) Never

b) Rarely

c) Sometimes

d) Fairly often

e) Frequently 

5) Malnutrition can lead to...? (Check all that apply)

a) Increased healthcare costs

b) Increased risk of falls 

c) Increased hospital readmission rates 

d) Loss of independence and frailty 

6) Social determinants of health are associated with risk for malnutrition.

a) True

b) False

Step 1: Implement Validated Screening Tools (pages 12-14)

7) Why should AAAs screen clients for malnutrition and other health risks? 

a) To help heal the condition(s) and allow older adults to remain in the community.

b) To make the most appropriate referrals clients need to improve their physical and mental 

health.

c) Because AAAs have services that address the conditions screened for, and we refer 

clients to medical experts in addition to the community supports we offer.

d) All of the above.

8) What screening tools does your AAA already use? (Check all that apply)

a) Level One Screen

b) DETERMINE checklist
c) HDM Priority Screening

d) Other: Fill in

Step 2: Address Root Causes (pages 15-17)

9) Look at the chart provided in this section. Please list other services/programs that you offer 

that are not listed to address social determinants of health?

a) Food and Nutrition: Fill in

b) Housing: Fill in

c) Transportation: Fill in

d) Financial: Fill in 

e) Utilities: Fill in

f) Personal Safety: Fill in 

g) In-Home Care: Fill in

h) Social Supports: Fill in

i) Mental Health: Fill in

j) Health Care Referral: Fill in

k) Employment: Fill in

l) Health Education: Fill in 

Step 3: Monitor Client Progress and Quality of Services (pages 18-21)

10) Why is it important to follow up with clients? (Check all that apply)

a) Track progress towards established goals and outcomes

b) Provide encouragement and positive reinforcement 

c) Re-screen for continued unmet needs and additional referrals

d) Ensure quality of services provided 

Professional Roles & Responsibilities (pages 21-22)

11) Please observe your role on the chart provided. Do you feel that the suggested roles are 

appropriate based on your job duties? What might you remove or add? (Executive Director, 

please look at the chart overall and provide comments regarding any section). Fill in.

Strategies for Moving Forward (pages 23-29)

12) Which of the three partnership scenarios seems most feasible for your organization?

a) Partnering with insurance companies

b) Regional partnerships

c) Partnering with hospitals and CTOs

d) I’m not sure (N/A) 

13) Please look at the separately provided 3-page list of ICD-10 codes. Please list up to three Z 

codes that might fit with services you are already providing.

a) Fill in 

b) Fill in

c) Fill in 

Appendices 

14) What is the most useful resource or section for you? What is missing? Fill in

Overall 

15) What pieces of the toolkit did you find most helpful and why? What suggestions do you 

have regarding how to improve the toolkit?

16) Overall, how would you rate the toolkit?

a) Poor - needs a lot of work

b) Fair - needs quite a bit of work, but on the right track

c) Good - almost there! 

d) Excellent - high quality, ready for sharing with AAAs

e) Comment box
6 

Addressing Malnutrition 

in Community Living 

Older Adults: A Toolkit for 

AAAs

Toolkit for setting up internal processes that prepare 

AAAs to address older adults with malnutrition. 
Addressing Malnutrition in Community 

Living Older Adults

A Toolkit for Area Agencies on Aging 

Version 2 Issued July 2019

Grant funds from the Administration for Community Living (ACL), Grant Number 90INNU0002 and the Maryland Department of Aging assisted 

in the development of this material. Its contents are solely the responsibility of the authors and do not necessarily represent the official views 

of the ACL or Department. 
1

Table of Contents

Acknowledgements 2

About this Project 3

Executive Summary 4

How to Use This Toolkit 6

Why Is Malnutrition Important? 7

Establish a Vision and Path to Success 15

Process Flow Planning

 Step 1: Implement Validated Screening Tools

 Step 2: Address Root Cause(s)

 Step 3: Monitor Client Progress and Quality of Services

18

19

20

23

Define Roles & Responsibilities 27

Engage Partners 31

Conclusion 40

Abbreviations and Acronyms 41

References 43

Appendices 45
2

Acknowledgements 

We sincerely thank the following Maryland Area Agencies on Aging (AAAs) who helped 

by pre-testing the toolkit and contributing feedback. Each AAA devoted significant staff 

time and resources to generously assist with this project.

● Baltimore City Health Department, Division of Aging and CARE Services

● Carroll County Bureau of Aging and Disabilities

● Maintaining Active Citizens (MAC, Inc.) and it's Maryland Living Well Center of 

Excellence

● Washington County Commission on Aging

We also are grateful to the following organizations:

● Bethesda NEWtrition & Wellness Solutions - participated in the creation of this 

document as well as contributed to and edited the content.

● Administration for Community Living - supported this project through grant 

90INNU0002 as well as staff assisted by reviewing and providing feedback on 

the materials.
3

About this Project

In 2017, The Maryland Department of Aging was selected as one of six national 

“Innovations in Nutrition Services and Programs” grant awardees providing pioneering 

approaches for addressing the nutritional health of older adults. The Administration for 

Community Living (ACL), issued this first-ever “innovations” grant opportunity to drive 

improved health outcomes for senior meal program recipients by promoting higher 

service quality and increased program efficiency through innovative nutrition service 

delivery models. Our Department acknowledges and appreciates ACL’s leadership in 

funding unique initiatives, such as this grant project.

The two year grant also supports: 1) creating novel post-discharge, shelf-stable 

meal packages that meet individual’s needs based on their health condition(s), 2) 

testing the effectiveness of a model malnutrition awareness workshop for seniors at risk 

for falls (Stepping Up Your Nutrition), 3) establishing cross-referral links between the 

state’s healthcare system and the aging network, and 4) creating a mobile phone “app” 

to help determine the best approaches to address nutritional risk in community settings. 

Grant partners include the Maryland Department of Health, Maintaining Active Citizens’ 

(MAC, Inc.) Maryland Living Well Center of Excellence, Bethesda NEWtrition and 

Wellness Solutions, and the University of Maryland’s School of Nutrition Science.

The Maryland Department of Aging and our grant partners recognize that 

Area Agencies on Aging (AAAs) have a unique opportunity to address an 

emerging issue driving healthcare costs: older adult malnutrition. This toolkit’s 

goal is to develop a nationally-relevant template for aging network providers to screen 

for and address social determinants of health (SDOH), as well as communicate 

effectively with healthcare partners regarding malnutrition risk and older adults. Along 

with the pioneering work of national and other states’ leaders who have begun turning 

their attention to malnutrition across the hospital, post-acute and community settings, 

we hope this toolkit will act as an additional and important “piece of the puzzle” to 

facilitate active engagement by local aging network organizations.
4

Executive Summary 

Why Is Malnutrition Important? 

● The aging network’s mission to “Maximize the independence, well-being, and 

health of older adults” aligns with the importance of addressing malnutrition.

● Aging network staff often know their clients well, develop person-centered 

approaches, and are best-suited to identify malnutrition risk. 

● Malnutrition or “poor nutrition” is more common than we realize and causes 

significant risk for illness, falls and poor quality of life. It often goes undetected, 

but there are signs that can be identified in the community, which can prevent 

these deleterious outcomes. 

● The aging network is able to impact malnutrition through providing services that 

address social determinants of health, which contribute to malnutrition risk.

● Hospitals are unable to manage the complex needs of malnourished patients, but 

community-based organizations (CBOs) have years of experience providing 

services that support nutritional well-being. 

● CBOs are important partners for healthcare, to smooth malnourished patients’ 

transitions of care and prevent malnutrition in community-residing older adults. 

Establish a Vision and Path to Success

● Clarify why your CBO is devoting resources to addressing malnutrition and 

establish a vision statement.

● Acknowledge that your organization provides services that address the social 

determinants of health and YOUR STAFF ARE THE EXPERTS in this arena.

● Consider how to most effectively utilize existing staff and programs; create 

partnerships; learn about new programs and services. 

Process Flow Planning

Follow the “community-based malnutrition care pathway”:

● Step 1: Implement validated screening tools and integrate into assessments.

● Step 2: Address root cause(s). Based on the screenings, conduct eligibility 

counseling and provide appropriate and documented referrals. A sample referral 

table is provided.

● Step 3: Monitor client progress and quality of services. A sample community care 

plan is provided and follow up is optimally provided at regular intervals. 

Implement quality assurance tools; upgrades to IT system may be required. 
5

Define Roles & Responsibilities

● Malnutrition is not solved through the provision of food alone. In order to 

effectively address malnutrition, an interdisciplinary approach with cross-referrals 

to various services is required. 

Engage Partners

● Partner with insurance companies, consider regional alliances, or contract 

directly with hospitals, Care Transition Organizations, and primary care 

providers. 

● Review examples of successful healthcare-community partnerships including 

MAC, Inc. and the Southern Maine Agency on Aging.

● ICD-10 social determinants of health codes can be used for billing 

reimbursement with healthcare. Case studies are shared.

● Sample healthcare presentation and discussion tips are provided.
6

How to Use this Toolkit

This toolkit is designed to help set up internal processes that prepare AAAs to 

address older adults with malnutrition, or other health conditions. Although it suggests 

healthcare partnerships as the end goal and includes recommendations for setting up 

successful linkages, it is not intended to be a detailed guide on how to construct a 

partnership with a healthcare organization.

1. To educate yourself and your staff on what malnutrition is, what it looks like, how 

common it is among older adults, and how you can improve the quality of life of your 

clients through providing resources that address the many risk factors.

2. To help you think about why your agency may want to address malnutrition and 

establish an organizational vision. This process begins by identifying what your agency 

is already doing and then considering what additional steps you could take.

3. To understand the process components required to effectively address communitybased malnutrition and utilize templates provided to create and implement a plan for 

your agency. 

4. To acknowledge that it takes a team effort to address malnutrition and work across 

disciplines within an organization to establish defined roles for various staff members. 

5. To understand healthcare partnership models and billing reimbursement strategies 

and to prepare for conversations with potential partners, both in the healthcare arena 

and elsewhere. 
7

Why Is Malnutrition Important?

Community-Based Aging Network Mission

The national network of organizations serving older adults in the community, 

often called the “aging network,” consists of State Departments of Aging, Area Agencies 

on Aging (AAAs) and Local Providers such as Aging and Disability Resource Centers 

(ADRCs or Maryland Access Points, aka MAP), home delivered meals organizations 

and so on. Since 1972, when the Older American’s Act was created, this interconnected 

system of support programs and services has provided millions of meals, health 

insurance counseling sessions, physical activity programs, and much more to hundreds 

of thousands of people annually. 

The Administration for Community Living (ACL) was created in 2012 by the U.S. 

Department of Health and Human Services to serve as the Federal agency responsible 

for improving the lives of older adults and people with disabilities through services, 

research and education. The ACL mission statement reads “Maximize the 

independence, well-being, and health of older adults, people with disabilities across the 

lifespan, and their families and caregivers.” As will be outlined throughout this toolkit, 

addressing malnutrition aligns with the mission of the aging network.

While some interactions with older adults, their families and caregivers are brief 

(eg, a call asking for a referral), many staff who work in the aging network feel a deep 

commitment to assisting participants and may know an older adult for months or years, 

seeing them daily or weekly (eg, at meal sites, home delivered meals, senior center 

gyms, etc.). These dedicated staff often describe having “a servant’s heart” and when 

asked will share why malnutrition, among other conditions, are important to address:

“Our seniors count on us, we have to be there for them.”

“People spend such a short time in the hospital and in the doctor’s office, so it’s 

really important for community staff to send positive health messages.”

"Without adequate nutrition not only do our bodies lack necessary nutrients, but 

our will to engage socially and for ourselves becomes impacted." - COO, AAA.

"Nutrition is a pathway to health and longevity which when addressed 

appropriately can reduce future economic burden of healthcare costs and 

prolong the need for other home and community based programs." -CEO, AAA.
8

Everyday Examples of How Staff Identify Malnutrition 

AAA staff members are well poised to identify signs of malnutrition because they are the 

“eyes and ears” in the community. Nutrition staff especially get to know a lot about their 

participants and can be important resources to make timely referrals when there is a 

significant change in behavior, medical condition or living situation. 

“My drivers know exactly what to look for to identify warning signs. If the house 

isn’t being kept up, if a client seems more confused than usual, that can mean 

a change in their support system or medical status.” -Home-Delivered Meals 

Coordinator.

“I could tell from across the parking lot when I saw John that he was not taking 

his medications and was not doing well. I contacted our MAP office to ask them 

to engage with John and his medical provider to see what we could do to help.” 

-Senior Center/Congregate Meals Supervisor.

Malnutrition: What is it?

“You Are What You Eat” is a phrase we have all heard, and it is essentially true. 

The food we eat and drink makes up our heart, lungs, hormones, bones and brain. Our 

bodies are made up of the nutrients we get from our food (protein, calcium, water, etc.). 

We can eat all the right foods, but if our 

hormones - insulin for example - or organs 

aren’t working properly, the good nutrients 

we eat won’t be used to improve our health. 

In fact, if nutrients don’t go where they 

belong, they can cause problems, often 

seen as chronic diseases including heart 

disease and diabetes.

Malnutrition or “poor nutrition” is 

defined as “the inadequate intake of 

nutrients, particularly protein, over time 

and may contribute to chronic illness 

and acute disease or illness and 

infection.” 1It is a hidden condition in the 

body that affects - and is affected by -

medical conditions as well as social 

determinants of health. Because 

malnutrition is an imbalance in the body 

related to nutrients, a person may be fat, 

thin or average build and still be at risk 

for this condition. In fact, you can’t tell 

if a person has malnutrition just by 

looking at them.
9

When a dietitian or physician diagnoses malnutrition, they look for a person to 

have at least two of the following conditions: inadequate food intake, weight loss over 

time, loss of muscle, reduced amount of body fat, fluid retention (edema, swelling), or 

reduced hand grip strength. 2

TRY THIS: What signs of malnutrition can you identify? 

1 2

3 4

1. https://www.caregivers.com/blog/2012/10/senior-nutrition-poll/ 

2. http://www.mayoressaludables.org/en/study-finds-food-scarcity-poor-oral-health-be-major-risk-factors-malnutrition-amongolder-adults

3. https://www.pccj.eu/browse/evidence-in-practice/item/5095-increasing-incidence-of-cachexia-following-stroke.html

4. http://sixtyandme.com/what-is-sarcopenia-and-how-can-older-adults-prevent-its-tragic-impacts/

ANSWER: You can’t tell for sure without a physical examination but there are clues, 

including:

1. Hollow eye sockets, sunken temples, cheeks

2. Prominence of collarbone/clavicles 

3. Muscle loss in hands

4. Fat loss in upper arm
10

Older adults are especially at risk for malnutrition because they may already 

have a weakened immune system, have several risk factors, and often have one or 

more chronic conditions. Many issues can lead to malnutrition, including health-related 

and social/economic factors including the ones listed below. 3,4

TRY THIS: Think of the clients you have seen during the past week. Did any of 

them have these malnutrition risk factors? (check all that apply)

❏ Poor appetite

❏ Poor dental health

❏ Trouble chewing or swallowing

❏ Changing taste buds

❏ Chronic diseases

❏ Medication side effects

❏ Dementia

❏ Depression

❏ Social isolation

❏ Limited income

❏ Food insecurity

It’s likely that you checked several items in the list above. That means you 

regularly see older adults at risk for malnutrition. 

What does that mean? YOU and your staff have the ability to identify 

malnutrition risk and address the causes through helping with your program and 

referring to other services offered in the community.

Malnutrition has a number of consequences, including increased risk for 

infection, delayed wound healing, higher rates of falls and fractures, loss of 

independence, and frailty, 5resulting in longer hospital stays, higher readmission rates, 

five times higher rates of illness and death, and 300% higher healthcare costs. 6,7

In Maryland, the estimated annual cost of malnutrition is $340,440,992, or 

approximately $55 per person. 8 See Appendix 1 for a list of websites you can visit for 

more information about malnutrition. 

Source: http://www.mealsonwheelsnys.org/MQC_Blueprint_web.pdf
11

Social Determinants of Health (SDOH)

As outlined above, social determinants of health play a large role in the risk for 

malnutrition. Studies show that 40-90% of poor health can be traced back to social, 

behavioral and economic factors. 9

“Health starts in our homes, schools, workplaces, neighborhoods, and communities. We 

know that taking care of ourselves by eating well and staying active, not smoking, getting 

the recommended immunizations and screening tests, and seeing a doctor when we are 

sick all influence our health. Our health is also determined in part by access to social and 

economic opportunities; the resources and supports available in our homes, 

neighborhoods, and communities; the quality of our schooling; the safety of our 

workplaces; the cleanliness of our water, food, and air; and the nature of our social 

interactions and relationships. The conditions in which we live explain in part why some 

Americans are healthier than others and why Americans more generally are not as 

healthy as they could be.” 10

Source: https://www.healthypeople.gov/2020/topics-objectives/topic/social-determinants-of-health

By addressing the SDOH, which contribute to malnutrition, you can help to 

reverse this condition. The table below outlines some potential scenarios and how they 

relate to malnutrition and SDOH.
12

Table 1: Social Determinants of Health and Malnutrition. 

Social Determinant Malnutrition Sample Scenarios

(causes and effects of malnutrition are IN BOLD)

Food and Nutrition Food and Nutrition Client has always followed a low fat diet, but her 

new diagnosis of cancer means she needs to put aside her usual 

dietary restrictions to avoid losing weight and strength needed for her 

cancer treatments. Unfortunately, she is unable to “let go” of years of 

dietary restrictions so does not eat enough to maintain her strength. 

She experiences weight loss, frailty and significant decline in 

ADLs.

Housing Shared housing with his daughter’s family means he only eats a hot 

meal when the family sits down together for a meal, which is only 

once or twice a week. He makes do with sandwiches and canned 

soup. This high salt diet makes his CHF worsen leading to 

frequent hospitalizations and ER visits.

Transportation A client has heard of the falls prevention and exercise classes and 

meals at the senior center but does not have access to transportation 

to attend. Without these low- or no-cost programs, s/he is unable to 

participate in exercise, learn about how to prevent falls or receive a 

meal that often provides up to two-thirds of most participant’s 

daily calories.

Financial The cost of nutritious foods to keep healthy are not affordable or 

accessible. Result is high blood pressure, obesity and heart disease 

despite medications and diet and medical counseling. These 

conditions increase inflammation and don’t allow the body to 

effectively store muscle in his/her organs and blood. Older adult 

becomes weak, lose independence and chronic conditions

worsen.

Utilities A client may be unaware of subsidies that assist low income seniors. 

So, money that could be used for nutritious food or medications must 

go towards utilities and rent. Chronic conditions and nutrition 

decline.

Personal Safety If a client is afraid to walk outside they may not get needed exercise 

for strength and to manage diabetes. Poor diabetes control results 

in the body being unable to store muscle even when s/he eats enough 

protein. High blood sugar leads to frequent hospital admissions, but 

client does not go to follow up visits due to safety concerns traveling 

to medical appointments.

In-Home Care A client who has difficulty bathing and grooming does not wish to 

attend senior center activities. In-home assistance can improve 

confidence in social interactions and facilitate improved health and 

medication management.

Social Support Client lives alone and is socially isolated. Meal time is brief and she 

often skips meals because sitting alone at the kitchen table is 

unappealing. Research shows that eating with others improves 

food intake. Congregate meals, volunteering and senior center 

activities provide this support and connection.
13

Mental Health Depression causes a decrease in appetite, resulting in weight 

loss, dehydration and poor nutrition. Client becomes isolated and 

weakness results in a fall.

Health Care 

Referral

A client may be in need of dental care but there are no available 

referrals. Therefore, s/he eats soft foods and avoids protein items like 

meats. Lack of protein results in weakness and social isolation.

Employment Lack of profession or volunteer opportunities may lead to social 

isolation and depression. Depression can result in overeating 

and lack of exercise, worsening chronic conditions.

Health Education Chronic Disease self-management workshops, and other 

evidence-based programs, provide education and allows for clients 

to feel activated and in control of their health. These classes have 

proven positive impacts on healthcare costs and on individuals’ 

mental/physical health.

Addressing Malnutrition in the Community: Sustainable, PersonCentered Impact

Research and healthcare awareness about the impact of malnutrition on health 

outcomes has focused mostly on improving malnutrition in the hospital setting, while 

acknowledging the critical importance of addressing individuals’ nutritional health prior 

to and after hospital admission.

Only recently has progress emerged on preventing, identifying, and managing 

malnutrition during transitions of care and in the community setting. 4 Hospitals only 

have the capacity to provide short-term intervention and are not equipped to 

address the complex social needs that often accompany malnutrition. They 

already recognize the costly impact of malnutrition and appreciate the role of the 

community. 

Healthcare organizations have monetary incentives and financial penalties which 

can motivate them to partner with community-based agencies, like AAAs, if they are 

aware of the services and programs AAAs offer including: 1) managing transitions of 

care from hospital to home, 2) offering social services and preventive health 

programming and 3) providing benefits counseling and eligibility screening. Social 

supports, including assistance with housing, nutrition and income, have been shown to 

improve health and reduce healthcare costs. 9

Effective implementation of high quality AAA services can therefore reduce

healthcare costs. As outlined earlier, our programs and services interact with individuals 

at risk for malnutrition on a regular basis. 
14

Why should AAAs consider partnering with healthcare? Organizations may gain 

access to additional resources such as:

● Improved health and quality of life for our clients and community,

● Expanded referral options to appropriately assist older adult,

● Additional funding stream(s),

● Increased cost-effectiveness of existing programs such as chronic disease selfmanagement, meals programs, SHIP, MAP etc.,

● Opportunities to offer a wider number and types of services,

● Enhanced quality assurance of current and new programs,

● New staffing resources and increased professional training opportunities for staff,

● Improved technology and documentation of high quality service delivery to better 

justify funding.

Questions to Consider

1. Define malnutrition in your own words. 

2. Describe a client who might be at risk for malnutrition, perhaps someone you’ve 

seen or spoken to this past week?

3. What are the benefits to your organization of taking on malnutrition? What are 

the barriers and how might you overcome them? Who can you partner with to be 

successful?
15

Establish a Vision and Path to Success

What is your Vision?

Look back at the Why is Malnutrition Important? section. Clarify why your 

organization is becoming involved in addressing malnutrition. Establish an organizationwide vision that drives each division’s roles. Some examples could include:

● To meet the unmet needs of our community and the older adults we serve.

● To improve staff collaboration to enhance efficiency and effectiveness of 

our staff and resources.

● To have an impact on healthcare costs while bringing in new revenue.

FILL IN: What is your agency’s vision for defeating malnutrition?

______________________________________________________________________

Aging Network “Owns” Social Determinants of Health!

AAAs already provide a wide variety of services for older adults that address 

SDOH and allow them to live healthfully and safely in their homes, including in-home 

care, case management, home-delivered meals, transportation, prevention of elder 

abuse and neglect and evidence-based programs. In fact, AAAs are the leading 

experts at providing social services that address social determinants of health. 

Tackling malnutrition is not a matter of making changes to these programs and services, 

but instead thinking about how to most effectively screen and refer to these programs.

Use Existing Staff and Programs Efficiently and Effectively

Executive Directors can 

establish uniform policies and 

procedures for staff within 

existing programs and services 

that can positively affect and 

even cure this and other 

conditions. As we pursue clinicalcommunity partnerships, the goal 

for local aging organizations -

where there often are no 

healthcare staff - will be to 

perform screenings for 

malnutrition and other conditions. 

Screening is a process for determining if there 

may be a problem. Screening differs from 

assessment and diagnosis, which often requires 

a medical expert. There are validated tools for 

screen for various conditions, including 

malnutrition. Validated tools have been tested for: 

11

1. reliability (the ability to produce consistent 

results), 

2. validity (the ability to produce true results), and 

3. sensitivity (the probability of correctly identifying 

a patient with the condition).
16

There are a number of validated 

malnutrition risk screening tools, including the 

Malnutrition Screening Tool (MST), which is a 

quick and easy tool containing just two 

questions. 12

Should a “positive” screen occur, AAAs need 

to establish a process to notify the persons’ 

healthcare provider in order to:

• Facilitate the healthcare provider’s ordering of

further tests, referrals to specialists, physical

therapy, etc. and

• Communicate community-based interventions,

which will both demonstrate our organization’s

impact, potentially secure funding based on

effectiveness and allow for effective clinicalcommunity approaches to addressing the

illness(es).

Truly, only by working hand-in-hand 

“across care settings” (eg, between hospital 

and community), will individuals have the best chance at improving their health 

and quality of life.

Consider Offering Additional Programs and Services

Stepping Up Your Nutrition (SUYN), one of 

the evidence-informed workshops offered by 

AAAs, is specifically focused on malnutrition 

related to falls risk. Participants identify their 

personal nutrition risk status and establish their 

own goals to improve nutritional status and 

muscle strength. SUYN could be an appropriate 

referral for an individual with malnutrition or 

could help identify a root cause for an 

individual referred for falls. See Appendix 2 for 

a list of evidence-based programs available 

across Maryland.

Are you at Nuritional Risk?

High Nutrition Risk: Score below 50

Consult with your healthcare team as soon as possible to address the areas of nutrition concern and improve your nutrition status identify resources to help you reduce your risk.

Moderate Nutrition Risk: Score 50-54

Take action to improve your nutrition health.Discuss options with your healthcare team and identify resources to help you reduce your risk.

Low Nutrition Risk: Score above 54

Keep up the good work! Your eating habits are working to keep you healthy and strong.

Source: https://nutritionandaging.org/wp-content/uploads/2018/10/steppingupyournutritionsuynfactsheet1537983645540.pdf
17

The phrase “food is medicine” is becoming increasingly popular among the news 

and media, as a number of organizations are starting to focus on this concept. The 

Food Is Medicine Coalition is an association of 20+ nationwide non-profit medically 

tailored food and nutrition providers that is leading much of the research and policy 

advocacy in this field. Massachusetts is also pioneering some of this work, with the 

launch of their Food Is Medicine State Plan in June 2019. In Maryland, the Department 

of Aging is piloting medically tailored, shelf-stable meal packages for older adults 

transitioning from hospital to home that are based on the “food is medicine” model. 

These packages are geared toward individuals with malnutrition, food security, and/or 

high risk for readmission and could serve as a bridge to integrate patients with other 

AAA service offerings, including home delivered meals, food assistance programs, etc.

Nutrition education and/or counseling can supplement these programs. In-home 

medical nutrition therapy (MNT) could be a service offering to consider. The Elder 

Services of the Merrimack Valley, Inc., a AAA in Massachusetts, has launched an inhome MNT program that has been popular with healthcare partners. In this program, 

clients with type 2 diabetes and chronic kidney disease are covered for up to three 

hours of counseling in year one and two hours in subsequent years by a Registered 

Dietitian, who is able to bill for reimbursement. You can learn more about MNT at the 

Academy of Nutrition and Dietetics website here.

Every AAA offers nutrition education, much of which will be helpful to prevent or 

address malnutrition. Consider options that focus on adequate protein, managing 

chronic conditions and looking for the warning signs of malnutrition. See Appendix 1 for 

client education materials.

Next, we’ll share how to appropriately incorporate screening tools and refer to existing 

and/or new programs and services that address malnutrition.

Questions to Consider

1. What is your organization’s vision to address malnutrition?

2. What services are you or your existing partners already providing that may

address malnutrition risk among clients?

3. What additional services could you provide or connect clients with?
18

Process Flow Planning

Once you have created a vision for your agency and have established a set of 

referral service offerings, it is time to lay out the steps you will take to identify and 

address malnutrition among clients in your agency. This “community-based 

malnutrition care pathway” has been divided into three steps, which include:

Step 1: Implement validated screening tools

Step 2: Address root causes(s)

Step 3: Monitor client progress and quality of services 

Each of these steps will be reviewed in greater detail in the following pages.

Figure 1: Overview of Community-Based Malnutrition Care Pathway - Steps and Tools 

Involved.

1. IMPLEMENT VALIDATED SCREENING TOOLS

Intake clients that are self-referred from the community or referred by healthcare or 

outside organizations.

Screen clients with validated malnutrition and social determinant of health tools.

Tool: List of malnutrition and SDOH screening tools.

2. ADDRESS ROOT CAUSE(S)

Refer clients to new and/or existing programs and services that can address the root 

cause(s) of malnutrition and implement interdisciplinary cross-referrals. Document 

screening results and service/program referrals.

Tool: Sample Referral Table.

3. MONITOR CLIENT PROGRESS AND QUALITY OF SERVICES

Document client goals, referrals, action steps, and progress notes.

Follow up with clients at established intervals to re-screen for continued unmet needs 

and assure the quality of services provided.

Report positive screens, ICD-10 codes, client status and outcomes to healthcare 

partners.

Tool: Sample Community Care Plan. 
19

Step 1: Implement Validated Screening Tools

Screening is the first step to identify what issues a client might need to address. 

Validated screening tools are processes that have been developed through extensive 

testing and will assure you that your result can be used with confidence. AAAs already 

utilize a number of screening tools on their clients, which may vary from state to state. 

AAAs in the state of Maryland are required by Medicaid to screen clients who have a 

need for long term services and supports with a Level 1 Screen, congregate/home 

delivered meal clients with the DETERMINE checklist, and home delivered meal clients 

with the Home Delivered Meals Priority Screening. See Appendix 3 for more details 

regarding Maryland screening tools. 

In order to adequately address malnutrition, it is important for AAAs to screen for 

SDOH, which may exacerbate or contribute to malnutrition. A SDOH screening tool 

will allow for the identification of uncaptured social needs and for referrals to be 

made to appropriate services that address the root causes of malnutrition. One 

AAA in Maryland, MAC, Inc., screens select clients for malnutrition using the 

Malnutrition Screening Tool (MST) and for social determinants of health using an 

internally created tool. See Appendix 4 for a copy of this tool. These screening tools 

can be integrated into program or intake assessments, disease prevention 

programs, evidence based health promotion classes, etc. A more centralized 

approach can be employed or perhaps each department could screen for certain issues, 

such as social isolation, falls risk or depression. 

The choice of malnutrition and SDOH screening tool(s) utilized by a AAA 

may vary depending on fiscal resources, staff time, training and preferences, 

coordination with existing AAA databases and healthcare electronic medical 

record (EMR) systems, the availability of programs to address screening 

components and other local issues. See Appendix 5 for a list of malnutrition and 

SDOH tools. There is no universal tools used across the healthcare system for SDOH. 

The Social Interventions Research & Evaluation Network (SIREN) has created a 

comparison table to assist with the selection of a SDOH screening tool. It contains the 

most widely used tools and describes the target population and social domains 

addressed by each tool. SIREN is also in the process of releasing a systematic review

of screening tools to assist organizations with choosing an appropriate tool for their 

population. 
20

Step 2: Address Root Cause(s)

To effectively address the root, or underlying, causes of malnutrition and allow an 

individual to improve their mental and physical health, person-centered screening, 

referrals to programs and services, as well as eligibility counseling should take place. 

With the implementation of new screening tools, needs that may have previously gone 

under the radar will be identified. This will allow for better service planning and 

more comprehensive care for the client.

Generally, the more SDOH that are addressed, the better overall result will be for 

the person. Although, often, a few, key changes can positively affect someone’s 

physical and mental health, which reinforces healthy actions. As outlined earlier, and 

below, there may be many SDOH which could be addressed to help correct malnutrition 

and improve health; however...

THE ONLY SOLUTIONS THAT WILL WORK ARE THOSE WHICH THE CLIENT WILL 

ACTUALLY DO.

The AAA staff should identify clients’ wants, needs, and preferences and discuss 

which services and programs fit these needs. Often, motivational interviewing skills 

will be helpful in working with individuals, in order to allow them to prioritize and 

select solutions. A successful approach is often based on starting with one or two 

ideas, and then over time additional programs or services to may be added to improve 

their health and independence. 

Once priority areas are determined by the client, and at established follow-up 

intervals, the sample referral table below can be completed to document the screening 

results and recommended services and programs. 

This form can be sent to the healthcare provider along with the Community 

Care Plan in the following section. Social determinants ICD-10 codes are embedded 

in the table, which will be explained in greater detail in the Engage Partners section. 

Note that this is only a sample as each AAA offers a different set of programs and 

services.
21

Table 2: Sample Referral Table - Social Determinants of Health with ICD-10 codes. 

Care Planning 

Components

AAA Referral Programs and Services

Food and Nutrition 

Z594

❏ Senior Center Congregate Meals

❏ Home-Delivered Meals

❏ Nutrition counseling, MNT, nutrition education, and care planning 

❏ Commodity Supplemental Food Program (CSFP)

❏ Community food resources (Food Bank, etc.)

❏ Senior Farmers Market Nutrition Program

❏ Stepping Up Your Nutrition

❏ Post-discharge, medically-tailored meals

Housing

Z590

❏ Assisted Living (including SALGHS)

❏ Ramp Assistance

❏ Home Modification

❏ Assistive Technology

❏ Durable Medical Equipment 

❏ Congregate Housing Services Program

Transportation

Z650

❏ County or Regional Transit

❏ Cab/Bus Vouchers

❏ Senior Village 

❏ Community for Life

Financial

Z590

Application assistance for financial aid: 

❏ SNAP

❏ Medicaid

❏ State Health Insurance Program (SHIP)

❏ Energy-assistance programs

❏ Income-tax assistance

❏ Medicare Part A, B, C, D

❏ Medicare Billing, Appeals, Denials, Grievances

❏ Medicare Fraud Assistance 

❏ Oral nutritional supplements (Ensure, etc) 

❏ Prescription assistance

❏ Assistance for dental, eye care, hearing aids

Utilities

Z590

❏ Low-Income Home Energy Assistance Program (LIHEAP)

❏ Electric Universal Service Program (EUSP) 

❏ Universal Service Protection Program (USPP)

❏ Utility Assistance (other)

Personal Safety

Z600 

❏ Elder Abuse

❏ Legal Assistance 

❏ Emergency Response Systems

❏ Falls Prevention (Stepping On, Matter of Balance, Tai Chi for Better 

Balance)
22

❏ Arthritis foundation classes (Walk with Ease)

In-Home Care

Z602

In-Home Care

Z602

(con’t)

❏ Sitters and in-home care services (personal care, chore service)

❏ Home Care agencies

❏ Community First Choice

❏ Senior Care

❏ Home-delivered meals

❏ Dietitian referral

❏ Senior Village

Social Supports

Z600 or Z630

❏ Senior Center (exercise, socialization, Congregate Meals) 

❏ Telephone Reassurance 

❏ Support Groups: Caregivers, Renal, Stroke, ALS, Parkinson’s

❏ Adult Day Care

❏ Volunteer opportunities

Mental Health

Z640 or Z650

❏ PEARLS: Program to Encourage Active, Rewarding Lives

❏ Enhance Wellness

❏ Healthy IDEAS

❏ Behavioral Health Referral (Core Service Agency or Health 

Department)

Health Care Referral

ICD-10 code dependent on 

root cause

❏ Primary Care Physician

❏ Clinics: Dental, Eye, Physical Therapy

❏ Community Health Worker

❏ Adult Medical Day Care

❏ Local health department

❏ Home care agencies

❏ Medical supplies

Employment

Z560 

❏ Senior Employment 

❏ AAA volunteer coordinator

❏ Community volunteer opportunities

Health Education

Z550 

Self-management workshops: 

❏ Diabetes Self-Management (Spanish version available) 

❏ Chronic Disease Self-Management (Spanish version available)

❏ Chronic-Pain Self-Management

❏ Cancer Thriving and Surviving 

❏ Falls Prevention (Stepping On, Matter of Balance, Tai Chi for Better 

Balance) 

❏ SAIL (Stay Active and Independent for Life) 

❏ Aging Mastery 

❏ Enhance Fitness 

❏ Lifelong Learning 

❏ Medication Management

❏ Wellness Center Gym
23

Step 3: Monitor Client Progress and Quality of 

Services

The final but ongoing task is to monitor client progress with a care plan, rescreen clients as needed, and assure the quality of services provided. 

Monitoring Progress: A Community Care Plan

A care plan outlines:

● individual assessed care needs, 

● the types of services provided to meet those needs, 

● who will provide the services and when. 

And, it is person-centered and developed with input from the individual.

Establishing regular contact with clients is imperative to addressing the range of 

SDOH that may be involved and also to provide regular, positive reinforcement 

for each step forward. This regular contact should be systematized, with 

responsibilities established and documentation incorporated. 

Goals and action steps should be established with the client and a goal date 

should be established. Referrals to services or other staff should be made. Follow up 

dates are suggested for 30, 60, and 90 days, but these can be adjusted based on staff 

capacity. Follow up should be made to check in on progress toward goals, provide 

encouragement, and see if any additional referrals are needed. The updated status and 

referrals should be documented. This sample is an open format, but a standardized 

checklist could be provided if desired. 

For example, consider an individual with diabetes. A malnutrition and SDOH 

screen are completed and the results are as follows: malnutrition (negative), personal 

safety (positive), health care referral (positive), and transportation (positive). 

A sample care plan for this individual is provided below. This form can be sent 

to the healthcare provider along with the Referral Table in the previous section. 

Notice in the care plan below that the goal is person-centered, but it also addresses the 

healthcare provider’s goal for an improvement in diabetes control.
24

Figure 2: Sample Community Care Plan - Initial and Follow Up Monitoring.

CLIENT NAME: Sally Jones DATE: January 1, 2019

GOAL (OUTCOME): Feel strong enough to attend grandson’s graduation.

ACHIEVE BY DATE: June 20, 2019

Step 1: Sign up for exercise class to build up strength.

Step 2: Set up doctor’s appointment to check on diabetes medications.

Step 3: Establish method of transportation to get to class/appointment.

NOTES:

Referral made to Health Promotion Coordinator to enroll in Stepping 

On.

Contacted doctor regarding positive screens. Faxed referral table, care 

plan.

Assisted in getting a cab voucher for transportation.

 DATE: January 1, 2019

 STAFF SIGNATURE: Linda Johnson, MAP Program Coordinator

30 DAY FOLLOW UP: 

Mrs. Jones attended her first Stepping On class yesterday and has an 

appointment scheduled with her doctor. Rescreened for social 

determinants of health. No changes, no new referrals made

DATE: February 4, 2019

STAFF SIGNATURE: Linda Johnson, MAP Program Coordinator

60 DAY FOLLOW UP: 

.

DATE:

STAFF SIGNATURE:

90 DAY FOLLOW UP: 

DATE:

STAFF SIGNATURE:
25

Quality Assurance 

Quality assurance may include client satisfaction, evidence based workshop 

retention rates, fidelity monitoring of evidence-based classes, measuring of outcomes 

(eg, hospital readmissions, ER visits, etc.), and monitoring staff adherence to protocols 

for documentation and communicating with healthcare. Contracts with healthcare will 

often incorporate expectations for quality measurement, so it is important to 

consider what you currently do and what your organization might be willing to do 

in the future (assuming adequate funding and staffing).

Be prepared to measure quality of services; emphasize the importance of quality 

and meeting established standards with your staff. Allowing significant variety in 

providing referrals or documentation will not support fruitful and long-term healthcare 

contracting for AAA services.

A recent report listed key factors for measuring the effectiveness and quality of 

home and community-based services, listed below. 13 For additional quality assurance 

resources, see Appendix 6.

● Provides for a person-centered system that optimizes individual choice and 

control...

● Promotes social connectedness and inclusion ...in accordance with individual 

preferences

● Includes a flexible range of services that are sufficient, accessible, appropriate, 

effective dependable and timely...

● Integrates healthcare and social services to promote 

well-being

● Promotes privacy, dignity, respect and 

independence....

● Ensures each individual can achieve the balance of 

personal safety and dignity of risk...

● Supplies and supports an appropriately skilled 

workforce...

● Supports family caregivers

● Engages individuals in the design, implementation, 

and evaluation of the system and its performance

● Reduces disparities by offering..services that are...culturally sensitive and 

linguistically appropriate

● Coordinates and integrates to best meet needs and maximize 

efficiency/affordability

● Delivers cost-effective services

● Supplies valid, meaningful, integrated, aligned, accessible, outcome-oriented 

data...

● Fosters accountability through measurement and reporting of quality of care and 

consumer outcomes
26

Chesapeake Regional Information System for Patients (CRISP)

When partnering with healthcare, an IT system is essential, especially for 

reimbursement purposes including tracking, reporting and billing. The Regional Health 

Information Exchange (HIE)- Chesapeake Regional Information System for Patients 

(CRISP), which serves Maryland, West Virginia, and the District of Columbia, has the 

capacity to allow AAAs to communicate with healthcare partners in real-time. Through a 

contract with CRISP, AAAs could:

● Embed referrals to evidence-based programs and 

other non-clinical services

● Report patient engagement, enrollment, and 

completion of programs

● Document provisions of programs and services 

(including ICD-10 codes)

● Alert providers of patient’s conditions, gaps, or 

needed services through care alerts

In addition, CRISP could be utilized to track return on 

investment (ROI), including pre/post hospital and 

emergency department utilization and changes in cost of 

care. 

CRISP has begun to work with hospitals and community-based providers to 

begin tracking social determinants of health needs as well as referrals to evidencebased programs and community-based services. As this opportunity expands 

statewide, AAAs should be in the position to align with their hospital’s or payor 

partner’s medical records technology and CRISP data sharing infrastructure.

Questions to Consider

1. What screening tools does your AAA already use and which clients are 

screened? Would it be feasible to implement an additional SDOH screening tool 

for all or select clients? 

2. Looking at Table 2, what services/programs does your AAA offer to address each 

of the social determinants of health? Could you create your own form?

3. Do you currently document a “care plan” or “person centered plan of care”? If 

not, what would it take to implement one?

4. What does your current quality assurance structure look like? If you don’t have 

one in place, consider reviewing resources in Appendix 6.
27

Define Roles & Responsibilities

In this section, we’ll look at how AAAs can positively impact malnutrition by using 

a team approach. Traditionally, AAA staff members tend to work in “silos” and may not 

be aware of the full extent of activities happening across the organization. However, an 

interdisciplinary team approach is required to adequately support an older adult 

at risk for malnutrition. Malnutrition is not solved with food alone, although it is often a 

first step, but most clients will require a more comprehensive set of services. All of the 

SDOH domains previously discussed, including chronic conditions, financial limitations 

and social isolation need to be addressed. 

Executive Director

As the lead administrator for your agency, creating the vision and services your 

organization delivers to existing and prospective clients, you can have an impact on 

healthcare costs while bringing in new revenue. You can work with your team as well as 

community healthcare partners to identify and treat malnutrition. A good place to begin 

is to estimate existing healthcare costs of malnutrition for individuals in your community. 

In order to foster organizational commitment:

● Review existing resources and research best practices. Brainstorm ideas that are 

feasible given your existing resources.

● Establish cross-departmental meetings to develop healthcare-community 

linkages.

● Create a malnutrition coalition. Encourage your Board of Directors to reach out to 

healthcare providers, non-profits, community foundations and other communitybased organizations (Visiting Nurses, Homemaker Services, etc.) to identify 

potential partners, coalition members and funding opportunities.

In order to become involved:

● Initiate meetings with hospital administration (Medical Director, Population 

Health, etc.) or discharge/social work personnel.

● Consider developing joint proposals with hospitals or health departments for 

grant opportunities which relate to providing healthcare in the community and/or 

preventive health approaches.

● Inform your stakeholders, including clients, caregivers, and government, about 

your initiatives. Enlist their in-kind support and financial resources.

● Identify which organizations in your community are paying the costs for 

malnourished seniors. Meet with them to understand discharge nutritional care 
28

plans and potential service models which they feel could be appropriate for 

individuals discharged with malnutrition.

● Review alternative payment options for providing new or existing services. 

Consider starting with small changes or additions to services or assessment 

processes. Build a solid initial partnership model and deliver specific tasks.

● Identify organizations which provide a variety of support services that address all 

of the causes of malnutrition.

Program Directors 

As a program director, you may see clients with lack of transportation, financial 

strain, issues with housing, social isolation, multiple chronic conditions, etc. which are 

all risk factors for malnutrition. You receive referrals and refer to services to address 

these social determinants of health and are therefore a key player in addressing 

malnutrition risk. To start, consider the many factors which can increase risk for 

malnutrition, including social, psychological, economic and health-related factors and 

think about how your organization can effectively support older adults to combat these 

issues.

In order to foster organizational commitment:

● Acknowledge pieces of the “malnutrition puzzle” that you can identify during 

screening.

● Work across your organization to determine what each department can do to 

screen or educate clients for their risk of malnutrition and offer validated tools.

● Consider existing and new initiatives which can address the social and 

environmental causes of malnutrition.

● Participate in cross-departmental meetings and list activities as potential items 

which your organization can use to identify or treat malnutrition.

● Support your Executive Director’s efforts and be prepared to learn more about 

what hospitals feel could be critical community supports for their patients. Assist 

with presentation materials which summarize your current services and consider 

adjusting them, based on healthcare partner feedback.

In order to become involved:

● Cross-refer to services and programs your organization offers.

● Provide follow-up with targeted client to ensure that individuals have received 

needed services.

● Provide information on resources, services, and benefits and assistance with 

completion of documents.
29

● Consider ways to provide regular updates to healthcare partners regarding client

status and assist with supporting care plans.

Cross-Referrals 

The figure below shows how interdisciplinary cross-referrals can be made to 

support an older adult at risk for malnutrition. As discussed in the previous section, it is 

important that staff roles are established and streamlined documentation is 

implemented. The team members roles below are an example, as staffing may vary 

across AAA’s and some staff members may oversee multiple program areas.

Figure 3: Interdisciplinary Team Approach to Address the Social Determinants of 

Health.

Older Adult

Nutrition

Food and MAP, SC, 

Nutrition

Housing MAP, SC

Transportation MAP

Financial MAP, SC, 

SHIP

Utilities MAP, SC

Personal 

Safety

HP, MAP, 

SC

In-Home 

Care

MAP, SC, 

SHIP

Social 

Supports

HP, MAP, 

SC

Mental 

Health

HP, MAP, 

SC

Health Care 

Needs MAP

Employment MAP

Health 

Education

HP, MAP, 

Nutrition

Key. HP= Health Promotion. SC= Senior Care.
30

Each AAA staff can support and inform a patient’s care plan, address the 

underlying causes of malnutrition, and communicate with healthcare partners 

regarding progress made and interventions implemented. See Appendix 7 for a 

more detailed list of suggested professional roles that align with the three steps of the 

community-based malnutrition care pathway. 

Questions to Consider

1. Do you feel the suggested roles and cross-referrals apply to your agency? 

2. What additional staff members might you include in the malnutrition pathway 

process?
31

Engage Partners

Partnership Scenarios

Consider implementing a variety of partnerships to provide programs and services to 

prevent and address malnutrition in your AAA jurisdiction.

Community Partners and Food Resources

Existing partnerships may be leveraged in the fight against malnutrition. For 

example:

● How can a transportation provider help with getting clients to a falls prevention 

class? 

● Consider whether SNAP referrals are being maximized for low-income clients. 

● Can congregate meal sites expand beyond senior centers and include partner 

organizations such as churches, soup kitchens or libraries? 

● If you screen for depression, does your agency have a resource for referrals 

such as a local PEARLS provider, outpatient counselor or Core Services 

Agency?

For food insecure clients, there are a number of referrals that may be 

appropriate. See Appendix 8 for a sample Community Food Resource List. 

• Contact your local food bank for a list of local resources and provide their number 

to persons inquiring about food access. 

• Refer clients who need food to a congregate meal site, or refer to home delivered 

meals if they are homebound.

• Contact MDoA to become a local provider of the Commodity Supplemental Food 

Program (also known as “My Groceries to Go Program” in Maryland).

• Lastly, for individuals who are also suffering from chronic conditions, medically 

tailored food based on the “food is medicine” approach (see Establish a Vision 

and Path to Success section) may be a good choice for your organization. 

Insurance Companies 

In 2018 Congress enacted the Chronic Care Act, which allows additional 

supplemental benefits to Medicare beneficiaries enrolled in Medicare Advantage 

plans (MA). According to Title III of the Act, the changes are part of a MA value-based 

insurance design, allowing MA plans to create structures that vary benefits, costsharing, and supplemental benefits offered to enrollees with qualifying chronic diseases. 

As stated in the preamble of the Act, all of these changes are meant “to improve 
32

management of chronic diseases, streamline care coordination, and improve quality 

outcomes.” 

The measures will help the chronically ill get basic treatment at home, so that 

they can remain independent and out of the hospital. This will reduce the frequency of 

chronically ill patients needing hospitalization, which will free up room for non-chronic 

emergency room visits. This model approach will inform policymakers of the services 

that offer the most benefits to different populations, which may prompt policymakers to 

expand those benefits to people in the rest of traditional Medicare. 

Beginning January 1, 2019, the Center for Medicare and Medicaid Services 

(CMS) expanded supplementary benefits to be “primarily health-related” if they were 

used to 1) diagnose an illness 2) compensate for physical impairments, 3) ameliorate 

the functional/psychological impact of injuries or health conditions or 4) reduce 

avoidable emergency and health care utilization. 

Figure 4: Expansion of Supplemental Benefits in 2019.

Source:https://nutritionandaging.org/wp-content/uploads/2019/03/Part-1_The-Evolving-Healthcare-LegislationLandscape_Combined_Final.pdf

The Bipartisan Budget Act of 2018 further expanded supplemental benefits by 

eliminating the “primary health-related” standard for individuals with chronic conditions, 

which essentially created a new category of benefits for 2020, which must have a 

“reasonable expectation of improving or maintaining health or overall function.” MA 

plans will expand to address SDOH, most notably nutrition, housing and 

transportation.

Not covered by Original Medicare.

Primary health-related: Now a supplemental benefit will be considered “primarily health-related” if it used to:

• Diagnose an illness

• Compensate for physical impairments

• Acts to ameliorate functional/psychological impact of injuries or health conditions

• Reduces avoidable emergency and health care utilization

• Adult day care services (must be state-licensed)

• Home-based palliative care (and not hospice- eligible)

• In-home support services (must be provided by individuals licensed by the state to provide personal care services or in a manner that is otherwise consistent with state requirements)

• Support for caregivers of enrollees

• Medically-approved non-opioid pain management

• Stand-alone memory fitness benefit

• Home & bathroom safety devices and modifications (must be temporary)

• Transportation

Plan must incur non-zero direct medical cost.
33

Figure 5: Further Expansion of Supplemental Benefits.

The Bipartisan Budget Act of 2018 eliminated the “primarily health-related” standard for supplemental benefits for individuals with chronic conditions, effectively establishing a new 

category of benefits, beginning in 2020.

Special Supplemental Benefits for the Chronically Ill (SSBCI)

BBA specifies that MA plans may offer supplemental benefits that are not primarily-health related. May not include: Non-medical transportation, home-delivered meals, food and produce.

Benefit must have a “reasonable expectation of improving or maintaining health or overall function.”

Plans can target enrollees based on chronic condition and other factors, such as social determinants of health. May not include capital or structural improvements to the home that would 

increase its taxable value.

Source:https://nutritionandaging.org/wp-content/uploads/2019/03/Part-1_The-Evolving-Healthcare-LegislationLandscape_Combined_Final.pdf

There are several commercial insurance companies in Maryland offering the 

Medicare Advantage plans. These plans, starting January 2019, are required to offer 

the above services to their beneficiaries. Every year the insurance companies submit

their benefits package to Medicare for approval in early June. For the insurance 

companies to be able to offer a particular benefit to its members, it has to be on this 

plan so it is accounted for in the premium they will charge the members. The major 

insurance companies that offer Medicare Advantage plans in Maryland are: Aetna, 

Cigna, Erickson, Humana, Johns Hopkins, Lasso and United Healthcare. A full listing 

can be found here. 

Regional AAA Partnerships 

With a national network of over 600 AAAs in the National Association of Area 

Agencies on Aging (n4a), AAAs have the capability to join together, regionally or 

statewide, to scale up services to a broader population. An example is the Eastern 

Virginia Care Transitions Partnership, a coalition 5 AAAs, 4 health systems, 69 

skilled nursing facilities, and 3 Medicaid managed care organizations. Discharged 

patients are referred by hospitals to AAAs for case management, referral assistance, 

benefits counseling, family caregiver support, and other non-clinical services including 

meals and transportation. Funding is supported by a per-member per-month 

reimbursement by the Medicaid MCOs. The program led to a reduction in 30-day 

readmission rates from 18.2 to 8.9%, and avoided 1,804 readmissions with $17 

million in savings.15
34

Hospitals, PCPs, and CTOs

Maryland has a unique all payer hospital rate setting system whereby the Health 

Services Cost Review Commission (HSCRC) establishes uniform payment structures 

based on population health goals, which incentivizes cost reduction. 

In 2019, the Maryland Department of Health (MDH) rolled out the Maryland 

Comprehensive Primary Care Model (MDPCP), designed to expand improvements in 

care and reductions in the growth of healthcare spending from hospitals to communitybased healthcare providers such as primary care providers, skilled-nursing facilities, 

home health providers, and others. In 2019, newly created Care Transition 

Organizations (CTOs) began working with these providers to assist them with care 

management, data tools and informatics, practice transformation technical assistance, 

social services connections, hospital care coordination and behavioral health 

integration. A list of the CTOs for 2019 can be found here.

Figure 6: The Maryland Primary Care Program Structure.

Source:https://pophealth.health.maryland.gov/Documents/Maryland%20Comprehensive%20Primary%20Care%20Model/MPCP%20

-%20Presentation%20Web.pdf

Across the state of Maryland there are approximately 386 primary care practices 

enrolled in this program (as of May 2019). The MDPCP supports the overall health care 

transformation process and allows primary care providers to play an increased role in 

prevention and management of chronic disease and prevention of unnecessary hospital 

utilization. Each primary care practice that has enrolled in the MDPCP program receives 

a care management fee (CMF) per attributed Medicare beneficiary in the practice. This 

CMF is to be used by the practice to help with patient needs for care coordination with 

social service resources and access to care as determined by the practice. AAAs can 
35

partner (ie, have contracts) with primary care practices and provide care 

coordination services to get reimbursed with a portion of the CMF.

Another alternative could be partnering with area CTOs for specific 

services (home delivered meals, housing assistance etc.) to receive payment for 

services rendered. Any partnership or contractual arrangement would depend on each 

AAA’s capacity for types of services they provide and would depend on the CTO’s 

perceived needs.

Examples of Success

The MAC, Inc. Living Well Center of Excellence (LWCE) has established 

contracts with multiple hospitals in their regional area. Many of these partnerships 

began with referrals for Chronic Disease Self-Management Education (CDSME) 

workshops. Based on successful outcomes through consistent data reporting, these 

partnerships have expanded to include other programs offered by the AAA and have 

resulted in reimbursement for these services. 

The Southern Maine Agency on Aging (SMAA) has also had success at 

developing contractual agreements with a number of local hospitals, health plans, and 

medical practices. The chief executive officer, Larry Gross, states that he was motivated 

to “really address our mission to improve quality of life for older adults, and to work 

more closely with others who shared our interests.” 14 SMAA initiated these partnerships 

by inviting heads of local health plans and hospitals to join their board of directors. 

Gross emphasizes that his keys to success were talking about contracts up front, 

instead of performing work for free, and utilizing volunteers, who gave 80,000 hours of 

service in 2016, and allowed their agency to increase service volume by 25%. 14

Billing Reimbursement Options 

ICD-10 codes are used by physicians, insurance companies, public health 

agencies and organizations, etc. to represent diagnoses. ICD-10 stands for International 

Statistical Classification of Diseases and Related Health Problems 10th Revision; it is 

published, copyrighted, and updated by the World Health Organization. There is an 

ICD-10 code for every disease, disorder, injury, infection and symptom and they are 

utilized in many ways, including processing health insurance claims and compiling 

national health statistics. ICD-10 codes Z55-Z65 capture socioeconomic and 

psychosocial circumstances (i.e. social determinants of health). 
36

Below is a shortened list of the ICD-10 codes for social determinants of health 

that are most relevant to AAAs. Under each of the SDOH categories there are more 

specific codes pertaining to situations. The categories point out where to look for more 

specific codes if needed. For an extended list of SDOH ICD-10 codes, click here. 

Identification and coding with the appropriate Z code for SDOH reflects the risk an 

individual is at for poor health outcomes. 

These Z codes show the “risk” for individuals, which may result in a higher care 

management fee (CMF) paid by Medicare to primary care. In other words, Z codes = 

higher risk= higher potential reimbursement. AAAs could partner with these 

healthcare organizations to provide case management and document social needs with 

the ICD-10 codes. This CMF could then be utilized to pay the AAA. In another scenario, 

this coding has the potential to show insurance companies that these individuals need 

services like housing, meals etc. which would directly/indirectly be paid by them.

Table 3: Social Determinants of Health ICD-10 Codes.

SDOH Sample ICD-10 Codes 

Living Situation 

(Housing, 

Utilities)

Z590 - Problems related to housing and economic circumstances

Z600 - Problems related to social environment

 Z602 - Problems related to living alone

Food Z590 - Problems related to housing and economic circumstances 

 Z594 - Lack of adequate food and safe drinking water 

Safety Z600 - Problems related to social environment 

Financial Strain Z590 - Problems related to housing and economic circumstances 

Employment Z560 - Problems related to employment and unemployment 

Family and 

Community 

Support

Z630 - Other problems related to primary support group, including 

family circumstances

Z600 - Problems related to social environment 

Education Z550 - Problems related to education and literacy 

Mental Health Z650 - Problems related to other psychosocial circumstances 
37

SDOH ICD-10 Code Case Studies 

SCENARIO ONE

Suzy,* who is the sole caregiver for her 78 year old bed bound mother, was referred 

by her church to the local AAA. Suzy revealed that she had reached her breaking 

point and needed help but did not have the resources to pay for assisted living or 

caregivers from a private agency. 

Through the screening process by MAP, 

Suzy’s mother was identified at risk for:

➔ Living arrangements: Z599

➔ Financial: Z596

➔ Food and nutrition: Z594

➔ In Home care: Z602

➔ Social support: Z600

In addition, Suzy herself was identified 

with the following risk factors:

➔ Dependent needing care: Z636

➔ Burnout: Z730

➔ Lack of relaxation and leisure:

Z732

Suzy’s mother was set up with the following services by the AAA:

1. Respite care through the local ARC.

2. Caregiver program and support group.

3. Home-delivered meals 3 times per week.

4. In-home care 4 hours a day for 5 days per week (waiting list).

5. Connection with a local bible group and volunteer from the local school 1-2

times per week.

MAP staff encouraged Suzy to call her mother's insurance company, Aetna Medicare 

Advantage, and check her benefit eligibility. Suzy found the Aetna MA plan would pay 

for in-home care and meals as long as the primary care physician (PCP) did the preauthorization.

The AAA faxed the referral to the PCP for needed services with the ICD-10 codes for 

SDOH. The PCP used the codes to get the services covered. Aetna MA plan 

reimbursed the AAA for the meals and the private agency providing the caregiver. 

In addition, Suzy herself was given resources and connected to caregiver support 

groups near her. 
38

SCENARIO TWO

Barbara* is an 85 year old who lives alone in a one bedroom apartment. She had 

multiple admissions to community hospital emergency room. The Emergency Room 

Department staff determined that there were no significant medical issues but that 

Barbara was struggling with anxiety. 

The PCP took on the patient and their Nurse Practitioner (NP) did a home visit: 

● Barbara was not taking her medications and many of them were expired.

● There was almost no food in the refrigerator.

● Barbara asked for water and stated she was hungry. Her lips and mouth 

were dry. 

The NP referred Barbara to an on-staff Social Worker and Registered Dietitian (RD). 

The RD brought nutritional supplements; the patient declined a referral for homedelivered meals. 

The family expressed they were unable to assist with Barbara’s care. The PCP felt it 

was an unsafe environment and referred the case to Adult protective services (APS) 

of the county. 

The following diagnosis codes were identified for this situation:

➔ Living arrangements: Z599

➔ Financial: Z596

➔ Food and nutrition: Z594

➔ Living alone: Z602

Preferred solution: This client would have been better served if referred to the AAA by 

the hospital and PCP. 

Under the Care Redesign program and the MDPCP, the AAA could have been 

identified as the community resource to provide support to the patient, saving the PCP 

significant time resources and better meeting the needs of the client. 

*Names have been changed to protect privacy.
39

Initiating Conversations with Healthcare

Meetings with prospective healthcare partners should outline:

1. Identify what the healthcare partner is most concerned about.

2. Share the specific services and programs provided by your organization which 

address SDOH and health conditions (or risks for health conditions) that can 

reduce their costs.

3. Formulate an agreeable initial service for funding, based on quality and outcome 

measures that will be transparent to both parties.

4. Once successful, continue to develop the partnership to incorporate additional 

programs/services. A promising approach is shared risk contracting.

Contracting with healthcare can be complicated, with many options, opportunities 

and pitfalls. AAAs are strongly encouraged to seek out resources and experienced 

peers to learn about the best approach for your organization. Appendix 9 shares 

presentations you can customize for meetings with healthcare and Appendix 10

contains additional website resources. 

As demonstrated in this and earlier sections, ongoing support, communication 

among AAA staff and healthcare, with adequate documentation, are key 

components of addressing malnutrition and health conditions in the community.

Questions to Consider

1. Do you have existing partnerships, programs and services that can help clients 

address their risk for malnutrition? If yes, how can you create an internal system 

to manage these clients? 

2. Are you ready to meet with healthcare organizations - a hospital, insurance 

company or PCP - to create a contractual cross-referral relationship? If not, what 

resources do you need?

3. Which ICD-10 codes fit with services you are already providing or referring 

clients to? 
40

Conclusion 

In summary, “Addressing Malnutrition in Community Living Older Adults: A Toolkit for 

Area Agencies on Aging” has shared:

● How the problem of malnutrition in our communities is relevant to the aging 

network’s core mission to “Maximize the independence, well-being, and health of 

older adults” 

● Why AAAs are critical partners for healthcare and Maryland’s unique payment 

system, to smooth malnourished patients’ transitions of care and prevent 

malnutrition in community-residing older adults. 

● The importance of establishing a vision and path to success by defining a project 

mission and assigning staff roles, documenting processes, and embedding 

quality assurance. 

● How to develop your organization’s “community-based malnutrition care 

pathway.”

● The importance of engaging partners - new and existing - to create an effective, 

high quality process to expand resources and service offerings.

The toolkit also provided you with:

● Template forms that incorporate ICD-10 codes

● Internal and external cross-referral suggestions 

● Case studies

● Questions to consider as you develop your plans

● Sample healthcare presentations and discussion tips 

We hope you have found this toolkit helpful! The journey towards effective management 

and elimination of community-based older adult malnutrition is just beginning. We 

welcome you to join us in this emerging endeavor.
41

Abbreviations and Acronyms 

AAA Area Agency on Aging

ACL Administration for Community Living

ADL Activities of Daily Living

ADRC Aging and Disability Resource Center 

ALS Amyotrophic Lateral Sclerosis

APS Adult Protective Services

CBO Community-Based Organization

CDSME Chronic Disease Self-Management Education

CHF Congestive Heart Failure

CHW Community Health Worker 

CMF Case Management Fee

CMS Center for Medicare and Medicaid Services 

CRISP Chesapeake Regional Information System for Patients

CSFB Commodity Supplemental Food Program

CTO Care Transformation Organization 

EMR Electronic Medical Record

EMT Emergency Medical Technician

EUSP Electric Universal Service Program

ER Emergency Room

HDM Home-Delivered Meal

HIE Health Information Exchange

HP Health Promotion 

HSCRC Health Services Cost Review Commission 

ICD-10 International Statistical Classification of Disease and Related 

Health Problems, 10th Revision

IDEAS Identifying Depression, Empowering Activities for Seniors

IT Information Technology

LIHEAP Low-Income Home Energy Assistance Program

LTSS Long Term Services & Supports

LWCE Living Well Center of Excellence

MA Medicare Advantage 

MAC Maintaining Active Citizens

MAP Maryland Access Point 

MCO Managed Care Organization

MDH Maryland Department of Health

MDPCP Maryland Primary Care Program

MNT Medical Nutrition Therapy 

MQii Malnutrition Quality Improvement Initiative 
42

MST Malnutrition Screening Tool

NP Nurse Practitioner 

n4a National Association of Area Agencies on Aging 

PCP Primary Care Provider 

PEARLS Program to Encourage Active, Rewarding Lives 

RDN Registered Dietitian Nutritionist 

RD Registered Dietitian 

ROI Return on Investment 

SAIL Stay Active and Independent for Life

SALGHS Senior Assisted Living Group Home Subsidy 

SDOH Social Determinants of Health 

SHIP Senior Health Insurance Program

SIREN Social Interventions Research & Evaluation Network

SMAA Southern Maine Agency on Aging

SNAP Supplemental Nutrition Assistance Program

SUYN Stepping Up Your Nutrition

SW Social Worker 

USPP Universal Services Protection Program
43

References

1. Malnutrition Quality Improvement Initiative. (2018). Briefing: The Value of Quality

Malnutrition Care. Retrieved from

http://mqii.defeatmalnutrition.today/static/pdf/briefing-the-value-of-qualitymalnutrition-care.pdf.

2. Becker, P. J., Carney, L. N., Corkins, M. R., Monczka, J., Smith, E., Smith, S. E.,

... & White, J. V. (2014). Consensus statement of the Academy of Nutrition and

Dietetics/American Society for Parenteral and Enteral Nutrition: indicators

recommended for the identification and documentation of pediatric malnutrition

(undernutrition). Journal of the Academy of Nutrition and Dietetics, 114(12),

1988-2000.

3. Lloyd, J. L. (2017, February). Hunger in Older Adults: Challenges and

Opportunities for the Aging Services Network. Retrieved from

https://www.mealsonwheelsamerica.org/docs/defaultsource/research/hungerinolderadults-fullreport-feb2017.ppdf?sfvrsn=2.

4. Hickson, M. (2006). Malnutrition and ageing. Postgraduate medical journal,

82(963), 2-8.

5. Barker, L., Gout, B., & Crowe, T. (2011). Hospital malnutrition: prevalence,

identification and impact on patients and the healthcare system. International

journal of environmental research and public health, 8(2), 514-527.

6. DefeatMalnutrition.Today. Retrieved from Malnutrition

http://defeatmalnutrition.today/sites/default/files/documents/CMKT_15_00385a_

Malnutrition_Info_Graphic_OnePage_Update_FA.pdf.

7. Avalere, DefeatMalnutrition.Today. (2017, March). National Blueprint: Achieving

Quality Malnutrition Care for Older Adults. Retrieved from

http://www.defeatmalnutrition.today/sites/default/files/documents/MQC_Blueprint

_web.pdf.

8. Goates, S., Du, K., Braunschweig, C. A., & Arensberg, M. B. (2016). Economic

burden of disease-associated malnutrition at the state level. PloS one, 11(9),

e0161833.

9. Brewster, A. L., Kunkel, S., Straker, J., & Curry, L. A. (2018). Cross-sectoral

partnerships by area agencies on aging: Associations with health care use and

spending. Health Affairs, 37(1), 15-21.
44

10.Healthy People 2020. Social Determinants of Health. Retrieved from 

https://www.healthypeople.gov/2020/topics-objectives/topic/social-determinantsof-health

11.The Joint Commission. Question: Definition of validated and non-validated 

screening tool for substance use. Retrieved from 

https://manual.jointcommission.org/Manual/Questions/UserQuestionId03Sub001

5.

12.Dialogue Proceedings/Advancing Patient-Centered Malnutrition Care Transitions. 

(2018, July 27). Retrieved from https://avalere.com/insights/dialogueproceedings-advancing-patient-centered-malnutrition-care-transitions.

13.Quality in Home and Community-Based Services to Support Community Living: 

Addressing Gaps in Performance Measurement Final Report, September 2016. 

National Quality Forum. Retrieved from 

http://www.qualityforum.org/Publications/2016/09/Quality_in_Home_and_Commu

nityBased_Services_to_Support_Community_Living__Addressing_Gaps_in_Perform

ance_Measurement.aspx.

14.Aging Today. (2017, January). The Southern Maine Agency on Aging: A Patient 

Approach Nets Multiple Contracts. Retrieved from 

https://www.asaging.org/blog/southern-maine-agency-aging-patient-approachnets-multiple-contracts.

15.Freda, B., Kozick, D., & Spencer, A. (2018). Partnerships for Health: Lessons for 

Bridging Community-Based Organizations and Health Care Organizations. 

Retrieved from https://www.chcs.org/media/CBOHCO_Partnership_update_032018.pdf. 
45

Appendices

Appendix 1: Malnutrition Resources 

● Alliance for Aging Research-Malnutrition in Older Adults

● American Society for Parenteral and Enteral Nutrition Malnutrition Toolkit

● Defeat Malnutrition Today

● Malnutrition Quality Improvement Initiative (MQii) Toolkit

● National Council on Aging Community Malnutrition Resource Hub

● National Council on Aging Malnutrition Toolkit

● National Resource Center on Nutrition & Aging

● The Gerontological Society of America
46

Appendix 2: Evidence-Based Programs in Maryland

● Aging Mastery Program

● Arthritis Foundation Classes (Aquatics, Exercise Program, Tai Chi, Walk with

Ease)

● Diabetes Prevention Program (Medicare, National)

● Enhance Fitness

● Enhance Wellness

● Healthy Eating for Successful Living in Older Adults

● HomeMeds

● Matter of Balance

● Move with Balance

● Otago

● Powerful Tools for Caregivers

● Program to Encourage Active and Rewarding Lives (PEARLS)

● Self-Management Programs (Chronic Disease, Chronic Pain, Cancer Thriving &

Surviving, Diabetes, Spanish versions)

● Stay Active and Independent for Life (SAIL)

● Stepping On

● Tai Ji Quan: Moving for Better Balance

● TimeSlips

The MAC, Inc. LWCE website contains descriptions about each program, flyers, and 

links to workshop registration: https://www.mdlivingwell.org/programs/
47

Appendix 3: Screening Tools Currently Required for Maryland AAA’s

Screening Tool Details Use

Level 1 Screen 

REQUIRED FOR 

ELIGIBILITY IN 

MEDICAID LONG 

TERM 

SUPPORTS AND 

SERVICES. 

Purpose: Screen and triage individuals 

for Medicaid community programs, 

including the Community Options 

waiver, Community First Choice, and 

Medical Assistance Personal Care.

Components:

● Instrumental Activities of Daily 

Living

● Activities of Daily Living

● Living Arrangement

● Health Status

● Communication, Cognition and 

Behavior

● Financial Questions

● Referral Questions

Length: Thirty one questions

Score: Priority category and referral 

recommendations generated 

● Determine functional eligibility for 

Medicaid community services

● Provide information, referrals, 

Options Counseling and access to 

home and community-based 

services 

DETERMINE 

Your Nutritional 

Health (Nutrition 

Screening 

Initiative) 

REQUIRED BY 

ACL FOR 

SENIOR 

NUTRITION 

PROGRAM USE 

(CONGREGATE 

AND HOME 

DELIVERED).

Purpose: Identify persons at risk for 

poor nutrition, based upon SDOH. 

Components:

● Disease

● Eating poorly

● Tooth loss/mouth pain

● Economic hardship

● Alcohol problems

● Reduced social contact

● Multiple medications

● Involuntary weight loss/gain

● Ability to shop, cook and/or feed 

self

Length: Ten questions

Score: 0-2 not at risk, 3-5 moderate 

nutritional risk, 6 + high nutritional risk

● Home delivered or congregate meal 

program

● RDN counseling or nutrition 

education

● Social and exercise programming to 

address isolation

● Dental referral 

● Social services or community group 

if elevated alcohol intake noted

● Physician/pharmacy or medication 

management referral if multiple 

medications noted

● Financial assistance if unable to 

afford medications and/or food

Home Delivered 

Meals Priority 

Screening

REQUIRED BY 

MDoA FOR ALL 

HOME 

DELIVERED 

MEAL SERVICE 

PROVIDERS.

Purpose: Effectively identify persons 

most at need for meals and to 

determine other services which may 

best meet clients’ current needs.

Components: 

● Ability to acquire groceries and 

prepare meals

● Food insecurity assessment

Length: Eight questions

Score: A-E levels of priority 

Determine if client would benefit most 

from:

● Fully prepared home-delivered 

meals

● Income eligibility review and/or 

SNAP

● Grocery assistance, including the 

Commodity Supplemental Food 

Program 
48

Appendix 4: MAC Inc. Maryland Living Well Center of Excellence 

Social Determinants of Health Screening Tool

Name:____________________________________________ Phone Number:_________________________

Preferred Language:_________________________________ Best time to call:________________________

In the last 12 months, did you ever eat less than you felt 

you should because there wasn’t enough money for food?

____

____NO

YES NOTES:

In the last 12 months, has your utility company shut off 

your service for not paying your bills?

____YES

____NO

Are you worried that in the next 2 months, you may not 

have stable housing?

____YES

____NO

Do you have difficulty in taking the medicine/prescriptions 

prescribed by your doctor?

____YES

____NO

Are you able to get/pay for your 

medicine? Do you understand what 

medicine to take when and what it 

is for?

In the last 12 months, have you needed to see a doctor 

but could not because of cost?

____YES

____NO

In the last 12 months, have you ever had to go without 

health care because you didn’t have a way to get there?

____YES

____NO

I see or talk to family members at least once a week. ____YES

____NO

I see or talk to friends at least once a week. ____YES

____NO

On a weekly basis I participate in social activities or 

attend organized groups, such as choirs, support groups, 

cultural performances, group meals, exercise classes, etc.

____YES

____NO

Do you ever need help reading or understanding hospital 

or other materials from your physician?

____YES

____NO

Are you afraid you might be hurt in your apartment 

building or house?

____YES

____NO

In the past three months, have you had a fall? If you fell in 

the past three months, how many times did it limit your 

regular activities for at least a day, or you saw a doctor? 

#_______

____YES

____NO

Do you worry about falling? 

____YES

____NO

Over the past two weeks, have you had little interest or 

pleasure in doing things, or felt down, depressed, or 

hopeless?

____YES

____NO

If you checked “YES” to any boxes above, would you like 

to receive assistance with any of these needs?

____YES

____NO

Are any of your needs urgent? (i.e., “I don’t have food or a 

place to sleep tonight)

____YES

____NO

Screened by:___________________________ Referred to:________________________ Date:_________________
49

Appendix 5: List of Malnutrition and Social Determinants of Health 

Screening Tools

Malnutrition 

● Malnutrition Screening Tool (MST)

● Mini Nutritional Assessment (MNA)

a. MNA-Short Form (MNA-SF)

● Malnutrition Universal Screening Tool (MUST)

● Nutrition Risk Screening (NRS-2002)

● Subjective Global Assessment (SGA)

● Patient Generated Subjective Global Assessment (PG-SGA)

● Seniors in the Community: Risk Evaluation for Eating and Nutrition (SCREEN I 

and SCREEN II)

● Short Nutritional Assessment Questionnaire (SNAQ)

● Validated Malnutrition Screening and Assessment Tools: Comparison Guide

Social Determinants of Health

● Accountable Health Communities Health-Related Social Needs Screening Tool

● PRAPARE: Protocol for Responding to and Assessing Patients’ Assets, Risks, 

and Experiences

● Health Leads Social Needs Screening Toolkit

● Institute of Medicine Social and Behavioral Domains and Measures

● WellRx Toolkit

● Total Health Assessment Questionnaire for Medicare Members

● Kaiser Permanente’s Your Current Life Situation Survey

● HealthBegins Upstream Risk Screening Tool

● Social Need Screening Tools Comparison Table
50

Appendix 6: Quality Assurance Resources

● Home and Community Based Services: Quality Management Roles and

Responsibilities

● Improving Quality of Services

● Measuring the Quality of Home- and Community-Based Services: A

Conversation about Strategic Directions for Research and Policy

● Quality Measurement for Home and Community Based Services (HCBS) and

Behavioral Health in Medicaid

● Quality in Home and Community-Based Services to Support Community Living:

Addressing Gaps in Performance Measurement

● Quality of Home- and Community-Based Services
51

Appendix 7: Suggested Professional Role Delineation 

MAP

Implement Screening Tools

● Level 1 Screen

● Malnutrition Screen

● SDOH Screen

Address Root Cause(s)

● Enroll/refer to Nutrition, HP, Senior Care, and/or SHIP. 

● Refer to behavioral health, caregiver support, physician, CHW

● Transportation to healthcare appointments and referral sites

● Groceries program, pet food, call reassurance, etc.

Monitor Progress and Quality 

● Lead care plan implementation and documentation

● Track referrals

● Share client care plan goals with healthcare

● Assist with hospital messages and progress

Nutrition

Implement Screening Tools

● DETERMINE Checklist

● HDM PriorityScreen

● Malnutrition Screen

● SDOH Screen 

Address Root Cause(s)

● Enroll/refer to MAP, HP, Senior Care and/or SHIP

● Person centered service/meal plan

● Provide social interaction

● Provide relevant nutrition education

● Nutritionally balanced food, hydration

● Reduce social isolation

● Manage chronic conditions 

Monitor Progress and Quality 

● Periodic screening, as appropriate, note in care plan

● Inform care plan as new service options become available and seem appropriate 

● Perform quality assurance related to respective service(s)

● Update care plan as client participates in programs

● Adjust care plan as information changes

● Assist with communicating hospital messages

SHIP 

Implement Screening Tools

● Benefits Checkup

● Malnutrition Screen 

● SDOH Screen

Address Root Cause(s)

● Enroll/refer to MAP, Nutrition, HP and/or Senior Care 

● Address gaps in insurance coverage (income)
52

● Reduce stress and financial concerns related to billing and potential fraud

● Allows client to access affordable medical care and medications

Monitor Progress and Quality 

● Periodic screening, as appropriate, note in care plan

● Inform care plan as new service options become available and seem appropriate

● Perform quality assurance related to respective service(s)

● Update care plan as client participates in programs

● Adjust care plan as information changes

● Assist with communicating hospital messages

Health Promotion 

Implement Screening Tools

● Varies based on program staff certifications

● Malnutrition Screen

● SDOH Screen

Address Root Cause(s)

● Enroll/refer to MAP, Nutrition, Senior Care and/or SHIP

● Chronic disease management

● Exercise to improve strength

● Improve nutrition/malnutrition

● Social isolation

● Address falls risk

● PEARLS to address depression

Monitor Progress and Quality 

● Periodic screening, as appropriate, note in care plan

● Inform care plan as new service options become available and seem appropriate

● Perform quality assurance related to respective service(s)

● Update care plan as client participates in programs

● Adjust care plan as information changes

● Assist with communicating hospital messages

Senior Care

Implement Screening Tools

● Level 1 Screen

● Malnutrition Screen

● SDOH Screen

Address Root Cause(s)

● Enroll/refer to MAP, Nutrition, HP and/or SHIP

● Refer to behavioral health, caregiver support, physician, CHW

● Provide PEARLS or refer to other mental health supports

Monitor Progress and Quality 

● Periodic screening, as appropriate, note in care plan

● Inform care plan as new service options become available and seem appropriate

● Perform quality assurance related to respective service(s)

● Update care plan as client participates in programs

● Adjust care plan as information changes

● Assist with communicating hospital messages
53

Appendix 8: Sample Community Food Resource List

Food and Nutrition Assistance in Somerset County 2019

Worrying about whether or not you will have enough food is stressful. Regular, nutritious meals 

are necessary for seniors to stay healthy. The following resources are here to help you.

Food Needs Program 

Name

Number Contact Name Other Information

For 

homebound: 

Delivered 

meals & 

Grocery bags

Meals on 

Wheels by 

Somerset MAC 

Senior Services

410-651-3400 All staff Delivered meals 

Monday, Tuesday, 

Thursday, for 60 and 

older

Therapeutic 

Home 

Delivered 

Meals

Moveable 

Feast

410-327-3420

Ext. 12

All staff Delivered frozen 

meals for all ages

Senior Center 

Noon Meals

Westover and 

Deal Island 

MAC Senior 

Services 

Centers

410-651-3400 All staff Noon meal Tuesday 

and Thursday for 60 

and older

Dinner Friday 

& Saturday 

6-7:30 PM

H.O.P.E. 

Ministry

11724 

Somerset Ave, 

Princess Anne

410-726-7910

or

443-880-7871

Steve Milligan

Wayne Muir

Eat dinner and take 

home a bag lunch

Nutrition 

Education and 

Supplement 

Assistance

MAC 

Registered 

Dietitian

410-742-0505

Ext. 144

Karla 

Beardsley

Call for appointment 

or questions

Nutrition 

Counseling

McCready 

Hospital 

Dietitian

410-968-1801

Ext. 3250

Jeannette 

Jardin

Call for appointment

Food Stamps 

(SNAP)

Social Services

30397 Mt. 

Vernon Rd, 

Princess Anne

410-677-4330 All Staff Need proof of 

address, income, 

expenses, SS card, 

and picture ID

Emergency 

and monthly 

food pantry

Maryland Food 

Bank-Eastern 

Shore

410-742-0050 Teresa See

Jennifer Small

Find a food pantry 

close by

www.mdfoodbank.org

click “find food”

Emergency 

and monthly 

food pantry

“Food Share”

Seton Center 

Catholic 

Charities

410-651-9608 All Staff Need proof of 

address, income, 

food stamps, SS 

card, and picture ID

Grocery 

Shopping 

Online

Walmart 

Pocomoke City 

Supercenter

410-957-9600 All Staff Order at 

www.walmart.com

and pick up at store
54

Appendix 9: Sample Presentations for Healthcare
55
56
57

For access to this PowerPoint, please contact Judy Simon at 

judy.simon@maryland.gov. 
58

You can access this infographic at: https://acl.gov/sites/default/files/programs/2019-

03/MealProgramValueProposition.pdf
59

Appendix 10: Healthcare-Community Partnership Resources

● A Roadmap to Financial and Programmatic Sustainability for Community-Based 

Organizations: Understand the Business Environment and Your Place Within It

● Aging and Disability Business Institute

● Chronic Care Management Information Resource

● Community-Clinical Linkages for the Prevention and Control of Chronic 

Diseases. A Practitioner's Guide

● Fundamentals of Community-Based Managed Care: A Field Guide

● HCBS Business Acumen Center

● HCBS Business Acumen Toolkit. 

○ Step 1: Prepare. Understand the Business Environment and Your Place 

Within It. 

○ Step 2: Plan. Use Business Intelligence to Build the Strategic Plan for 

Your Organization

● Healthcare Policy and Practice Opportunities for Senior Nutrition Programs. 

○ Part 1: The Evolving Healthcare Legislation Landscape. 

○ Part 2: Launching an In Home Medical Nutrition Therapy Program

● Health Care and Community-Based Organizations Have Finally Begun 

Partnering to Integrate Health and Long-Term Care 

● Learn the Basics about Medicare Advantage and Position Your Organization for 

New Partnerships

● Partnerships for Health: Lessons for Bridging Community-Based Organizations 

and Healthcare Organizations

● Sustainability and Revenue Generation in an Evolving Senior Nutrition Business 

Environment

● The Aging Network in Transition: Hanging in the Balance

● Using Community Partnerships to Integrate Health and Social Services for HighNeed, High-Cost Patients
7 

Expanded Food Security 

Screener: Home Delivered 

Meals Prioritization Tool

Paper screening tool, app, and instructions. 
Expanded Food Security Screener

Home-Delivered Meals Prioritization Tool 

Developed by the College of Agriculture & Natural Resources Department of Nutrition and Food Science 

at the University of Maryland. 

WHO should use this tool? 

Home-delivered meal program 

administrators that: 

A Have a waiting list or limited 

resources to serve all applicants; 

B Want to demonstrate to funders 

and policy-makers the level of 

need in their community; and/or 

C Want to understand if they are 

 reaching those with the greatest 

need, or if more outreach is needed 

to identify the most food insecure. 

HOW should it be used? 

As a screening tool as early as 

possible at application or referral 

HOW are the results useful?

The results show risk factors the 

applicant is experiencing, and the 

level of priority for home-delivered 

meal services, and may inform alternative or additional support services 

that could beneft clients. 

Screening Questionnaire 

and Point Calculator 

provided on reverse. 

The Researchers Behind this Tool 

The research design and the assessment 

model was developed by Nadine Sahyoun, 

professor of nutrition epidemiology, and 

Anna Vaudin, graduate student in the 

college’s Department of Nutrition and Food 

Science. Their work focuses on assessing 

the nutritional status of the older adult 

population and studying the relationship 

between nutrition risk factors and health 

outcomes. 

nsahyoun@umd.edu 

amvaudin@gmail.com 

agnr.umd.edu 

The Procedure 

1. As early as possible after client application/referral and determination of

elegibility for home delivered meals, the screening should be conducted via

telephone or in person.

2. Priority Level is calculated and recorded for each client:

Level A: Highest priority for service and follow-up assessments.

Levels B, C, D, and E: See below for recommendations of support

service.

Priority Levels and Recommended Nutrition Service(s) 

 LEVEL CRITERIA PRIORITY LEVEL REASONING SERVICE 

A Unable to cook 

and no reliable 

help

Even if food is affordable and in 

the home, it cannot be prepared, 

therefore, it is unlikely there are 

consistent healthy meals. 

Home-Delivered 

Meals PRIORITIZED 

on wait list if 

resources are limited. 

B Can cook or has 

help. Economically 

food insecure. 

Cannot obtain 

groceries.

Affordablilty and access to 

groceries are both issues. 

With fnancial support and grocery 

delivery, healthy meals could be 

prepared at home. 

Home-Delivered 

Meals ALL clients 

should receive homedelivered meals if 

resources are 

available. 

If there is a wait list for 

home-delivered meals 

clients should be 

prioritized B - E. 

Regardless of wait list 

status, all clients may 

beneft from additional 

nutrition services: 

USDA Supplemental 

Nutrition Assistance 

Program (SNAP) 

Grocery Delivery 

Services 

Additional State 

or Local Services 

as Needed 

C Can cook or has 

help. Economically 

food insecure. Can 

obtain groceries. 

Affordability is the only issue, 

can obtain groceries and prepare 

healthy meals at home. 

D Can cook or has 

help. Economically 

food secure. 

Cannot obtain 

groceries. 

Groceries and food delivery are 

affordable, not physically limited 

from food preparation (or help is 

available) therefore healthy meals 

can be prepared at home. 

E Can cook or has 

help. Economically 

food secure. Can 

obtain groceries. 

These individuals fulfll the basic 

eligibility requirements for the home 

delivered meal program; however, 

they are able to afford and obtain 

groceries, and are not physically 

limited from food preparation (or 

help is available), therefore healthy 

meals can be prepared at home. 
 

 

 

 

	 		 	 

	 		 	 

	 	 

 

	 		 

 

 

Client Name 

The following questions ask about your ability to 

get food and prepare meals. You are eligible for 

the service regardless of your income. 

1 a If you had groceries available, would you

be able to use them to prepare hot meals? 

 

Expanded Food Security Screener

Home-Delivered Meals Prioritization Tool 

NO 

Proceed to Question 1b

b Do you have reliable help with meal preparation?

YES NO >STOP

YES 

Proceed to Question 2

Proceed to Question 1a

2 During the last month... 

Applicant is a Level A Priority

a ...how often was this statement true? The food that we bought just didn’t last, and we didn’t

 have money to get more. 

Often (1 point) Sometimes (1 point) Never (0 point) 

b ...how often was this statement true? We couldn’t afford to eat balanced meals.

Often (1 point) Never (0 point) 

c ...did you or other adults in your household ever cut the size of your meals because there wasn’t 

 enough money for food? 

YES (1 point) 

d ...did you or other adults in your household ever skip meals because there wasn’t enough money for food?

YES (1 point) NO (0 point) 

e ...did you ever eat less than you felt you should because there wasn’t enough money for food?

YES (1 point) 

f ...were you ever hungry but didn’t eat because you couldn’t afford enough food?

YES (1 point) NO (0 point) 

Sometimes (1 point) 

NO (0 point) 

NO (0 point) 

Proceed to Question 2

Add the points from questions 2a – f and enter it here:

3 Are you able to get groceries into your home when you need them? 

YES – Select the point range below: 

0 – 1 Points Level E Priority 

2 – 6 Points Level C Priority 

0 – 1 Points LeveL D Priority 

NO – Select the point range below: 

2 – 6 Points Level B Priority 

See chart on page one for explanation of Priority Levels and recommended service(s). 

Developed by the College of Agriculture & Natural Resources Department 

of Nutrition and Food Science at the University of Maryland. 

Grant funds from the Administration for Community Living (ACL), Grant # 90INNU0002 and the Maryland 

Department of Aging (MDoA) assisted in the development of this material. This presentation is solely 

the responsibility of the authors and do not necessarily represent the offcial views of the ACL or MDoA. 
Expanded Food Security Screener

Home-Delivered Meals Prioritization Tool 

TRAINING MANUAL

Developed by the College of Agriculture & Natural Resources Department 

of Nutrition and Food Science at the University of Maryland. 

Grant funds from the Administration for Community Living (ACL), Grant # 90INNU0002 and the Maryland 

Department of Aging (MDoA) assisted in the development of this material. This presentation is solely 

the responsibility of the authors and do not necessarily represent the offcial views of the ACL or MDoA. 
Introduction

What is Food Security? According to the Food and Agriculture Organization, “food security exists when all people, at all times, 

have physical and economic access to suffcient, safe, and nutritious food that meets their dietary 

needs and food preferences for an active and healthy life.” 

The four main dimensions of food security are: 

• availability (determined by food production and markets) 

• accessibility (physical and economic) 

• utilization (including the preparation of food) 

• stability of the other three dimensions over time 

What is the Expanded Food 

Security Screener? 

Current tools for measuring food security only measure the economic access component. However, 

in older adults, and especially the homebound population, there may be physical issues that interfere 

with an individual’s ability to obtain and prepare adequate nutritious food. The Expanded Food Security Screener (FSS-Exp) builds on the US Department of Agriculture 6-item Household Food Security 

Survey Module (HFSSM), which is a validated tool used to assess food security based on questions 

that ask about ability to afford food. The FSS-Exp combines this economic access information with 

the other indicators of food security for older adults that indicate need for services: ability to get 

groceries into the home and ability to prepare meals. To fully understand an individual’s level of need 

for a meal, the FSS-Exp also takes into account whether the person has help available to accomplish 

these tasks. 

How does the FSS-Exp work 

as a Home-Delivered Meals 

Prioritization Tool? 

The FSS-Exp quickly gathers information on an individual’s economic access to food, their ability to 

get groceries into their home, and their ability to prepare meals, with or without help. This information is used to categorize applicants into one of fve priority levels. The categorization scheme for 

these priority levels is based on the issues that could be specifcally addressed by a meal delivered to 

the home. This tool provides home-delivered meal (HDM) programs with a concise version of the most 

essential information about each individual’s food security needs. HDM programs can use this information to make quick decisions about how to use their organization’s resources most effciently and 

effectively to support the needs of that client, thus allowing the meal program to provide person-centered services. 

What does screening mean 

and how is it different than 

assessment? 

A screening tool is used to detect risk quickly and effciently. When screening, you are trying to fnd 

those at the highest risk early on, in order to mitigate further decline. Assessment is more in-depth 

and thorough, but takes more time. This is why screening takes place before assessment, in order to 

quickly identify those who may be at high risk and thus in need of intervention. A follow-up assessment with those who are detected during screening will confrm, deny, and/or expand on the needs 

of an individual. Screening is less resource-intensive and tells you where to prioritize your more 

resource-intensive procedures (such as assessment and meals) in order to have the greatest impact. 

2
Reasons for Use of the 

HDM Prioritization Tool 

1. Prioritize initial and follow up services. The priority level generated by the tool will tell you 

who is at the greatest need for your services and allows you to provide the most appropriate 

type of service to meet the individual’s need. People at a higher priority level should receive initial 

or follow-up assessments frst, and may need immediate access to resources, as they are likely to 

be the most food insecure. Regardless of waitlist status, the priority level provides information on 

what additional or alternative services may be benefcial to a client. Using the tool this way can 

help your program make the greatest impact with the limited resources it has. 

2. Demonstrate need for funders and policy makers. Using the HDM Prioritization Tool to track the 

priority level for each client is a quick way to generate a profle of the needs of the population 

you serve, and how many of your clients are high priority. This can demonstrate to funders and 

policymakers the importance of dedicating resources to your program, in order to meet the needs 

of your clients. 

3. Indicate the need for outreach. The Older Americans Act requires HDM programs to reach 

those with the greatest need and to address food insecurity. This tool can help identify whether 

your program is meeting these goals or whether there may be persons in the community who are 

more food insecure and yet not receiving services. 

Development of the 

HDM Prioritization Tool

Consultation with 

Community Programs 

In the early stages of developing the tool, researchers from the University of Maryland, the nutrition director at the Maryland Department of Aging, and six nutrition program managers from Area 

Agencies on Aging throughout Maryland formed a workgroup around HDM prioritization. The goal was 

to work towards a standardized method for objectively assessing an applicant’s need for a meal. The 

workgroup had several meetings to discuss HDM prioritization, and over the course of these meetings, 

the risk factors and categorization criteria for the HDM Prioritization Tool were established 

The basis for the selection of the risk factors used for prioritization is the impact they may have on the 

ability of an older adult to eat a healthy diet. The ultimate goal of the HDM program is to make a healthy 

meal available to those who would not otherwise be able to get one. Therefore, all risk factors identifed 

in the literature that can lead to poor diet, and that may be remedied by a healthy meal delivered to the 

home, were identifed and included in the prioritization tool. The three factors that specifcally indicate 

the need for a home-delivered meal are: 

Selection of the Three 

Criteria for Prioritization 

1. if hot meals can be prepared, whether by the individual or by a reliable helper 

(such as family or hired homecare) 

2. economic access (being able to afford food) 

3. physical access (being able to get food into the home, either independently or with help). 

There may be other factors that affect whether or not a client is obtaining adequate nutrition (such as 

depression or dental health); however, these factors may not necessarily be addressed by a home-delivered meal, and so they are not considered when prioritizing a client for these services. For example, if 

someone has poor nutrition because they have trouble chewing, a home-delivered meal will not improve 

their health if they cannot chew it. If such risk factors are identifed, the client may be referred to services 

that can help address the issue (see the section titled “Creating a referral resource for your program”). 

3
Reasoning Behind 

Each Priority Level 

The three criteria measured by the tool are combined into 5 different priority levels. The following 

describes each priority level and the reasoning behind the ranking system. The priority level ranking 

assumes that there are limited spots for meals. If there are no limits on meal availability, clients should 

be added to the program frst-come-frst-served (see the section titled “Recommended Actions Based 

on Each Priority Level”). 

Level A 

Applicants who are categorized into priority level A are unable to prepare meals and do not have help. 

They are considered the highest priority: even if they are able to afford groceries and get them in their 

homes, it is unlikely that they can consistently eat a healthy diet because they are ultimately unable 

to prepare their food. If there is a waiting list, these individuals are priority for follow-up assessments 

and service. 

● 

Level B 

Applicants who are categorized into priority level B are able to prepare meals (with or without help), 

but cannot get groceries into their home and are economically food insecure. If space is available on 

the program, HDM programs could deliver affordable meals. However, if there is a waiting list, these 

individuals may get by if they can obtain both fnancial assistance and grocery delivery. 

Level C 

Applicants who are categorized into priority level C are able to obtain groceries and prepare meals 

(with or without help), but are economically food insecure. If HDMs are available, this is an affordable 

way for these individuals to get healthy meals. However, if there is a waiting list, these individuals 

would be able to obtain and prepare meals if they had fnancial assistance, such as the Supplemental 

Nutrition Assistance Program. 

Level D 

Applicants who are categorized into priority level D are economically food secure, able to prepare 

meals (with or without help), but have diffculty getting groceries into their home. If there is not 

funding to place them on the HDM program, these individuals would be able to prepare meals if they 

receive help with getting groceries (such as from a grocery delivery service). As they are not economically food insecure, they may be able to afford these services from a local grocery store, especially if 

someone is available to assist them in setting up these services. 

Level E 

Applicants who are categorized into priority level E are economically food secure and have the 

ability to get groceries into the home and prepare meals, either with or without help. These individuals 

are eligible for HDMs because they fulfll the basic requirement of the Older Americans Act Nutrition 

Program (being homebound and 60 years of age or older). However, since they are not economically 

food insecure, and are physically able to get and prepare food or have help, they may be considered 

the lowest priority and, in case of limited funds, can be placed on the waitlist and/or referred to 

other services. 

4
How to Use the Tool

When the Tool Should 

be Used 

Before you use the tool, check whether the person is eligible to receive HDMs based upon your organization’s 

criteria. In general, this means the person must be 60 years or older and be homebound. The spouse of an 

eligible person may also receive meals. 

The HDM Prioritization Tool is meant to be used as a screening tool. It should be administered by phone as soon 

as an applicant calls in or is referred to the program. The best method for administration is to incorporate the 

tool into your program’s intake procedures. Each program can determine when it is the best time to ask questions 

during the intake conversation. 

Many programs repeat the screen once a home visit occurs. While all of the questions don’t need to be repeated, 

staff can check that the frst screen collected accurate information. If you receive additional information in a 

follow-up assessment that contradicts the priority level assigned during the screening, the priority level may be 

adjusted based on this information. The client may not have understood the question, or may have represented 

their abilities in a way that is contradictory to what your staff member sees in the assessment. Additionally, their 

status may have changed between the screening and the assessment. For example, if a client that was screened as 

priority level A has obtained a home health aide who cooks for them each day, they are no longer priority level A 

and you should ask the additional questions in the screener to determine if they are priority level B, C, D or E. 

Staff members have access to both a paper copy of the screening tool, a Microsoft Excel form, and a mobile 

application. Any of these can be used to calculate the priority level for a client. The following instructions 

outline each method. 

The Different Methods 

of Using the Tool Paper Tool 

The questions are on one sheet of paper and can be used as follows: 

1. Read the introductory statement 

2. Ask Question 1a about meal preparation and mark the client’s answer. If the Answer to Question 1a is “No”, 

you will also ask Question 1b. If the client's answer is again "No", stop the questionnaire. This client is 

considered priority level A and no further information is needed. 

3. If the client's answer to Question 1a or 1b is "Yes", continue to the next set of questions (Questions 2a-f) 

about ability to afford food. Ask these 6 questions and mark down the client’s answers. 

4. Ask the Question 3 about ability to get groceries and mark the client’s answer. 

5. Finish your intake conversation with the client. 

6. After you fnish speaking with the client you can calculate their priority level as described below. 

 • As mentioned in #2 above, if they are priority A, you are fnished with the screener. 

 • Otherwise, look at the point values noted next to each answer for Questions 2 a-f. Add up these points 

 and write the total in the red box. 

 • Look at the client’s answer to Question 3, the fnal question. Below the answer are two boxes, each with 

 a point range next to it. Select the box with the point range that contains the point total you wrote in the 

 red box. This will tell you the priority level for this client. 

Excel Form 

You can access a Microsoft Excel form that displays the questions, allows you to select the client's answers, and 

then calculates the client's priority level and stores it in an Excel sheet. It is simple to use and stores all of your 

client's priority levels in one place. To obtain this version of the tool, send an email to nsahyoun@umd.edu and 

amvaudin@gmail.com, and include the name and location of your program. You will receive an email with the Excel sheet. 

Mobile Application 

There is a mobile application (“app”) available that acts as a calculator to generate a client’s priority level. You 

can also obtain an Airtable spreadsheet: a spreadsheet that is stored on the Airtable website, and is linked to 

your app so that it will collect the results of the screener for your program. These are generated individually per 

program, and your Airtable spreadsheet will be protected by a user name and password that you generate. 

5
Instructions for Using 

the Mobile Application 

To obtain an app and spreadsheet for your program’s use, send an email to nsahyoun@umd.edu and

amvaudin@gmail.com and include the name and location of your program. You will receive an email 

with a link to the app, and an email with instructions for downloading the app as well as accessing 

HD the Airtable spreadsheet that is linked to it. 

MP 

1. Open the app. The icon for the app should look like this: HD 

MP 

2. On the screen that says “Welcome to the Home-Delivered Meals Prioritization Tool!” tap “Next” 

3. Read the introductory statement to the client and then tap "Next". 

4. The screen will now have the frst question to ask the client. Read the question and select the 

client’s answer by tapping on it. You will automatically be taken to the next question to read. 

5. Continue reading the questions and tapping the client’s answers. Please note: the questions that 

show up for you to ask may be different from client-to-client. This is because the client’s answers 

to some of the questions determine what additional questions need to be asked to calculate their 

priority level. For example, if the client answers that they are unable to cook, and then that they 

do not have help, the questionnaire will end. The app will determine this for you, and will show 

you the correct questions to ask each client. 

6. If you arrive at the food insecurity questions page, make sure to select an answer for every 

question and then scroll down to the bottom of the page and tap “next” to continue. If you do 

not answer every question, the priority level cannot be calculated. 

7. If you have to go back to a previous page to change an answer, tap the “back” button at the 

bottom of the page you are on. Please note that this will erase all answers for questions that 

come after the page you go back to, and you will have to answer these questions again. 

8. After you have selected answers for all of the questions, you will reach a page with spaces to 

enter the name of the client and their county. Tap each text box to type in the appropriate information, then tap “Submit”. This step is essential for the app to calculate the client’s priority level 

and submit the collected information to the Airtable spreadsheet. Once you tap “Submit”, the 

next screen shows you the priority level that has been calculated: 

Tapping “Submit” multiple times may result in duplicate records in the Airtable spreadsheet. 

If this happens, you can delete the extra record from the spreadsheet. 

9. Tap "Restart" to enter the information for another client. If you are fnished, close the app. 

10. To access the information collected by the app, open the Airtable link that was sent to you when 

you requested the app. Follow the directions to create an Airtable account for access to the 

spreadsheet. Make sure to record your username and password for future access. 

11. Your spreadsheet will be under “Bases shared with me” and will have the same name as the app. 

Click the icon to open and view the spreadsheet, which will contain the results from all of the 

times you have used the app. 

12. To download your results spreadsheet, click the three dots symbol at the top bar and click “Download 

CSV.” This will download the information from the table in a fle you can open in Microsoft Excel. 

6
Recommended Actions Based

On Each Priority Level 

The priority level will give you information on the best actions to take for each client. Your action will 

also depend on whether or not your program has a waiting list. Below is a description of the best action 

for programs both with and without a waiting list. 

If you do not have a waiting list: 

Every applicant may be eligible to receive meals, regardless of priority level. All applicants may also 

beneft from additional services, such as those noted in the chart below. The applicant’s priority level 

will help guide you towards the appropriate additional services. It is possible these additional services 

may provide enough support to these clients so that they don’t need HDMs, which will create space for 

higher-priority individuals. However, if you have space on the program, all eligible applicants will beneft 

from receiving meals. 

If you do have a waiting list: 

Applicants should be prioritized for service based on priority level, date of application, and availability 

of a delivery route to provide the meals. Priority level A applicants are highest priority for receiving 

home-delivered meals. They should be scheduled frst for a follow-up assessment and should be placed 

next on the waiting list for service (after the other priority level A applicants who were screened 

previously, and pending route availability). Next on the waiting list should be priority level B applicants, 

in order of screening date, then priority level C applicants, etc. 

Applicants who are priority level B through E may beneft from alternative food and nutrition services 

other than HDMs. Your program may be able to facilitate assistance for these individuals that helps 

them get food, even if your program cannot provide them with meals. If these supports are suffcient 

for these applicants, they may not need HDMs, freeing up more space on your program for those who 

have the greatest need for meals. The following table shows the supports that may be helpful to clients 

in each priority level: 

 LEVEL RECOMMENDED ACTION POSSIBLE ADDITIONAL OR ALTERNATIVE SERVICES 

A NWL: Home Delivered Meals 

WL: Highest priority on wait list 

Home-delivered meals are the most appropriate support for these clients 

Further inquiries to the applicant may reveal additional 

benefcial supports 

B NWL: Home-delivered meals and suggest additional services 

WL: Second highest priority on wait list, suggest alternative 

services 

Financial-based nutrition support services such as SNAP 

Help with getting groceries, such as grocery delivery or 

transportation services 

C NWL: Home-delivered meals and suggest additional services 

WL: Third highest priority on wait list, suggest alternative services 

Financial-based nutrition support services such as SNAP 

D NWL: Home-delivered meals and suggest additional services 

WL: Fourth highest priority on wait list, suggest alternative services 

Help with getting groceries, such as grocery delivery or 

transportation services 

E NWL: Home-delivered meals and suggest additional services 

WL: Lowest priority on wait list, suggest alternative services 

Further inquiries to the applicant may reveal the type of support required 

NWL= No Existing Wait List WL= Existing Wait List 

7
Creating a Referral Resource 

for Your Program 

How to Document and Use 

the Results in Your Program 

 

Re-screening 

Each c ommunity and each state may have different services available for older adults. An assessment of 

need will indicate which services are most appropriate to assist each client. Creating a reference resource 

will help you smoothly and effciently refer HDM clients or applicants to additional or alternative services. 

This involves collecting the names and contact information for the organizations (or people within your 

organization) who can start the process of enrolling them with these services. A suggested method is to 

create categories (fnancial, grocery delivery, and any other additional helpful resources, such as dental, 

mental health, insurance, etc) and list the available services and contact information. Examples of these 

resources are shown at the end of this manual. 

Maintain a record of the priority level for each client. You can do this by adding it to the information you 

keep on that client, and/or maintaining a separate spreadsheet that contains the client’s name, the date 

screened, the priority level, and any other information you would like to include (for example, a column 

showing whether or not the client is on the meal program). If you are using the appor the Excel form, they 

will generate a spreadsheet for you with the results of the screener that can be downloaded and modifed 

to suit your purposes. 

Looking at the priority levels of your clients can help you identify the need for additional programs or services, which can result in new partnerships or funding sources. For example, setting up a volunteer grocery 

shopping service or initiating the Commodity Supplemental Food Program may be a new program needed 

in your community. 

A spreadsheet can be used to manage enrollment in your program if you have a waitlist. If you have a spot 

open up on your meal program, you can use this spreadsheet to fnd the person who is at the highest priority. If you have multiple persons at the same priority level, you can choose the one who has been waiting the 

longest based on the date they were screened. And, maintaining the list can identify unmet need in areas 

where you may not have an existing HDM route. 

You can also create a report that shows the levels of need of those being served, and of those who are on 

your wait list (if you have one). This can be used to generate funding and support. If you are serving many 

people who are low priority, this may indicate the need for outreach to see if there are people who are high 

priority in your community but do not know about your services. 

This tool was developed and tested as a screening tool, and is designed to be administered to people 

who are applying for or waiting to receive meals. However, when completing annual reassessments, your 

program may wonder whether the priority level of a client who has been on the program has changed. 

There may be other opportunities for re-screening, such as after a signifcant change in a person’s health 

or living situation (e.g., death of a spouse, return from hospital, etc.), and it is also mandatory during regular 

reassessments in some states. 

The questions in this tool have not been designed specifcally for determining the priority level of people 

who are already receiving support from the program. So, when using the screening tool during a reassessment, preface the questions with the following statement: 

“The following questions are about the diffculties you might have if you were not receiving home-delivered 

meal services. Please answer the questions based on what your abilities would be if you were not receiving 

home-delivered meals.” 

8
Sample Report from 

the Maryland 

Department of Aging 

Showing the 

Distribution of Priority 

Levels Across Maryland

Fiscal Year 2018 

9
Sample Referral 

Table from the 

Maryland Department 

of Aging 

10

Care Planning 

Components

AAA Referral Programs and Services

Food and Nutrition • Senior Center Congregate Meals

• Home-Delivered Meals

• Nutrition counseling, education, and care planning 

• Commodity Supplemental Food Program

• Community food resources (pantries, etc)**

• Senior Farmers Market Nutrition Program

• Malnutrition workshop: Stepping Up Your Nutrition

• Post-discharge, medically-tailored meals

Housing • Assisted Living (including SALGHS)

• Ramp Assistance

• Home Modification

• Assistive Technology

• Durable Medical Equipment 

• Congregate Housing Services Program

Transportation • County or Regional Transit

• Cab/Bus Vouchers

• Senior Village 

• Community for Life

Financial Application assistance for financial aid:

• SNAP

• Medicaid

• State Health Insurance Program (SHIP_

• Energy-assistance programs

• Income-tax assistance

• Medicare Part A, B, C, D

• Medicare Billing, Appeals, Denials, Grievances

• Medicare Fraud Assistance 

• Oral nutritional supplements (Ensure, etc) 

• Prescription assistance

• Assistance for dental, eye care, hearing aids

Utilities • Low-Income Home Energy Assistance Program (LIHEAP)

• Electric Universal Service Program (EUSP) 

• Universal Service Protection Program (USPP)

• Utility Assistance (other)

Personal Safety • Elder Abuse

• Legal Assistance 

• Emergency Response Systems

• Falls Prevention (Stepping On, Matter of Balance, Tai Chi for

Better Balance)

• Arthritis foundation classes (Walk with Ease)
In-Home Care • Sitters and in-home care services (personal care, chore service)

• Home Care agencies

• Community First Choice

• Senior Care

• Home-delivered meals

• Dietitian referral

• Senior Village

Social Supports • Senior Center (exercise, socialization, Congregate Meals) 

• Telephone Reassurance 

• Support Groups: Caregivers, Renal, Stroke, ALS, Parkinson’s

• Adult Day Care

• Volunteer opportunities

Mental Health • PEARLS: Program to Encourage Active, Rewarding Lives

• Enhance Wellness

• Healthy IDEAS

• Behavioral Health Referral (Core Service Agency or Health

Department)

Health Care Referral • Primary Care Physician

• Clinics: Dental, Eye, Physical Therapy

• Community Health Worker

• Adult Medical Day Care

• Local health department

• Home care agencies

• Medical supplies

Employment • Senior Employment 

• AAA volunteer coordinator

• Community volunteer opportunities

Health Education Self-management workshops:

• Diabetes Self-Management (Spanish version available) 

• Chronic Disease Self-Management (Spanish version available)

• Chronic-Pain Self-Management

• Cancer Thriving and Surviving 

• Falls Prevention (Stepping On, Matter of Balance, Tai Chi for

Better Balance) 

• SAIL(Stay Active and Independent for Life) 

• Aging Mastery 

• Enhance Fitness 

• Lifelong Learning 

• Medication Management

• Wellness Center Gym

Grant funds from the Administration for Community Living (ACL), Grant Number 

90INNU0002 and the Maryland Department of Aging assisted in the development of this 

material. Its contents are solely the responsibility of the authors and do not necessarily 

represent the official views of the ACL or Department.

11
Developed by the College of Agriculture & Natural Resources Department 

of Nutrition and Food Science at the University of Maryland. 

Grant funds from the Administration for Community Living (ACL), Grant # 90INNU0002 and the Maryland 

Department of Aging (MDoA) assisted in the development of this material. This presentation is solely 

the responsibility of the authors and do not necessarily represent the offcial views of the ACL or MDoA. 
HDM 

PRIORITIZATION 

TOOL AND TRAINING 

MANUAL

Feb 26, 2020
Introduction to the Newly-Designed Tool

■ Brief description of

– Who should use the tool

How the tool should be used

How the results are useful

–

–

Who should use this tool? Home-delivered meal program administrators that: A. Have a waiting list or limited resources to serve all 

applicants; B. Want to demonstrate to funders and policy-makers the level of need in their community; and/or C. Want to 

understand if they are reaching those with the greatest need, or if more outreach is needed to identify the most food insecure.

How should it be used? As a screening tool as early as possible at application or referral.

How are the results useful? The results show risk factors the applicant is experiencing, and the level of priority for home-delivered meal 

services, and may inform alternative or additional support services that could benefit clients.
■

Introduction to the Newly-Designed Tool

Outlines the procedure for using the tool

The Procedure: 1. As early as possible after client application/referral and determination of eligibility for home delivered meals, the screening should be conducted via telephone or in person. 2. Priority Level is calculated and 

recorded for each client: Level A. Highest priority for service and follow-up assessments. Level B, C, D, and E.: See below for recommendations of support service.
■

–

–

–

Introduction to the Newly-Designed Tool

Priority Levels

Describes criteria for each level

Describes reasoning for assigning level

Outlines recommended services based on 

priority level and wait list status
■

■

Introduction to the Newly-Designed Tool

Added introductory statement

Added the word “hot” in front of meals in question 1a
Calculate

Food 

Security

Score

Introduction to the Newly-Designed Tool
■ Combine Food Security Score with ability to get groceries to 

obtain priority level B through E.

Introduction to the Newly-Designed Tool
Training Manual

■ Background on food security, screening, and why we should do 

this screening in HDM applicants 

Background on the development of the HDM Prioritization Tool

In-depth explanation of priority levels

How to use the tool

■

■

■

– Including the different methods

■ Paper Tool

Excel Form

Mobile App

■

■
Excel Form Demo
Mobile Application

■ Can be used on Android and Apple devices

Instructions for obtaining the app are on page 6 of the Training Manual

Acts as a calculator to determine priority level

Stores data in an online spreadsheet (AirTable – password protected)

■

■

■
■ Explanations of recommended actions based on priority level and wait list 

vs no wait list

■ Guidance on creating a 

referral resource

■ How to document the results

■ Re-screening

Training Manual

(continued)
Training Manual 

(continued)
■ Sample Referral Table

Training Manual 

(continued)
8 

Maryland Discharge Meal 

Program Materials

Resources to provide shelf-stable, medicallytailored meals to seniors being discharged from 

hospitals.
MDMP TRACKING SHEET 'Send this form via HIPAA compliant manner to Alice Chan at AliceChan@umm.edu by the 5th business day of each month 

'Fill out these sections as they pertain to your hospital. 

Patient 

# 

Patient 

First Name 

Patient 

Last Name 

Medical 

Record 

Number 

Admission 

Date 

Discharge 

Date Referred By Insurance Provider Referral Criteria Met List Diagnosis 

Diet Type (only 

choose ONE) 

Initial Meal Package 

Days of

meals Location Date 

Follow-U

Location 

0 Example Template 1234567 9/10/18 9/16/18 Sally Jones. 

Case Manager Aetna 

✓ Specific diagnosis

Food insecurity 

✓ Malnutrition 

✓ T2DM 

CHF 

COPD 

✓ CO'HH 

Enhanced Healina Hospital 

Discharge 3 9/16/18 

✓ Home Visit 

Care Clinic 

AAA 

CO'HH 

1 Enhanced Healina 

CO'HH 

2 Enhanced Hea/ina 

CO'HH 

3 Enhanced Healing 

CO'HH 

4 Enhanced Hea!ina 

CO'HH 

5 Enhanced Healing 

CO'HH 

6 Enhanced Healina 

CO'HH 

7 Enhanced Healina 

CO'HH 

8 Enhanced Hea/ina 

CO'HH 

9 Enhanced Healing 

CO'HH 

10 Enhanced Healina 

CO'HH 

11 Enhanced Healino 

CO'HH 

12 Enhanced Healing 
 

 

 

 

 

MARYLAND DISCHARGE MEAL PROGRAM PILOT: ORDERING INSTRUCTIONS 

Package sizes: Outer package dimension – 15.5”x 11.5”x 11.5”

Weight per box – 22-24 lbs. for 6 days box 

Weight per bag – 11-12 lbs for each cloth grocery bag 

 Note: Enhanced Healing package will be slightly heavier than Carb-Controlled/Heart-Healthy 

Order processing for the pilot follows: 

Deliveries will occur on Thursdays and Fridays, so please place orders no later than Tuesdays at 

10:30AM. 

Delivery windows: either 8-12PM or 12-4PM 

Minimum order size: 20 boxes 

Note: Orders will be standardized to a 50/50 split of each of the 2 diet types (1⁄2 Carb-Controlled/HeartHealthy and 1⁄2 Enhanced Healing) 

Please send email orders to Tracey, the main contact, and cc Jessica, Zak, and Gary. 

Email address: Tracey Ivison (Partner Services Supervisor) - tivison@mdfoodbank.org 

Jessica Corcelius (Partner Services Director) – jcorcelius@mdfoodbank.org 

Zak Jeffries (Warehouse Manager) - zjeffries@mdfoodbank.org 

Gary Melvin (Transportation Manager) – gmelvin@mdfoodbank.org 

Email is the best and most effective way to contact the team however phones are: 

Tracey Ivison – 443.297.5180 

Jessica Corcelius 443.297.5193 

Zak Jeffries - 443.297.5207 

Gary Melvin – 443.297.5149 

Email instructions: 

Email subject line: Maryland Discharge Meal Program New Order 

Email should include: 

 Desired delivery date 

 Delivery location 

 Quantity of boxes 
What’s in your

Box?

                                               

Day 1 3

Day 2

Day 4 Day 6

Day 5

Boxes either contain:

Carb‐Controlled,

Heart‐Healthy

meal plan

or

Enhanced

Healing

meal plan

Each patient only gets one type of meal plan

Use the Patient Selection Flowsheet to help you determine which meal plan is right for your patient

Day

Provide tote bags to the patients

Each patient gets four (4) bags

total (12 days of food) – an

initial set of bags at discharge

and the remainder at follow‐up

A B
           

           

           

         

                         

       

             

         

           

                 

           

       

       

         

       

       

         

       

   

           

                                 

                                      

                     

                               

Your patient will either get a Carb‐Controlled, Heart‐

Healthy or a Enhanced Healing meal package plan.

Here are the differences between the two:

Carb‐Controlled, Heart‐Healthy

• Calorie range 1500 – 1700 per day

• Carbohydrates are 45‐55% of total

calories in accordance with the

adult Dietary Reference Intake*

• Carbohydrates are spread evenly

between meals.

• Meals are about 3‐4 carb choices each

and snacks are 1‐2 carb choices.

• Moderate total fat (25 – 33% of

total calories)

• Adequate protein for maintaining

muscle (18 – 20% of total calories)

• Sodium is under 2,000 mg per day

Enhanced Healing

(high energy & high protein)

• Higher calories for medical

conditions that use more energy

(1900 – 2500 Calories per day)

• Adequate protein for maintaining

muscle (over 100 grams per day)

• No restrictions on fat,

carbohydrates, or sodium

Additional information for both meal package plans: 

• Easy to prepare.  Requires:

• Spreading with a knife

• Opening a can

• Pulling off a cap

• Mixing

• Puncturing with a straw

• Pulling open a package

• Additional kitchen items required:

• Water

• Bowls & plates

• Forks, knives & spoons

• Can opener

• Microwave

• Optional: scissors (if patient has

difficulty opening packages)

Grant funds from the Administration for Community Living (ACL) and the Maryland Department of Aging assisted in

the development of this material. Points of view or opinions contained herein are those of the authors and do not

necessarily represent the official position or policies of the ACL or Department.

*SOURCE: Dietary Reference Intakes for Energy, Carbohydrate, Fiber, Fat, Fatty Acids, Cholesterol, Protein, and Amino Acids (2002/2005).

https://www.ncbi.nlm.nih.gov/books/NBK56068/table/summarytables.t5/?report=objectonly
MDMP Patient Selection Flowsheet 

Start Is My Patient Eligible? 

Does your patient have any of the following orders at time of discharge? 

- A sodium restriction of less than 2000mg per day? 

A fluid restriction of less than 1500mL per day? 

A potassium, phosphorous or protein restriction 

A modified texture diet order 

-

-

-

No to all Yes to any 

Your patient is not eligible for meal packages.* 

Is any of the following true about your patient at time of discharge? 

-

-

-

Patient is being discharged to a facility that provides more than seven (7) 

meals per week (assisted living facility, skilled nursing facility, etc.) 

Patient has a diagnosed food allergy 

Patient has Celiac Disease 

No to all Yes to any 

Your patient is not eligible for meal packages.*

 Is any of the following true about your patient at time of discharge? 

-

-

Patient has no access to refrigeration or storage space (i.e. patient does not 

have a place of residence) 

Patient has an active substance addiction (including alcohol) and is not 

currently in active treatment 

No to all Yes to any 

Your patient is not eligible for meal packages. 

Please see the Community Referral Handout for 

more options. 

Is your patient older than 50? 

Yes No 

Your patient is not eligible for meal packages. 

Please see the Community Referral Handout for 

more options. 

* Please contact your inpatient dietitian for further evaluation if you have any questions or if you are unsure of patient eligibility. 

Provide this flowsheet to the dietitian and nutritional information for meal packages found on the back. 

Which Meal Package Plan? 

Patient has higher nutritional needs based on 

medical condition. This includes: 

-

-

-

COPD diagnosis 

Positive malnutrition risk screen or malnutrition 

diagnosis 

Order for dietary supplements 

Patient has need for diabetes diet and/or 

heart-healthy diet OR has no dietary restrictions 

(regular diet order) 

Provide patient with the 

Enhanced Healing

Meal Package 

Provide patient with the 

Carb-Controlled, Heart-Healthy 

Meal Package 

Grant funds from the Administration for Community Living (ACL), Grant Number 90INNU0002-02-01 and the Maryland 

Department of Aging assisted in the development of this material. Its contents are solely the responsibility of the 

authors and do not necessarily represent the official position or policies of the ACL or Department. 
Lunch rinneD nacksS 1 saltTo

tsfakaerB

Day 1 Day 2 Day 3 Day 4 Day 5 Day 6 Corn Flakes, Fruit Cup, Granola Bar, Milk 

Oatmeal, Craisins, Granola Bar, Milk 

Cereal, Craisins, Granola Bar, Milk Corn Flakes, Fruit Cup, Granola 

Bar, Milk 

Cereal, Fruit Cup, Granola Bar, Milk 

Oatmeal, Raisins, Granola Bar, Milk 

unchL

Tuna, Crackers, Tomato Soup, Mayo Packet 

Rice & Quinoa, Corn Cup, Salsa, 

Protein Bar 

Tuna, Corn Cup, Vegetable Soup, 

Crackers, Peanut Butter 

Chicken, Crackers, Chicken Noodle Soup 

Tuna, Crackers, Tomato Soup, Peanut butter 

Rice & Quinoa, Corn Cup, Vegetable Soup, Yogurt 

rneniD Pasta, Chicken, Green Bean Cup, Yogurt Chicken, Raisins, Crackers, Mayo Packet, Carrot Cup, Chocolate Milk Salmon, Mac & Cheese, Green Bean Cup Rice & Quinoa, Tuna, Green Bean Cup, Mayo Packet, Yogurt Chicken, Mac & Cheese, Carrot Cup Salmon, Pasta, Carrot Cup, Mayo Packet sacknS Pretzels, Peanut Butter, Chocolate Milk, Ensure, Protein Bar Pretzels, Peanut Butter, Ensure, Applesauce, Yogurt Fruit Cup, Yogurt, Protein Bar, Fruit Snacks, Ensure Applesauce, Ensure, Chocolate Milk, Protein Bar Fruit Snacks, Yogurt, Ensure, Applesauce, Protein Bar Fruit Cup, Ensure, Protein Bar, Crackers, Peanut Butter 

1 salotT Kcal Pro Fat CHO Na+ K+ 2430 123 75 334 2850 2789 

g g g mg mg 

Kcal Pro Fat CHO Na+ K+ 

2360 99 76 322 2740 2895 

g g g mg mg 

Kcal Pro Fat CHO Na+ K+ 2018 110 65 265 2565 2507 

g g g mg mg 

Kcal Pro Fat CHO Na+ K+ 1970 105 58 274 2270 2684 

g g g mg mg 

Kcal Pro Fat CHO Na+ K+ 2018 106 67 266 2365 2499 

g g g mg mg 

Kcal Pro Fat CHO Na+ K+ 2430 105 77 334 2465 2750 

g g g mg mg 

Carb-Controlled, Heart-Healthy 

Day 1 Day 2 Day 3 Day 4 Day 5 Day 6 

tsfaakerB Corn Flakes, Fruit Cup, Granola Bar, Milk 68g of Carbs Oatmeal, Granola Bar, Milk 46g of Carbs Cereal, Craisins, Milk 64g of Carbs Corn Flakes, Fruit Cup, Granola Bar, Milk 68g of Carbs Cereal, Fruit Cup, Milk 58g of Carbs Oatmeal, Granola Bar, Milk 46g of Carbs 

Crackers, Tuna, Tomato Soup, 

Mayo Packet 

45g of Carbs 

Pasta, Chicken, Green Bean Cup, Yogurt 

60g of Carbs 

Crackers, Peanut Butter 

33g of Carbs 

Rice & Quinoa, Corn Cup, Salsa, Protein Bar 

68g of Carbs 

Raisins, Chicken, Carrot Cup, Mayo 

Packet, Crackers 

48g of Carbs 

Fruit Snacks, Yogurt, Applesauce 

54g of Carbs 

Tuna, Corn Cup, Vegetable Soup, Crackers, Peanut Butter 

53g of Carbs 

Salmon, Pasta, Green Bean Cup, Mayo Packet 

45g of Carbs 

Fruit Cup, Yogurt, Granola Bar 

46g of Carbs 

Chicken, Crackers, Chicken Noodle Soup, Carrot Cup, Craisins 

57g of Carbs 

Pasta, Tuna, Green Bean Cup, 

Mayo Packet 

44g of Carbs 

Yogurt, Applesauce, Raisins 

57g of Carbs 

Crackers, Tuna, Tomato Soup, Peanut Butter 

56g of Carbs 

Chicken, Raisins, Crackers, Mayo Packet, Carrot Cup 

48g of Carbs 

Applesauce, Yogurt, Granola Bar 

49g of Carbs 

Rice & Quinoa, Vegetable Soup 

57g of Carbs 

Salmon, Pasta, Green Bean Cup, Mayo Packet 

45g of Carbs 

Yogurt, Fruit Snacks, Protein Bar 

51g of Carbs 

Kcal Pro Fat CHO Na+ K+ 1630 76 62 206 2035 1875 

g g g mg mg 

Kcal Pro Fat CHO Na+ K+ 1560 70 47 216 1850 1779 

g g g mg mg 

Kcal Pro Fat CHO Na+ K+ 1598 79 57 208 1890 2018 

g g g mg mg 

Kcal Pro Fat CHO Na+ K+ 1480 68 39 226 1855 1743 

g g g mg mg 

Kcal Pro Fat CHO Na+ K+ 1598 71 60 211 1685 2269 

g g g mg mg 

Kcal Pro Fat CHO Na+ K+ 1520 78 44 199 1545 1486 

g g g mg mg 

Enhanced Healing (high-protein, high-energy) 

1Nutrition facts are estimates based on most accurate data and may not reflect the exact nutritional makeup of the meal packages. Days 1-3 and Days 4-6 are packaged together and a client may not eat everything in 

the exact order as described on this page. 
 

 

 

 

 

 

 

 

 

 

 

 

 

 _______________________________________________________ 

Maryland Discharge Meal Program Pilot: Acknowledgement & Authorization 

Purpose & Background 

The first two weeks following a discharge from a hospital are very important for recovery. Many patients are at 

high risk for poor nutrition and readmission to the hospital during this time. The Maryland Discharge Meal Pilot 

Program is intended to help smooth the transition from hospital to home and to improve the nutritional status of 

the patients selected by the participating hospital for the pilot. 

The Program includes 12 days of medically tailored, shelf-stable food paid for by the Maryland Department of 

Aging via a grant from the federal Administration for Community Living. The Maryland Food Bank assembles 

the food packs for the Program. The initial pack of food will be provided by the hospital upon discharge and the 

second pack of additional food will be available for pickup at a follow-up visit or delivered during a home visit. 

Participating individuals will be asked to reply to an anonymous client feedback survey. 

Not all patients are medically eligible for this meal program. Eligibility criteria is included in the Patient 

Selection Flowsheet. 

I understand, acknowledge, and agree that: 

1. I am receiving the initial food pack from the hospital discharging me, 

2. I will pick up (or if the hospital so provides, receive) the second pack, 

3. My discharging hospital has discussed this pilot program with me in detail and explained to me where I 

have to go and what I have to do to pick up the second pack, 

4. I have discussed the eligibility criteria and have disclosed any relevant information to the hospital, 

5. This program does not deal with emergency situations and if I need immediate help, I will call 911, 

6. This is a voluntary program, 

7. At any time, I have the right to revoke my consent to the release of information I have provided below, 

and that, in any event, my consent will expire one year from the date I sign this acknowledgement, and 

8. There is no cost to participate, but the food provided is for my consumption alone and must not be given 

or sold to others. 

Client Authorization for Release of Information 

I consent to: 

1. The hospital contacting me in person, by telephone, or by mail for a follow up feedback survey, 

2. The hospital sending the results of the survey in an anonymous* fashion so that my identity is not 

disclosed, to the Maryland Department of Aging, 

3. My discharging hospital sharing certain anonymous* information with the Maryland Department of 

Aging so the Department can know what food packs have been provided by hospitals and been picked 

up by participants, and 

4. My discharging hospital sharing certain health information developed by the hospital with the 

University of Maryland St. Joseph Medical Center so the effectiveness of the pilot can be evaluated. 

*Anonymous means no personally identifying information, such as name or address, is reported and all data is 

reported in a summary format so no individual can be identified. 

I have read this and understand it. If there were parts I did not understand, I asked questions and had it 

explained to me. 

Name of Patient (Printed) 

Signature of Patient Date 

Name of Discharging Hospital 
 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

If you need food or other support.... 

These 

resources 

may help! 

Have you applied for SNAP? 

 “SNAP” stands for “Supplemental Nutrition Assistance

Program” - formerly known as food stamps. SNAP is a 

government program. You can apply directly to the 

state or get help with your application. The Maryland 

State Information/ Hotline Number is 1-800-332-6347. 

 Maryland Food Bank has a SNAP Outreach Team that 

can help with your application. Phone toll-free 1-888-

808-7327, Monday-Friday 8am to 5pm. 

Area Agencies on Aging provide a wide array of services to 

people 60 or older, including hot or cold home-delivered meals 

and group dining (senior center meals). To get connected with 

your local Area Agency on Aging, call the Maryland Department 

of Aging at 410-767-1100. 

Maryland Acccess Point (MAP) is a onestop source of information and assistance for 

long term services and supports. These include...

• Information on health 

• Transportation 

• Income and financial aid 

• Senior and community centers and clubs 

• Nutrition and meals 

• Pharmacy assistance 

• Housing 

• Volunteer opportunities 

• And more! 

Get connected by calling 1-844-627-5465 or go 

to www.MarylandAccessPoint.info 

Grant funds from the Administration for Community Living (ACL) and the Maryland Department 

of Aging assisted in the development in this material. Points of view or opinions contained 

herein are those of the authors and do not necessarily represented the official position or 

policies of the ACL or Department. 
These 

resources 

may help!

If you need food or other support....

Food Pantries want to help. 

To find a food pantry in your area: 

1. Go to the Maryland Food Bank website https://mdfoodbank.org 

2. Click on the words “Find Food” in the top right-hand corner. 

3. Scroll down, then click inside the grey box below the words “Address or Zip Code”

4. Enter your address or zip code, select the “within” miles and click on “Submit”

These 

resources 

may help! 

Other services can help by easing emotional or 

financial burdens in other parts of your life. 

The United Way has a free, confidential information and 

referral service. 

To get help, call 2-1-1, 24 hours a day, 7 days a 

week. 

If you can’t reach them by calling 2-1-1, use 

these numbers: 

• Greater Baltimore: 410-685-0525 

Elsewhere in Maryland 1-800-492-

0618 

TTY (for hearing impaired) 410-685-

2159 (weekdays 8:30am-4:45pm). 

You can also go to the website 

www.211md.org 

•

•

•
What’s in your

Bag? Day 1 Breakfast 

Corn Flakes, Mixed Fruit Cup, PB & Dark Chocolate 

Granola Bar, Lowfat Milk 

Lunch 

Tuna, Classic Tomato Soup, Wheat Crackers, 

Mayonnaise To-Go 

Dinner 

Barilla Pasta (1/2 bag), Premium Chicken (1/2 

can), Green Beans, Blended Yogurt 

Snacks 

Wheat Crackers, Natural Peanut Butter 

Day 2 Breakfast 

Quaker Oatmeal, PB & Dark Chocolate Granola Bar, 

Lowfat Milk 

Lunch 

Brown Rice & Quinoa, Sweet Corn, Picante Sauce, 

Chocolate Deluxe Protein Bar 

Dinner 

Premium Chicken (1/2 can), Raisins, Diced Carrots, 

Mayonnaise To-Go, Wheat Crackers 

Snacks 

Fruit Snacks, Blended Yogurt, Applesauce 

Day 3 Breakfast 

Mini Wheats, Craisins, Lowfat Milk 

Lunch 

Tuna, Sweet Corn, Hearty Vegetable Soup, Wheat 

Crackers, Natural Peanut Butter 

Dinner 

Pink Salmon, Barilla Pasta (1/2 bag), Green Beans, 

Mayonnaise To-Go 

Snacks 

Mixed Fruit Cup, Blended Yogurt, PB & Dark 

Chocolate Granola Bar 

Nutritional Content 

Carbohydrates 

190 – 220 grams per day 

45 – 70 grams per meal 

15 – 25 grams per snack 

Sodium 

1500 – 2000 mg/day 

A Carb-Controlled, Heart-Healthy Meal Packages 
 

 

 

 

 

Carb-Controlled, Heart-Healthy 

Meal Packages 

The Carb-Controlled, Heart Healthy meal package is designed to 

provide you with the food you need to help you recover after your 

visit to the hospital. 

Balanced carbohydrates 

Carbohydrates (carbs) from the food you eat effect 

your blood sugar. These meals and snacks are 

balanced with the right amount of carbs to keep 

your blood sugar under control throughout the 

day. 

Pro Tip 

Be sure not to add any salt to 

these foods. Try other 

seasonings, like garlic powder, 

dried herbs, Mrs. Dash SaltFree seasoning, or other saltfree seasonings. 

Low salt 

Getting too much sodium 

(salt) can raise your blood 

pressure and be bad for your 

heart health. These meals 

are low in salt to keep your 

heart healthy and your blood 

pressure under control. 

Picture source: 

http://www.mrsdash.com/products/seasoningblends/%C2%AE-original-blend Easy to prepare 

These foods were chosen because they are singleserve, easy to prepare, and can be kept at room 

temperature for up to six months. 

We want you to stay healthy once you leave the 

hospital. Enjoy these foods on us! 

In addition to these meal packages, you may also need: 

Water, bowls & plates, forks, knives & spoons, can opener, microwave, scissors 

Grant funds from the Administration for Community Living (ACL), Grant Number 90INNU0002 and the Maryland Department of Aging assisted in the development 

of this material. Its contents are solely the responsibility of the authors and do not necessarily represent the official views of the ACL or Department. 
What’s in your 

Bag? Day 1 Breakfast 

Corn Flakes, Mixed Fruit Cup, PB & Dark Chocolate 

Granola Bar, Lowfat Milk 

Lunch 

Premium Chicken (1/2 can), Wheat Crackers, 

Hearty Chicken Noodle Soup, Diced Carrots, Craisins 

Dinner 

Barilla Pasta (1/2 bag), Tuna, Green Beans, 

Mayonnaise To-Go 

Snacks 

Blended Yogurt, Applesauce, Raisins 

Day 2 Breakfast 

Mini Wheats, Mixed Fruit Cup, Lowfat Milk 

Lunch 

Tuna, Classic Tomato Soup, Wheat Crackers, 

Natural Peanut Butter 

Dinner 

Premium Chicken (1/2 can), Wheat Crackers, 

Raisins, Mayonnaise To-Go, Diced Carrots 

Snacks 

Applesauce, Blended Yogurt, PB & Dark Chocolate 

Granola Bar 

Day 3 Breakfast 

Quaker Oatmeal, PB & Dark Chocolate Granola Bar, 

Lowfat Milk 

Lunch 

Brown Rice & Quinoa, Hearty Vegetable Soup 

Dinner 

Pink Salmon, Barilla Pasta (1/2 bag), Green Beans, 

Mayonnaise To-Go 

Snacks 

Blended Yogurt, Fruit Snacks, Chocolate Deluxe 

Protein Bar 

Nutritional Content

Carbohydrates 

190 – 220 grams per day 

45 – 70 grams per meal 

15 – 25 grams per snack 

Sodium 

1500 – 2000 mg/day 

B Carb-Controlled, Heart-Healthy Meal Packages 
Carb-Controlled, Heart-Healthy 

Meal Packages 

The Carb-Controlled, Heart Healthy meal package is designed to 

provide you with the food you need to help you recover after your 

visit to the hospital. 

Balanced carbohydrates 

Carbohydrates (carbs) from the food you eat effect 

your blood sugar. These meals and snacks are 

balanced with the right amount of carbs to keep 

your blood sugar under control throughout the 

day. 

Pro Tip 

Be sure not to add any salt to 

these foods. Try other 

seasonings, like garlic powder, 

dried herbs, Mrs. Dash SaltFree seasoning, or other saltfree seasonings. 

Low salt 

Getting too much sodium 

(salt) can raise your blood 

pressure and be bad for your 

heart health. These meals 

are low in salt to keep your 

heart healthy and your blood 

pressure under control. 

Picture source: 

http://www.mrsdash.com/products/seasoningblends/%C2%AE-original-blend Easy to prepare 

These foods were chosen because they are singleserve, easy to prepare, and can be kept at room 

temperature for up to six months. 

We want you to stay healthy once you leave the 

hospital. Enjoy these foods on us! 

In addition to these meal packages, you may also need: 

Water, bowls & plates, forks, knives & spoons, can opener, microwave, scissors 

Grant funds from the Administration for Community Living (ACL), Grant Number 90INNU0002 and the Maryland Department of Aging assisted in the development 

of this material. Its contents are solely the responsibility of the authors and do not necessarily represent the official views of the ACL or Department. 
What’s in your 

Bag? Day 1 Breakfast

Corn Flakes, Mixed Fruit Cup, PB & Dark Chocolate 

Granola Bar, Lowfat Milk 

Lunch

Wheat Crackers, Tuna, Classic Tomato Soup, 

Mayonnaise To-Go 

Dinner

Barilla Pasta, Premium Chicken (1/2 can), Green 

Beans, Blended Yogurt 

Snacks

Pretzels, Natural Peanut Butter, Chocolate Milk, 

Ensure Shake, Deluxe Chocolate Protein Bar 

Day 2 

Breakfast

Quaker Oatmeal, Craisins, PB & Dark Chocolate 

Granola Bar, Lowfat Milk 

Lunch

Brown Rice & Quinoa, Sweet Corn, Picante Sauce, 

Deluxe Chocolate Protein Bar 

Dinner

Wheat Crackers, Premium Chicken (1/2 can), 

Raisins, Diced Carrots, Mayonnaise To-Go, 

Chocolate Milk 

Snacks

Pretzels, Natural Peanut Butter, Ensure Shake, 

Applesauce, Blended Yogurt 

Day 3 Breakfast

Mini Wheats, Craisins, PB & Dark Chocolate Granola 

Bar, Lowfat Milk 

Lunch

Tuna, Sweet Corn, Hearty Vegetable Soup, Wheat 

Crackers, Natural Peanut Butter 

Dinner

Pink Salmon, Mac & Cheese, Green Beans 

Snacks

Mixed Fruit Cup, Blended Yogurt, Deluxe Chocolate 

Protein Bar, Fruit Snacks, Ensure Shake 

A Enhanced Healing Meal Packages 
Enhanced Healing 

Meal Packages 

The Enhanced Healing meal package is designed to provide you 

with the food you need to help you recover and stay strong after 

your visit to the hospital. 

High protein 

Protein helps keep your immune system strong, 

keep you from losing muscle, and helps wounds to 

heal. These foods give you enough protein to keep 

your muscles strong and to help you heal and 

recover after your hospital stay. 

High energy 

Eating a balanced diet and getting enough energy 

from your food is very important when you’re 

recovering. It can be hard to get enough to eat 

when you are sick, so these foods give you more 

energy in every bite. 

Easy to prepare 

These foods were chosen because they are singleserve, easy to prepare, and can be kept at room 

temperature for up to six months. 

We want you to stay healthy once you leave the 

hospital. Enjoy these foods on us! 

In addition to these meal packages, you may also need: 

Water, bowls & plates, forks, knives & spoons, can opener, microwave, scissors 

Grant funds from the Administration for Community Living (ACL), Grant Number 90INNU0002 and the Maryland Department of Aging assisted in the development 

of this material. Its contents are solely the responsibility of the authors and do not necessarily represent the official views of the ACL or Department. 
What’s in your 

Bag? Day 1 Breakfast

Corn Flakes, Mixed Fruit Cup, PB & Dark Chocolate 

Granola Bar, Lowfat Milk 

Lunch

Premium Chicken (1/2 can), Wheat Crackers, 

Hearty Chicken Noodle Soup 

Dinner

Brown Rice & Quinoa, Tuna, Green Beans, Blended 

Yogurt, Mayonnaise To-Go 

Snacks

Ensure Shake, Applesauce, Deluxe Chocolate Protein 

Bar, Chocolate Milk 

Day 2 Breakfast

Mini Wheats, Mixed Fruit Cup, PB & Dark Chocolate 

Granola Bar, Lowfat Milk 

Lunch

Tuna, Classic Tomato Soup, Wheat Crackers, 

Natural Peanut Butter 

Dinner

Premium Chicken (1/2 can), Mac & Cheese, Diced 

Carrots 

Snacks

Fruit Snacks, Blended Yogurt, Deluxe Chocolate 

Protein Bar, Applesauce, Ensure Shake 

Day 3 

Breakfast

Quaker Oatmeal, Raisins, PB & Dark Chocolate 

Granola Bar, Lowfat Milk 

Lunch

Brown Rice & Quinoa, Sweet Corn, Hearty Vegetable 

Soup, Blended Yogurt 

Dinner

Pink Salmon, Barilla Pasta, Diced Carrots, 

Mayonnaise To-Go 

Snacks

Mixed Fruit Cup, Ensure Shake , Deluxe Chocolate 

Protein Bar, Wheat Crackers, Natural Peanut Butter 

B Enhanced Healing Meal Packages
Enhanced Healing 

Meal Packages 

The Enhanced Healing meal package is designed to provide you 

with the food you need to help you recover and stay strong after 

your visit to the hospital. 

High protein 

Protein helps keep your immune system strong, 

keep you from losing muscle, and helps wounds to 

heal. These foods give you enough protein to keep 

your muscles strong and to help you heal and 

recover after your hospital stay. 

High energy 

Eating a balanced diet and getting enough energy 

from your food is very important when you’re 

recovering. It can be hard to get enough to eat 

when you are sick, so these foods give you more 

energy in every bite. 

Easy to prepare 

These foods were chosen because they are singleserve, easy to prepare, and can be kept at room 

temperature for up to six months. 

We want you to stay healthy once you leave the 

hospital. Enjoy these foods on us! 

In addition to these meal packages, you may also need: 

Water, bowls & plates, forks, knives & spoons, can opener, microwave, scissors 

Grant funds from the Administration for Community Living (ACL), Grant Number 90INNU0002 and the Maryland Department of Aging assisted in the development 

of this material. Its contents are solely the responsibility of the authors and do not necessarily represent the official views of the ACL or Department. 
Maryland Discharge Meal Program Pilot: Feedback Survey 

INFORMATION FOR SURVEY ADMINISTOR 

(NOT TO BE SHARED WITH PATIENT) 

PURPOSE/BACKGROUND: 

 The purpose of this survey is to collect feedback from clients participating in the Maryland 

Discharge Meal Program (MDMP) pilot in order to improve the program for future clients. 

 The surveys are anonymous and administered in the following order of preference: 

1) in person 

2) by telephone. If these attempts are unsuccessful, then 

3) by mail. 

 Document both successful and unsuccessful survey administration contacts on the MDMP 

tracking form. 

 Do not indicate patient’s name or any personal information on the forms. 

 The hospital MDMP coordinator will ensure proper tracking of the surveys and will fax 

groups of completed surveys by the 5th business day of each month to the Maryland 

Department of Aging FAX, to the attention of Laura Sena at 410-333-7943. 

INSTRUCTIONS FOR SURVEY ADMINISTRATION: 

STEP 1: 

Administer survey verbally face-to-face (if possible) at or around day 13 post-admission. 

Document patient’s responses on the attached form. 

STEP 2: 

If in-person administration is not possible, call the patient to administer the feedback survey 

verbally by telephone at or around day 13 post-discharge and document his/her responses on 

the attached form. If calls are unsuccessful, attempt twice more before day 30 post-discharge. 

STEP 3: 

If 3 phone call attempts do not succeed by day 30 post-discharge, send paper survey along 

with a stamped return envelope addressed to the Maryland Department of Aging with 

instructions to return within 2 weeks of receiving to: 

Laura Sena, Innovations in Nutrition Programs 

Maryland Department of Aging 

301 W. Preston Street, Suite 1007 

Baltimore, MD 21201 
Maryland Discharge Meal Program Pilot: Feedback Survey 

THIS PAGE INTENTIONALLY LEFT BLANK 
Maryland Discharge Meal Program Pilot: Feedback Survey 

This survey contains questions about the meal packages that you received from the Maryland 

Discharge Meal Program Pilot. Your answers will be kept confidential. For this set of questions, 

we would like you to think about how the meals may have helped you, compared with how you 

might have felt if you didn’t receive them. Do you feel the meal packages...

1. Helped you recover after being in the hospital? 

□ Yes 

□ No 

2. Kept you from losing weight? 

□ Yes 

□ No 

3. Helped you manage your health condition (for example, hypertension, diabetes, etc.)? 

□ Yes 

□ No 

4. Provided you with food that you wouldn’t have otherwise been able to buy or shop for?

□ Yes 

□ No 

5. Provided you with something to eat when you had difficulty preparing your own meals? 

□ Yes 

□ No 

6. Helped you eat healthier food? 

□ Yes 

□ No 

7. Considering all the meal packages combined, how much of the food did you eat? 

□ 1⁄4 or less 

□ 1⁄2 or less 

□ 3⁄4 or less 

□ Almost all 

8. Do you feel the foods met your nutritional needs based on your health condition? 

□ Yes 

□ No 

□ If yes, how? ____________________________ 

□ If no, why not? ____________________________ 

9. Of the foods you received, what were your top 3 favorites? 

1) _____________________________ 

2) _____________________________ 

3) _____________________________ 
 

Maryland Discharge Meal Program Pilot: Feedback Survey 

10. Of the foods you received, what were your 3 least favorite? 

1) _____________________________ 

2) _____________________________ 

3) _____________________________ 

11. Did you have any trouble opening the food packages? 

□ Yes 

□ No 

□ If yes, which ones? ____________________________ 

12. Was it easy to get the meal packages home from your hospital discharge and follow-up 

visit (if applicable)? 

□ Yes 

□ No 

□ If no, please describe any issues. ____________________________ 

13. Did the second meal package make it more likely for you to attend your follow-up visit? 

□ Yes 

□ No 

□ Not applicable 

14. Did you find the “What’s in Your Bag?” menus provided helpful?

□ Yes 

□ No 

□ If no, why not? ____________________________ 

15. Did the pilot program help you connect to organization(s) that provide wellness, meals, 

financial, housing, caregiver supports (or similar services)? 

□ Yes 

□ No 

□ If yes, what organization(s)? ____________________________ 

16. Did the pilot program help you connect to program(s) that can help you eat better, like 

senior centers, food pantries, SNAP, etc.? 

□ Yes 

□ No 

□ If yes, what program(s)? _______________________________ 

IF YOU RECEIVED THIS SURVEY BY MAIL, PLEASE PLACE YOUR COMPLETED 

FORM IN THE ENVELOPE PROVIDED AND MAIL BACK PROMPTLY. 

THANK YOU! WE APPRECIATE YOUR FEEDBACK! 

Date Survey Completed: _____________________________ 
Maryland Discharge Meal Program Pilot: 

Summary and Implementation Instructions 

*Note to host organization: BEFORE YOU DISTRIBUTE TO STAFF please 

fill in the underlined, highlighted sections that apply to your hospital. 

PROGRAM SUMMARY 

Background 

 Your hospital is one of four Maryland hospitals participating in the Maryland Discharge 

Meal Program Pilot. Congratulations in being part of this innovative project! 

 Each hospital will provide medically-tailored meals for 50 patients upon discharge, 

beginning in March 2019 through approximately May 2019. 

 Meals are shelf-stable and require minimal preparation (water, microwave, can opener). 

Complete nutritional support (3 meals and 2 snacks per day), except for fluid, is provided 

for 12 days post-discharge. The MDMP pilot offers two diet types. 

 The program is funded and overseen by the Maryland Department of Aging via a grant 

from the federal Administration for Community Living. 

 The Maryland Food Bank assembles the meal packages and delivers them to the hospital 

and a secondary, follow-up site for distribution 

 Your Hospital Coordinator is: __________________________, in case you have 

questions. 

Resources – located in Appendices. Please see detailed instructions on the following pages. 

Resource Purpose 

A: Tracking Sheet  Required tracking information for outcome data analysis and to keep 

track of project progress 

B: Ordering 

Instructions 

 Includes information about meal package dimensions and weight and 

instructions for placing email orders to the Maryland Food Bank 

C: Provider 

Educational Materials 

 Explains the two different diet types and what is inside of each box for 

healthcare providers 

D: Patient Selection 

Flowsheet 

 Lists circumstances that would make a patient ineligible for this 

program including certain diet restrictions, living circumstances, etc. 

 Includes information to help staff ensure a good match between 

patient and meal package 

E: Consent Form  Ensures patient is aware of purpose of project and agrees to terms 

regarding privacy and liability 

F: Community 

Referral Handout 

 Provides community based referrals for long-term support services, if 

needed 

G: Patient 

Educational Materials 

 Explains the diet provided and how to use the foods to create a daily 

menu of meals 

H: Feedback Survey  Collects anonymous feedback from patients to measure if pilot is 

meeting goals and objectives and to improve the program for future 

participants 

1 
 

Maryland Discharge Meal Program Pilot: 

Summary and Implementation Instructions 

IMPLEMENTATION INSTRUCTIONS 

TRACKING, ORDERING, MEAL PAKCAGING AND DISTRIBUTION 

Tracking the Pilot 

Person(s) Involved 

 Input tracking information: __________________________ 

Details: 

 The Tracking Sheet will be used to keep track of patient information for input into CRISP 

by Alice Chan at the University of Maryland St. Joseph Medical Center as well as pilot 

progress and logistics (including verification of patient’s signing the consent form and

hospital administration of feedback survey). 

 Hospital Coordinator - please ensure proper tracking and send the Tracking Sheet to 

Alice Chan via HIPAA-compliant, secure transmission methods at 

AliceChan@umm.edu by the 5th business day of each month. 

 There is space for 50 patients on the excel so please continue to add to the same Tracking 

Sheet throughout the pilot and submit as-is each month. 

 The “Referral Criteria” and “Diagnosis” sections as well as the Initial and Follow-Up 

Package “Location” and “Days of Meals” should be customized to your specific hospital.

Resource: 

 Tracking Sheet (Appendix A) 

Ordering Meal Packages (as needed, 50 patients per hospital) 

Person(s) Involved: 

 Place orders:__________________________ 

Details: 

 Orders are to be provided via email to the Maryland Food Bank, no later than Tuesdays at 

10:30AM for deliverers on Thursdays and Fridays. There is a minimum order size of 20 

boxes. Orders will be standardized to a 50/50 split of each diet type. 

 Email subject line should read “Maryland Discharge Meal Program New Order.” Include: 

o Desired delivery date 

o Delivery location 

o Quantity of boxes 

 Please send emails to Tracey, the main contact, and cc Jessica, Zak, and Gary. 

 Email addresses: 

o Tracey Ivison (Partner Services Supervisor) – tivison@mdfoodbank.org 

o Jessica Corcelius (Partner Services Director) – jcorcelius@mdfoodbank.org 

o Zak Jeffries (Warehouse Manager) – zjeffries@mdfoodbank.org 

o Gary Melvin (Transportation Manager) – gmelvin@mdfoodbank.org 

 Phone numbers: 

o Tracey Ivison – 443-297-5080 

o Jessica Corcelius – 443-297-5193 

o Zak Jeffries – 443-297-5207 

o Gary Melvin – 443-297-5149 

Resource: 

 Ordering Instructions (Appendix B) 

2 
 

 

Maryland Discharge Meal Program Pilot: 

Summary and Implementation Instructions 

Meal Packaging 

The MDMP program offers two diet types including Carbohydrate-Controlled, Heart-Healthy 

and Enhanced Healing (high-protein, high-energy). Each diet type has an “A” and “B” 3-day 

menu for increased variety. 

Packaging Ziploc bags (3) Grocery Totes (2) Box (1) 

# of day of 

meals One day/bag Three days/tote Six days/box 

Weight 3-4 lbs 11-12 lbs 22-24 lbs 

Dimensions 15.5” x 11.5” x 11.5”

 Each Ziploc bag contains a one day supply of meals 

 3 Ziplocs are packaged into one grocery tote which will be given to patients (three day 

supply of meals) 

 Two grocery totes are packaged into a box for transportation and storage purposes (six 

day supply of meals) 

Resource: 

 Provider Educational Materials (Appendix C) 

Meal Distribution 

Initial package at discharge  Follow-up package at follow-up and/or home visit 

 Each patient will receive 4 grocery totes total (12 day supply of meals). Each hospital 

will determine how many meals patients receive upon discharge and follow-up. 

 Patients will receive 1 or 2 grocery totes (a 3 or 6 day supply of meals) at hospital 

discharge 

 Patients will receive 3 or 2 grocery totes (a 9 or 3 day supply of meals) at follow-up after 

discharge 

 Meal packages are delivered in boxes. Hospitals are responsible for removing the grocery 

totes from the boxes before distribution to patients. 

3 
Maryland Discharge Meal Program Pilot: 

Summary and Implementation Instructions 

WHAT YOU NEED TO KNOW: STEP BY STEP 

Step 1: Patient Eligibility and Diet Selection 

Person(s) Involved: 

 Refer patients: __________________________ 

 Determine eligibility and meal package type: __________________________ 

Details: 

 Each hospital has decided which patient types are referred to this program. Typically, 

referral criteria is related to high risk for re-admission, medical diagnosis (CHF, COPD, 

and/or diabetes), malnutrition, food insecurity, etc. 

 Your hospital’s specific referral criteria includes: ________________________________ 

________________________________________________________________________ 

 Referred patients then are assessed for eligibility based on whether they are appropriate 

to receive the meals, which is based on their dietary restrictions, discharge destination, 

and other criteria outlined in the Patient Selection Flowsheet. 

 Eligible patients then need to be matched to one of the two diet types. This criteria is also 

outlined in the Patient Selection Flowsheet. If you have any questions, please contact 

your inpatient dietitian, as appropriate. 

Resource: 

 Patient Selection Flowsheet (Appendix D) 

Step 2: Obtain Patient Consent 

Person(s) Involved: 

 Administer consent form:__________________________ 

Details: 

 Execution of the consent form is required for participation in the pilot program. Hospital 

staff should administer the consent form to the patient and forms should be retained by 

the Hospital Coordinator. They should not be sent to the Maryland Department of Aging. 

Resource: 

 Consent Form (Appendix E) 

Step 3: Distribute Initial Meal Package 

Person(s) Involved: 

 Coordinate distribution at discharge: __________________________ 

Details: 

 The first meal package will be provided at hospital discharge. 

 The patient will receive 1 or 2 grocery totes (a 3 or 6 day supply of meals). 

 Patient educational materials will be pre-packaged within the meal package for the 

patient. These materials will explain the diet provided and how to use the foods to create 

a daily menu of meals. There will also be a handout with community-based referrals for 

long-term support services, if needed, including SNAP, Area Agencies on Aging, food 

pantries, and United Way 211. 

Resources: 

 Community Referral Handout (Appendix F) 

 Patient Educational Materials (Appendix G) 

4 
Maryland Discharge Meal Program Pilot: 

Summary and Implementation Instructions 

Step 4: Distribute Follow-Up Meal Package 

Person(s) Involved: 

 Coordinate distribution at follow-up: __________________________ 

Details: 

 The second meal package will be picked up by the patient at a follow-up visit and/or 

delivered during a home visit. The goal is to provide an incentive for the patient to attend 

their follow-up visit or comply with a home visit. 

 The patient will receive the remaining 3 or 2 grocery totes (a 9 or 6 day supply of meals). 

 This is an important time to discuss the Community Referral Handout with the patient. 

We encourage you to connect with your local Area Agency on Aging to identify needed 

services and programs. Also, Maryland Food Bank and local food pantry information is 

provided to address food insecurity issues. 

Resource: 

 Community Referral Handout (Appendix F) 

 Patient Educational Materials (Appendix G) 

Step 5: Administer Feedback Survey 

Person(s) Involved: 

 Administer feedback survey:__________________________ 

Details: 

 An anonymous feedback survey will be administered in the following order of preference 

by the hospital: 

1) in person at or around day 13 post-admission 

2) by telephone if in-person administration is not possible; at or around day 13-

post discharge; if unsuccessful, attempt twice more before day 30 post-discharge 

3) by mail if phone call attempts do not succeed by day 30 post-discharge; send 

paper survey along with a stamped return envelope addressed to the Maryland 

Department of Aging with instructions to return within 2 weeks of receiving to: 

Laura Sena, Innovations in Nutrition Programs 

Maryland Department of Aging 

301 W. Preston Street, Suite 1007 

Baltimore, MD 21201 

 As you administer the survey in-person or by phone, please complete the survey 

instrument 

 The survey administrator should document both successful and unsuccessful attempts to 

contact the patient on the Tracking Sheet 

 Hospital Coordinator - please ensure surveys contain no patient information and fax 

groups of completed surveys to the Maryland Department of Aging, to the attention 

of Laura Sena at 410-333-7943 by the 5th business day of each month. 

Resource: 

 Feedback Survey (Appendix H) 

5 
Maryland Discharge Meal Program Pilot: 

Summary and Implementation Instructions 

Appendix 

A. Tracking Sheet 

B. Ordering Instructions 

C. Provider Educational Materials 

D. Patient Selection Flowsheet 

E. Consent Form 

F. Community Referral Handout 

G. Patient Educational Materials 

H. Feedback Survey 

6 
Appendix A: Tracking Sheet 

MDMP TRACKING SHEET *Send this form via HIPAA compliant manner to Alice Chan at AliceChan@umm.edu by the 5th business day of each month 

*Fill out these sections as they pertain to your hospital.

Days of meals Date Days of meals Date

 Specific diagnosis

Food insecurity  Malnutrition

 T2DM

CHFCOPD

 CC/HH

Enhanced Healing

 Home Visit

Care ClinicAAA

In PersonPhoneMail

CC/HH In PersonEnhanced Healing Phone

Mail

CC/HH In PersonEnhanced Healing Phone

Mail

CC/HH In PersonEnhanced Healing Phone

Mail

CC/HH In PersonEnhanced Healing Phone

Mail

CC/HH In PersonEnhanced Healing Phone

Mail

CC/HH In PersonEnhanced Healing Phone

Mail

CC/HH In PersonEnhanced Healing Phone

Mail

CC/HH In PersonEnhanced Healing Phone

Mail

CC/HH In PersonEnhanced Healing Phone

Mail

CC/HH In PersonEnhanced Healing Phone

Mail

CC/HH In PersonEnhanced Healing Phone

Mail

CC/HH In PersonEnhanced Healing Phone

Mail

Feedback Survey 

AdministrationN/A

9/29 10/8 10/16

10/16

8

9

10

1112

Patient 

#

0

12

34

56

7

Patient Signed 

Consent

9/16/18

Follow-Up Meal Package

9/19/18 9

Location

Diet Type (only 

choose ONE) Location

Referred By Referral Criteria Met List 

Diagnosis

Initial Meal Package

3 9/16/18 Hospital 

Discharge 1234567

Discharge 

Date

Medical 

Record 

Number

Aetna Template

Insurance 

Provider

Sally Jones, 

Case Manager Example

Admission 

Date

9/10/18 9/16/18

Patient 

Last Name

Patient 

First Name

7 
 

 

 

 

Appendix B: Ordering Instructions 

MARYLAND DISCHARGE MEAL PROGRAM PILOT: ORDERING INSTRUCTIONS 

Package sizes: Outer package dimension – 15.5”x 11.5”x 11.5”

Weight per box – 22-24 lbs. for 6 days box 

Weight per bag – 11-12 lbs for each cloth grocery bag 

 Note: Enhanced Healing package will be slightly heavier than Carb-Controlled/Heart-Healthy 

Order processing for the pilot follows: 

Deliveries will occur on Thursdays and Fridays, so please place orders no later than Tuesdays at 

10:30AM. 

Delivery windows: either 8-12PM or 12-4PM 

Minimum order size: 20 boxes 

Note: Orders will be standardized to a 50/50 split of each of the 2 diet types (1⁄2 Carb-Controlled/HeartHealthy and 1⁄2 Enhanced Healing) 

Please send email orders to Tracey, the main contact, and cc Jessica, Zak, and Gary. 

Email address: Tracey Ivison (Partner Services Supervisor) - tivison@mdfoodbank.org 

Jessica Corcelius (Partner Services Director) – jcorcelius@mdfoodbank.org 

Zak Jeffries (Warehouse Manager) - zjeffries@mdfoodbank.org 

Gary Melvin (Transportation Manager) – gmelvin@mdfoodbank.org 

Email is the best and most effective way to contact the team however phones are: 

Tracey Ivison – 443.297.5180 

Jessica Corcelius 443.297.5193 

Zak Jeffries - 443.297.5207 

Gary Melvin – 443.297.5149 

Email instructions: 

Email subject line: Maryland Discharge Meal Program New Order 

Email should include: 

 Desired delivery date 

 Delivery location 

 Quantity of boxes 

8 
Appendix C: Provider Educational Materials 

9 

What’s In Your Box?

Boxes either contain:

Carb-Controlled, Heart-Healthy meal plan or Enhanced Healing Meal Plan.

Each patient only gets one type of meal plan.

Use the Patient Selection Flowsheet to help you determine which meal plan is right for your patient. 

Provide tote bags to the patients. Each patient gets four bags total (12 days of food) – an initial set of bags 

at discharge and the remainder at follow-up.

Tote Bag A: Points to meal plans for day 1, 2, and 3. 

Tote Bag B: Points to meal plans for day 4, 5, and 6.
Your patient will either get a Carb-Controlled, HeartHealthy or a Enhanced Healing meal package plan. 

Here are the differences between the two: 

Carb-Controlled, Heart-Healthy 

• Calorie range 1500 -1700 per day

• Carbohydrates are 45-55% of total

calories in accordance with the

adult Dietary Reference Intake*

• Carbohydrates are spread evenly

between meals. • Meals are about 3-4 carb choices each

and snacks are 1-2 carb choices.

• Moderate total fat {25 -33% of

total calories)

• Adequate protein for maintaining

muscle {18 -20% of total calories)

• Sodium is under 2,000 mg per day

Enhanced Healing 

(high energy & high protein) 

• Higher calories for medical

conditions that use more energy

(1900-2500 Calories per day)

• Adequate protein for maintaining

muscle (over 100 grams per day)

• No restrictions on fat,

carbohydrates, or sodium

Additional information for both meal package plans: 

• Easy to prepare. Requires: • Spreading with a knife • Opening a can • Pulling off a cap • Mixing • Puncturing with a straw • Pulling open a package• Additional kitchen items required: • Water • Bowls & plates • Forks, knives & spoons • Can opener • Microwave • Optional: scissors (if patient has

difficulty opening packages)

Grantfundsfrom the Adm inistration for Community Uving(ACL) and the Maryland Department of Agingassiste d in 

the developmentof thismaterial. Points of view or opinions contained herein are those of the author5and do not 

necessar ily represent the offic ial position or policies of the ACL or Department 

*SOURCE: Dietary Reference Intakes for Energy, Carbohydrate, Fiber, Fat, Fatty Acids, Cholesterol, Protein, and Amino Acids {2002/2005). 

https://www.ncbi.nlm.nih.gov/books/NBK56068/table/summarytables.t5/?report=objectonly 

10 
Appendix D: Patient Selection Flowsheet

Start Is My Patient Eligible? 

Does your patient have any of the following orders at time of discharge? 

- A sodium restriction of less than 2000mg per day? 

A fluid restriction of less than 1500mL per day? 

A potassium, phosphorous or protein restriction 

A modified texture diet order 

-

-

-

No to all Yes to any 

Your patient is not eligible for meal packages.* 

Is any of the following true about your patient at time of discharge? 

-

-

-

Patient is being discharged to a facility that provides more than seven (7) 

meals per week (assisted living facility, skilled nursing facility, etc.) 

Patient has a diagnosed food allergy 

Patient has Celiac Disease 

No to all Yes to any 

Your patient is not eligible for meal packages.*

 Is any of the following true about your patient at time of discharge? 

-

-

Patient has no access to refrigeration or storage space (i.e. patient does not 

have a place of residence) 

Patient has an active substance addiction (including alcohol) and is not 

currently in active treatment 

No to all Yes to any 

Your patient is not eligible for meal packages. 

Please see the Community Referral Handout for 

more options. 

Is your patient older than 50? 

Yes No 

Your patient is not eligible for meal packages. 

Please see the Community Referral Handout for 

more options. 

* Please contact your inpatient dietitian for further evaluation if you have any questions or if you are unsure of patient eligibility. 

Provide this flowsheet to the dietitian and nutritional information for meal packages found on the back. 

Which Meal Package Plan? 

Patient has higher nutritional needs based on 

medical condition. This includes: 

-

-

-

COPD diagnosis 

Positive malnutrition risk screen or malnutrition 

diagnosis 

Order for dietary supplements 

Provide patient with the 

Enhanced Healing

Meal Package 

Patient has need for diabetes diet and/or 

heart-healthy diet OR has no dietary restrictions 

(regular diet order) 

Provide patient with the 

Carb-Controlled, Heart-Healthy 

Meal Package 

11
Lunch rinneD nacksS 1 saltTo

Carb-Controlled, Heart-Healthy 

Day 1 Day 2 Day 3 Day 4 Day 5 Day 6 

tsfaakerB Corn Flakes, Fruit Cup, Granola Bar, Milk 68g of Carbs Oatmeal, Granola Bar, Milk 46g of Carbs Cereal, Craisins, Milk 64g of Carbs Corn Flakes, Fruit Cup, Granola Bar, Milk 68g of Carbs Cereal, Fruit Cup, Milk 58g of Carbs Oatmeal, Granola Bar, Milk 46g of Carbs 

Crackers, Tuna, Tomato Soup, 

Mayo Packet 

45g of Carbs 

Pasta, Chicken, Green Bean Cup, Yogurt 

60g of Carbs 

Crackers, Peanut Butter 

33g of Carbs 

Rice & Quinoa, Corn Cup, Salsa, Protein Bar 

68g of Carbs 

Raisins, Chicken, Carrot Cup, Mayo 

Packet, Crackers 

48g of Carbs 

Fruit Snacks, Yogurt, Applesauce 

54g of Carbs 

Tuna, Corn Cup, Vegetable Soup, Crackers, Peanut Butter 

53g of Carbs 

Salmon, Pasta, Green Bean Cup, Mayo Packet 

45g of Carbs 

Fruit Cup, Yogurt, Granola Bar 

46g of Carbs 

Chicken, Crackers, Chicken Noodle Soup, Carrot Cup, Craisins 

57g of Carbs 

Pasta, Tuna, Green Bean Cup, 

Mayo Packet 

44g of Carbs 

Yogurt, Applesauce, Raisins 

57g of Carbs 

Crackers, Tuna, Tomato Soup, Peanut Butter 

56g of Carbs 

Chicken, Raisins, Crackers, Mayo Packet, Carrot Cup 

48g of Carbs 

Applesauce, Yogurt, Granola Bar 

49g of Carbs 

Rice & Quinoa, Vegetable Soup 

57g of Carbs 

Salmon, Pasta, Green Bean Cup, Mayo Packet 

45g of Carbs 

Yogurt, Fruit Snacks, Protein Bar 

51g of Carbs 

Kcal Pro Fat CHO Na+ K+ 1630 76 62 206 2035 1875 

g g g mg mg 

Kcal Pro Fat CHO Na+ K+ 1560 70 47 216 1850 1779 

g g g mg mg 

Kcal Pro Fat CHO Na+ K+ 1598 79 57 208 1890 2018 

g g g mg mg 

Kcal Pro Fat CHO Na+ K+ 1480 68 39 226 1855 1743 

g g g mg mg 

Kcal Pro Fat CHO Na+ K+ 1598 71 60 211 1685 2269 

g g g mg mg 

Kcal Pro Fat CHO Na+ K+ 1520 78 44 199 1545 1486 

g g g mg mg 

tsfakaerB

Enhanced Healing (high-protein, high-energy) 

Day 1 Day 2 Day 3 Day 4 Day 5 Day 6 Corn Flakes, Fruit Cup, Granola Bar, Milk 

Oatmeal, Craisins, Granola Bar, Milk 

Cereal, Craisins, Granola Bar, Milk Corn Flakes, Fruit Cup, Granola 

Bar, Milk 

Cereal, Fruit Cup, Granola Bar, Milk 

Oatmeal, Raisins, Granola Bar, Milk 

unchL

Tuna, Crackers, Tomato Soup, Mayo Packet 

Rice & Quinoa, Corn Cup, Salsa, 

Protein Bar 

Tuna, Corn Cup, Vegetable Soup, 

Crackers, Peanut Butter 

Chicken, Crackers, Chicken Noodle Soup 

Tuna, Crackers, Tomato Soup, Peanut butter 

Rice & Quinoa, Corn Cup, Vegetable Soup, Yogurt 

rneniD Pasta, Chicken, Green Bean Cup, Yogurt Chicken, Raisins, Crackers, Mayo Packet, Carrot Cup, Chocolate Milk Salmon, Mac & Cheese, Green Bean Cup Rice & Quinoa, Tuna, Green Bean Cup, Mayo Packet, Yogurt Chicken, Mac & Cheese, Carrot Cup Salmon, Pasta, Carrot Cup, Mayo Packet sacknS Pretzels, Peanut Butter, Chocolate Milk, Ensure, Protein Bar Pretzels, Peanut Butter, Ensure, Applesauce, Yogurt Fruit Cup, Yogurt, Protein Bar, Fruit Snacks, Ensure Applesauce, Ensure, Chocolate Milk, Protein Bar Fruit Snacks, Yogurt, Ensure, Applesauce, Protein Bar Fruit Cup, Ensure, Protein Bar, Crackers, Peanut Butter 

1 salotT Kcal Pro Fat CHO Na+ K+ 2430 123 75 334 2850 2789 

g g g mg mg 

Kcal Pro Fat CHO Na+ K+ 

2360 99 76 322 2740 2895 

g g g mg mg 

Kcal Pro Fat CHO Na+ K+ 2018 110 65 265 2565 2507 

g g g mg mg 

Kcal Pro Fat CHO Na+ K+ 1970 105 58 274 2270 2684 

g g g mg mg 

Kcal Pro Fat CHO Na+ K+ 2018 106 67 266 2365 2499 

g g g mg mg 

Kcal Pro Fat CHO Na+ K+ 2430 105 77 334 2465 2750 

g g g mg mg 

1Nutrition facts are estimates based on most accurate data and may not reflect the exact nutritional makeup of the meal packages. Days 1-3 and Days 4-6 are packaged together and a client may not eat everything in 

the exact order as described on this page. 
 

 

 

 

 

 

 

 

 

 

_____________________________________________________________________________ 

_____________________________________________________________________________ 

_____________________________________________________________________________ 

Appendix E: Maryland Discharge Meal Program Pilot: Acknowledgement & Authorization 

Purpose & Background 

The first two weeks following a discharge from a hospital are very important for recovery. Many patients are at 

high risk for poor nutrition and readmission to the hospital during this time. The Maryland Discharge Meal Pilot 

Program is intended to help smooth the transition from hospital to home and to improve the nutritional status of 

the patients selected by the participating hospital for the pilot. 

The Program includes 12 days of medically tailored, shelf-stable food paid for by the Maryland Department of 

Aging via a grant from the federal Administration for Community Living. The Maryland Food Bank assembles 

the food packs for the Program. The initial pack of food will be provided by the hospital upon discharge and the 

second pack of additional food will be available for pickup at a follow-up visit or delivered during a home visit. 

Participating individuals will be asked to reply to an anonymous client feedback survey. 

Not all patients are medically eligible for this meal program. Eligibility criteria is included in the Patient 

Selection Flowsheet. 

I understand, acknowledge, and agree that: 

1. I am receiving the initial food pack from the hospital discharging me, 

2. I will pick up (or if the hospital so provides, receive) the second pack, 

3. My discharging hospital has discussed this pilot program with me in detail and explained to me where I 

have to go and what I have to do to pick up the second pack, 

4. I have discussed the eligibility criteria and have disclosed any relevant information to the hospital, 

5. This program does not deal with emergency situations and if I need immediate help, I will call 911, 

6. This is a voluntary program, 

7. At any time, I have the right to revoke my consent to the release of information I have provided below, 

and that, in any event, my consent will expire one year from the date I sign this acknowledgement, and 

8. There is no cost to participate, but the food provided is for my consumption alone and must not be given 

or sold to others. 

Client Authorization for Release of Information 

I consent to: 

1. The hospital contacting me in person, by telephone, or by mail for a follow up feedback survey, 

2. The hospital sending the results of the survey in an anonymous* fashion so that my identity is not 

disclosed, to the Maryland Department of Aging, 

3. My discharging hospital sharing certain anonymous* information with the Maryland Department of Aging 

so the Department can know what food packs have been provided by hospitals and been picked up by 

participants, and 

4. My discharging hospital sharing certain health information developed by the hospital with the University 

of Maryland St. Joseph Medical Center so the effectiveness of the pilot can be evaluated. 

*Anonymous means no personally identifying information, such as name or address, is reported and all data is 

reported in a summary format so no individual can be identified. 

I have read this and understand it. If there were parts I did not understand, I asked questions and had it explained 

to me. 

Name of Patient (Printed) 

Signature of Patient Date 

Name of Discharging Hospital 

13 
 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

Appendix F: Community Referral Handout 

If you need food or other support.... 

Have you applied for SNAP? 

 “SNAP” stands for “Supplemental Nutrition Assistance

Program” - formerly known as food stamps. SNAP is a

government program. You can apply directly to the

state or get help with your application. The Maryland

State Information/ Hotline Number is 1-800-332-6347.

 Maryland Food Bank has a SNAP Outreach Team that

can help with your application. Phone toll-free 1-888-

808-7327, Monday-Friday 8am to 5pm.

These 

resources 

may help! 

Area Agencies on Aging provide a wide array of services to 

people 60 or older, including hot or cold home-delivered meals 

and group dining (senior center meals). To get connected with 

your local Area Agency on Aging, call the Maryland Department 

of Aging at 410-767-1100. 

Maryland Acccess Point (MAP) is a onestop source of information and assistance for 

long term services and supports. These include...

• Information on health

• Transportation

• Income and financial aid

• Senior and community centers and clubs

• Nutrition and meals

• Pharmacy assistance

• Housing

• Volunteer opportunities

• And more!

Get connected by calling 1-844-627-5465 or go 

to www.MarylandAccessPoint.info 

Grant funds from the Administration for Community Living (ACL) and the Maryland Department 

of Aging assisted in the development in this material. Points of view or opinions contained 

herein are those of the authors and do not necessarily represented the official position or 

policies of the ACL or Department. 

14
These 

resources 

may help!

If you need food or other support....

Food Pantries want to help. 

To find a food pantry in your area: 

1. Go to the Maryland Food Bank website https://mdfoodbank.org

2. Click on the words “Find Food” in the top right-hand corner.

3. Scroll down, then click inside the grey box below the words “Address or Zip Code”

4. Enter your address or zip code, select the “within” miles and click on “Submit”

These 

resources 

may help! 

Other services can help by easing emotional or 

financial burdens in other parts of your life. 

The United Way has a free, confidential information and 

referral service. 

To get help, call 2-1-1, 24 hours a day, 7 days a 

week. 

If you can’t reach them by calling 2-1-1, use 

these numbers: 

• Greater Baltimore: 410-685-0525

Elsewhere in Maryland 1-800-492-

0618 

TTY (for hearing impaired) 410-685-

2159 (weekdays 8:30am-4:45pm). 

You can also go to the website 

www.211md.org 

•

•

•

15
What’s in your

Bag? Day 1 Breakfast 

Corn Flakes, Mixed Fruit Cup, PB & Dark Chocolate 

Granola Bar, Lowfat Milk 

Lunch 

Tuna, Classic Tomato Soup, Wheat Crackers, 

Mayonnaise To-Go 

Dinner 

Barilla Pasta (1/2 bag), Premium Chicken (1/2 

can), Green Beans, Blended Yogurt 

Snacks 

Wheat Crackers, Natural Peanut Butter 

Day 2 Breakfast 

Quaker Oatmeal, PB & Dark Chocolate Granola Bar, 

Lowfat Milk 

Lunch 

Brown Rice & Quinoa, Sweet Corn, Picante Sauce, 

Chocolate Deluxe Protein Bar 

Dinner 

Premium Chicken (1/2 can), Raisins, Diced Carrots, 

Mayonnaise To-Go, Wheat Crackers 

Snacks 

Fruit Snacks, Blended Yogurt, Applesauce 

Day 3 Breakfast 

Mini Wheats, Craisins, Lowfat Milk 

Lunch 

Tuna, Sweet Corn, Hearty Vegetable Soup, Wheat 

Crackers, Natural Peanut Butter 

Dinner 

Pink Salmon, Barilla Pasta (1/2 bag), Green Beans, 

Mayonnaise To-Go 

Snacks 

Mixed Fruit Cup, Blended Yogurt, PB & Dark 

Chocolate Granola Bar 

Nutritional Content 

Carbohydrates 

190 – 220 grams per day 

45 – 70 grams per meal 

15 – 25 grams per snack 

Sodium 

1500 – 2000 mg/day 

A Carb-Controlled, Heart-Healthy Meal Packages 16
What’s in your 

Bag? Day 1 Breakfast 

Corn Flakes, Mixed Fruit Cup, PB & Dark Chocolate 

Granola Bar, Lowfat Milk 

Lunch 

Premium Chicken (1/2 can), Wheat Crackers, 

Hearty Chicken Noodle Soup, Diced Carrots, Craisins 

Dinner 

Barilla Pasta (1/2 bag), Tuna, Green Beans, 

Mayonnaise To-Go 

Snacks 

Blended Yogurt, Applesauce, Raisins 

Day 2 Breakfast 

Mini Wheats, Mixed Fruit Cup, Lowfat Milk 

Lunch 

Tuna, Classic Tomato Soup, Wheat Crackers, 

Natural Peanut Butter 

Dinner 

Premium Chicken (1/2 can), Wheat Crackers, 

Raisins, Mayonnaise To-Go, Diced Carrots 

Snacks 

Applesauce, Blended Yogurt, PB & Dark Chocolate 

Granola Bar 

Day 3 Breakfast 

Quaker Oatmeal, PB & Dark Chocolate Granola Bar, 

Lowfat Milk 

Lunch 

Brown Rice & Quinoa, Hearty Vegetable Soup 

Dinner 

Pink Salmon, Barilla Pasta (1/2 bag), Green Beans, 

Mayonnaise To-Go 

Snacks 

Blended Yogurt, Fruit Snacks, Chocolate Deluxe 

Protein Bar 

Nutritional Content

Carbohydrates 

190 – 220 grams per day 

45 – 70 grams per meal 

15 – 25 grams per snack 

Sodium 

1500 – 2000 mg/day 

B Carb-Controlled, Heart-Healthy Meal Packages 17
Carb-Controlled, Heart-Healthy 

Meal Packages 

The Carb-Controlled, Heart Healthy meal package is designed to 

provide you with the food you need to help you recover after your 

visit to the hospital. 

Balanced carbohydrates 

Carbohydrates (carbs) from the food you eat effect 

your blood sugar. These meals and snacks are 

balanced with the right amount of carbs to keep 

your blood sugar under control throughout the 

day. 

Pro Tip 

Be sure not to add any salt to 

these foods. Try other 

seasonings, like garlic powder, 

dried herbs, Mrs. Dash SaltFree seasoning, or other saltfree seasonings. 

Low salt 

Getting too much sodium 

(salt) can raise your blood 

pressure and be bad for your 

heart health. These meals 

are low in salt to keep your 

heart healthy and your blood 

pressure under control. 

Picture source: 

http://www.mrsdash.com/products/seasoningblends/%C2%AE-original-blend Easy to prepare 

These foods were chosen because they are singleserve, easy to prepare, and can be kept at room 

temperature for up to six months. 

We want you to stay healthy once you leave the 

hospital. Enjoy these foods on us! 

In addition to these meal packages, you may also need: 

Water, bowls & plates, forks, knives & spoons, can opener, microwave, scissors 

Grant funds from the Administration for Community Living (ACL), Grant Number 90INNU0002 and the Maryland Department of Aging assisted in the development 

of this material. Its contents are solely the responsibility of the authors and do not necessarily represent the official views of the ACL or Department. 

18
What’s in your 

Bag? Day 1 Breakfast

Corn Flakes, Mixed Fruit Cup, PB & Dark Chocolate 

Granola Bar, Lowfat Milk 

Lunch

Wheat Crackers, Tuna, Classic Tomato Soup, 

Mayonnaise To-Go 

Dinner

Barilla Pasta, Premium Chicken (1/2 can), Green 

Beans, Blended Yogurt 

Snacks

Pretzels, Natural Peanut Butter, Chocolate Milk, 

Ensure Shake, Deluxe Chocolate Protein Bar 

Day 2 

Breakfast

Quaker Oatmeal, Craisins, PB & Dark Chocolate 

Granola Bar, Lowfat Milk 

Lunch

Brown Rice & Quinoa, Sweet Corn, Picante Sauce, 

Deluxe Chocolate Protein Bar 

Dinner

Wheat Crackers, Premium Chicken (1/2 can), 

Raisins, Diced Carrots, Mayonnaise To-Go, 

Chocolate Milk 

Snacks

Pretzels, Natural Peanut Butter, Ensure Shake, 

Applesauce, Blended Yogurt 

Day 3 Breakfast

Mini Wheats, Craisins, PB & Dark Chocolate Granola 

Bar, Lowfat Milk 

Lunch

Tuna, Sweet Corn, Hearty Vegetable Soup, Wheat 

Crackers, Natural Peanut Butter 

Dinner

Pink Salmon, Mac & Cheese, Green Beans 

Snacks

Mixed Fruit Cup, Blended Yogurt, Deluxe Chocolate 

Protein Bar, Fruit Snacks, Ensure Shake 

A Enhanced Healing Meal Packages 

19
What’s in your 

Bag? Day 1 Breakfast

Corn Flakes, Mixed Fruit Cup, PB & Dark Chocolate 

Granola Bar, Lowfat Milk 

Lunch

Premium Chicken (1/2 can), Wheat Crackers, 

Hearty Chicken Noodle Soup 

Dinner

Brown Rice & Quinoa, Tuna, Green Beans, Blended 

Yogurt, Mayonnaise To-Go 

Snacks

Ensure Shake, Applesauce, Deluxe Chocolate Protein 

Bar, Chocolate Milk 

Day 2 Breakfast

Mini Wheats, Mixed Fruit Cup, PB & Dark Chocolate 

Granola Bar, Lowfat Milk 

Lunch

Tuna, Classic Tomato Soup, Wheat Crackers, 

Natural Peanut Butter 

Dinner

Premium Chicken (1/2 can), Mac & Cheese, Diced 

Carrots 

Snacks

Fruit Snacks, Blended Yogurt, Deluxe Chocolate 

Protein Bar, Applesauce, Ensure Shake 

Day 3 

Breakfast

Quaker Oatmeal, Raisins, PB & Dark Chocolate 

Granola Bar, Lowfat Milk 

Lunch

Brown Rice & Quinoa, Sweet Corn, Hearty Vegetable 

Soup, Blended Yogurt 

Dinner

Pink Salmon, Barilla Pasta, Diced Carrots, 

Mayonnaise To-Go 

Snacks

Mixed Fruit Cup, Ensure Shake , Deluxe Chocolate 

Protein Bar, Wheat Crackers, Natural Peanut Butter 

B Enhanced Healing Meal Packages 20
Enhanced Healing 

Meal Packages 

The Enhanced Healing meal package is designed to provide you 

with the food you need to help you recover and stay strong after 

your visit to the hospital. 

High protein 

Protein helps keep your immune system strong, 

keep you from losing muscle, and helps wounds to 

heal. These foods give you enough protein to keep 

your muscles strong and to help you heal and 

recover after your hospital stay. 

High energy 

Eating a balanced diet and getting enough energy 

from your food is very important when you’re 

recovering. It can be hard to get enough to eat 

when you are sick, so these foods give you more 

energy in every bite. 

Easy to prepare 

These foods were chosen because they are singleserve, easy to prepare, and can be kept at room 

temperature for up to six months. 

We want you to stay healthy once you leave the 

hospital. Enjoy these foods on us! 

In addition to these meal packages, you may also need: 

Water, bowls & plates, forks, knives & spoons, can opener, microwave, scissors 

Grant funds from the Administration for Community Living (ACL), Grant Number 90INNU0002 and the Maryland Department of Aging assisted in the development 

of this material. Its contents are solely the responsibility of the authors and do not necessarily represent the official views of the ACL or Department. 

21
Appendix H: Maryland Discharge Meal Program Pilot: Feedback Survey 

INFORMATION FOR SURVEY ADMINISTOR 

(NOT TO BE SHARED WITH PATIENT) 

PURPOSE/BACKGROUND: 

 The purpose of this survey is to collect feedback from clients participating in the Maryland

Discharge Meal Program (MDMP) pilot in order to improve the program for future clients.

 The surveys are anonymous and administered in the following order of preference:

1) in person

2) by telephone. If these attempts are unsuccessful, then

3) by mail.

 Document both successful and unsuccessful survey administration contacts on the MDMP

tracking form.

 Do not indicate patient’s name or any personal information on the forms.

 The hospital MDMP coordinator will ensure proper tracking of the surveys and will fax

groups of completed surveys by the 5th business day of each month to the Maryland

Department of Aging FAX, to the attention of Laura Sena at 410-333-7943.

INSTRUCTIONS FOR SURVEY ADMINISTRATION: 

STEP 1: 

Administer survey verbally face-to-face (if possible) at or around day 13 post-admission. 

Document patient’s responses on the attached form. 

STEP 2: 

If in-person administration is not possible, call the patient to administer the feedback survey 

verbally by telephone at or around day 13 post-discharge and document his/her responses on 

the attached form. If calls are unsuccessful, attempt twice more before day 30 post-discharge. 

STEP 3: 

If 3 phone call attempts do not succeed by day 30 post-discharge, send paper survey along 

with a stamped return envelope addressed to the Maryland Department of Aging with 

instructions to return within 2 weeks of receiving to: 

Laura Sena, Innovations in Nutrition Programs 

Maryland Department of Aging 

301 W. Preston Street, Suite 1007 

Baltimore, MD 21201 

22 
Appendix H: Maryland Discharge Meal Program Pilot: Feedback Survey 

THIS PAGE INTENTIONALLY LEFT BLANK 

23 
 

Appendix H: Maryland Discharge Meal Program Pilot: Feedback Survey 

This survey contains questions about the meal packages that you received from the Maryland 

Discharge Meal Program Pilot. Your answers will be kept confidential. For this set of questions, 

we would like you to think about how the meals may have helped you, compared with how you 

might have felt if you didn’t receive them. Do you feel the meal packages...

1. Helped you recover after being in the hospital? 

□ Yes 

□ No 

2. Kept you from losing weight? 

□ Yes 

□ No 

3. Helped you manage your health condition (for example, hypertension, diabetes, etc.)? 

□ Yes 

□ No 

4. Provided you with food that you wouldn’t have otherwise been able to buy or shop for?

□ Yes 

□ No 

5. Provided you with something to eat when you had difficulty preparing your own meals? 

□ Yes 

□ No 

6. Helped you eat healthier food? 

□ Yes 

□ No 

7. Considering all the meal packages combined, how much of the food did you eat? 

□ 1⁄4 or less 

□ 1⁄2 or less 

□ 3⁄4 or less 

□ Almost all 

8. Do you feel the foods met your nutritional needs based on your health condition? 

□ Yes 

□ No 

□ If yes, how? ____________________________ 

□ If no, why not? ____________________________ 

9. Of the foods you received, what were your top 3 favorites? 

1) _____________________________ 

2) _____________________________ 

3) _____________________________ 

24 
 

Appendix H: Maryland Discharge Meal Program Pilot: Feedback Survey 

10. Of the foods you received, what were your 3 least favorite? 

1) _____________________________ 

2) _____________________________ 

3) _____________________________ 

11. Did you have any trouble opening the food packages? 

□ Yes 

□ No 

□ If yes, which ones? ____________________________ 

12. Was it easy to get the meal packages home from your hospital discharge and follow-up 

visit (if applicable)? 

□ Yes 

□ No 

□ If no, please describe any issues. ____________________________ 

13. Did the second meal package make it more likely for you to attend your follow-up visit? 

□ Yes 

□ No 

□ Not applicable 

14. Did you find the “What’s in Your Bag?” menus provided helpful?

□ Yes 

□ No 

□ If no, why not? ____________________________ 

15. Did the pilot program help you connect to organization(s) that provide wellness, meals, 

financial, housing, caregiver supports (or similar services)? 

□ Yes 

□ No 

□ If yes, what organization(s)? ____________________________ 

16. Did the pilot program help you connect to program(s) that can help you eat better, like 

senior centers, food pantries, SNAP, etc.? 

□ Yes 

□ No 

□ If yes, what program(s)? _______________________________ 

IF YOU RECEIVED THIS SURVEY BY MAIL, PLEASE PLACE YOUR COMPLETED 

FORM IN THE ENVELOPE PROVIDED AND MAIL BACK PROMPTLY. 

THANK YOU! WE APPRECIATE YOUR FEEDBACK! 

Date Survey Completed: _____________________________ 

25 
9 

Post-Discharge Meal 

Distribution Programs 

Report

Comprehensive review of meal package programs 

including the Maryland Discharge Meal Program.
Post-Discharge Meal 

Distribution Programs

Bethesda NEWtrition and Wellness Solutions 

Developed for the Maryland Department of Aging 

MAY 2019 

Grant funds from the Administration for Community Living (ACL), Grant Number 90INNU0002-02-01 and the Maryland Department 

of Aging assisted in the development in this material. Its contents are solely the responsibility of the authors and do not necessarily 

represent the official position or policies of the ACL or Department. 
Table of Contents 

Introduction ..................................................................................................................................................2

Background ...............................................................................................................................................2

About the Maryland Discharge Meal Program (MDMP) ..........................................................................2

Purpose of this Report..............................................................................................................................3

Literature & Program Review........................................................................................................................3

Review of Post-Discharge Meal Programs, Literature, Insurance Company Initiatives, and Other Similar 

Programs...................................................................................................................................................3

Impact on the MDMP..................................................................................................................................13

Meal Packages.........................................................................................................................................13

Educational Materials.............................................................................................................................13

Target Population ...................................................................................................................................14

Other Impacts & Considerations.............................................................................................................14

Continual Network Support and Feedback..................................................................................................15

Slack Network .........................................................................................................................................15

Quarterly Phone Meetings......................................................................................................................15

Conclusion and Acknowledgements............................................................................................................15

References...................................................................................................................................................16

Appendix A: Sample Menus.........................................................................................................................20

Appendix B: Sample Educational Material...................................................................................................22

Appendix C: Sample Workflow....................................................................................................................23

Appendix D: Sample Referral Form .............................................................................................................24
Introduction 

Background

Seniors leaving the hospital at risk for malnutrition have a higher rate of readmission and death. Some

studies estimate that as many as 30% of hospitalized patients may be malnourished at the time of their 

admission (Sharma et al., 2017) and as many as 49% of older adults are malnourished after discharge. 

(Buys et al., 2017) A recent study conducted by Sharma et al has shown that impaired nutrition status 

upon discharge can increase the incidence of readmission to the hospital both in the short-term (0-7 

days) and the longer-term (8-180 days) post discharge. (Sharma et al., 2017)

As the US population gets increasingly older, addressing senior malnutrition is becoming more of a 

priority. The number of Americans aged 65 and older is expected to almost double by 2050 to 88 million

(“World’s older population grows dramatically | National Institutes of Health (NIH),” n.d.) and those 85 

and older are projected to more than double by 2040 to 14.6 million. (Administration on Aging, 2017)

About the Maryland Discharge Meal Program (MDMP)

The Maryland Discharge Meal Program (MDMP) is part of an initiative put forward by the Maryland 

Department of Aging (MDoA). The program is funded by an Innovations in Nutrition Programs and 

Services grant from the Federal Administration for Community Living. The goal of the grant project is: to 

transform the Maryland Department of Aging’s Senior Nutrition Program (SNP) by using the epidemic of 

older adult malnutrition as the catalyst to introduce new evidence-based practices, cost-cutting 

measures, meal products, and service delivery methods that will forge new health care linkages and 

expand services to older adults in the community. (language from grant application)

The MDMP is a pilot that will provide shelf-stable, medically-tailored meals to 200 seniors being 

discharged from four hospitals in Maryland. The program partnered with Maryland Food Bank, which 

was responsible for purchasing, packaging, and distributing meal packages to the pilot hospitals. 

Hospital staff will then distribute the meal packages to patients leaving the hospital who meet the 

criteria for the program. Potential participants will be screened for eligibility based on their age, 

medical condition(s), and risk for malnutrition upon leaving the hospital. The pilot program will

particularly focus on addressing malnutrition risk associated with chronic conditions that have been 

identified as having high readmission rates for these particular hospitals.

A participant will receive one of two medically-tailored meal packages based on their medical needs. 

For this pilot, two types of meal packages are included. The Carb-Controlled, Heart-Healthy (CC/HH)

meal package is low in sodium, meets the DRI for macronutrients (protein, fat, and carbohydrates), and 

evenly distributes carbohydrates between meals and snacks. The CC/HH packages are intended to be 

used for participants with diabetes mellitus, hypertension, and/or congestive heart failure. The 

Enhanced Healing (EH) meal package is higher in protein and calories and has no restrictions on sodium, 

carbohydrates or fat. The EH package is intended to be used for participants who have higher energy 

needs due to their medical condition, such as chronic obstructive pulmonary disease. Table I, below,

contains a more specific nutritional summary.
Table I: Nutritional summary of MDMP meal packages

Meal package type Nutrition data (ranges)

Calories Carbohydrates Fat Protein Sodium

Carb-Controlled, 

Heart-Healthy 

(CC/HH)

1500 – 1700 per day 45-55% of total 

calories per day

 190 – 220 grams 

per day

 45 – 70 grams 

per meal

 15 – 25 grams 

per snack

25-33% of total 

calories per day

18% - 20% of total 

calories per day

Under 2,000 mg 

per day

Enhanced Healing (EH) 1900 – 2500 per day No restrictions No restrictions Over 100 grams per 

day

No restrictions

Purpose of this Report

With increased awareness of the impact of malnutrition on older adults, several initiatives to address 

this area of concern have been underway both in the US and abroad. Meal distribution programs similar 

to the MDMP have provided insight into processes, ideas, and potential collaborations that have been 

tried—both successfully and unsuccessfully—in the past. Takeaways from these programs informed the 

development of the MDMP. A review of relevant literature and similar programs/initiatives and their 

takeaways are profiled in the following pages. For each program reviewed, this report includes a 

compilation of costs and distribution methodology and what each program may do to ensure meals are 

culturally appropriate, person-centered, or medically-tailored.

Literature & Program Review 

Community and government programs have taken initiatives to tackle senior malnutrition using 

innovative care models and nutrition programs. Meals on Wheels America (“Meals on Wheels 

America,” n.d.) is one program that has been delivering meals to people’s homes for generations, 

however newer local initiatives are also underway. Table II, below, is a review of some of the programs 

that have informed the MDMP initiative.

Review of Post-Discharge Meal Programs, Literature, Insurance Company Initiatives, and 

Other Similar Programs

The MDMP is unique in that it targets all seniors who have nutritional risk regardless of socioeconomic 

status. Several programs in the US provide meals specifically for low-income individuals, such as home 

delivered meals provided through Medicaid or the Commodity Supplemental Food Program (CSFP)

(“Commodity Supplemental Food Program (CSFP) | Food and Nutrition Service,” n.d.). Additional 

programs serve older adults of any income but target those with economic or social needs, including the 

Older American’s Act congregate and home delivered meal programs (Administration for Community 

Living & Administration on Aging, 2014). While there is clearly a need to specifically address low-income 

seniors, malnutrition risk for seniors impacts all socioeconomic levels and therefore the MDMP does not 

have an income criteria for inclusion..

Programs reviewed here have a variety of goals and objectives, all centered around addressing high 

hospital admission and readmission rates, similar to the goals of the MDMP. For example, the Food is 

Medicine Coalition of California (CalFIMC) is specifically targeting adults suffering from congestive heart 

failure who they determined are at highest risk of hospital readmission and worsening health outcomes.
(Trust & Food, 2017) The Philadelphia MANNA project is targeting adults with AIDS or other chronic 

illness that puts them at high nutritional risk. And Flavor Harvest @Home provides their meal services 

for community members or recently discharged patients who have specific chronic conditions. Other 

programs only have an age requirement for eligibility, not subject to medical condition.

The types of meals offered by these programs vary widely, and some programs offer a variety of 

different meal types depending on the need of the participant. The MDMP meals are unique in that 

they are entirely shelf-stable. Only a few other programs have focused specifically on shelf-stable 

meals. One such program is the Metropolitan Interfaith Association (MIFA) No Hungry Senior program, 

which provided 7 shelf-stable meals to seniors who were deemed capable of light meal preparation. 

Maintaining Active Citizens’ Maryland Malnutrition Model (MDMM) offers shelf-stable emergency food 

bags and shelf-stable snack bags.

Table II: Review of programs and literature similar to MDMP

Food Is Medicine Coalition of California (CalFIMC)

Overview Coalition of meal providers in California; first multi-county and multi-organization study of this kind in the US; 

members include: Ceres Community Project, Food for Thought, The Health Trust, Mama’s Kitchen, Project Angel 

Food, and Project Open Hand.

Goals To reduce hospital and emergency department 30-day and 90-day readmissions, to show the cost-effectiveness of 

including medically-tailored meals as part of Medi-Cal covered benefits, and to inform California policy.

Funding Source(s) Funded by Senate Bill 97 passed in June of 2017, approved by Governor Jerry Brown and the California Legislature 

that provides $6 million for a 3-year project period.

Target Population Medi-Cal insurance beneficiaries who have a diagnosis of congestive heart failure (CHF) and have been discharged 

from an inpatient stay (at a hospital, emergency department or skilled nursing facility) resulting from exacerbation 

of CHF. Approximately 1,000 patients to be included. Patients need to be able to refrigerate and re-heat foods.

Meal Types Medically-tailored meals approved by a Registered Dietitian Nutritionist (RDN) that follow evidence-based practice 

guidelines. Meals are recommended based on a nutritional assessment or healthcare provider recommendations. 

3 meals per day are provided for 12 weeks.

Multi-organization and multi-county project—each of the organizations is familiar with the needs and cultural 

preferences of their target population.

Outcomes The Cal FIMC is an ongoing project (began in 2018), so outcomes are not available yet. Outcomes will be measured 

using data collected from Medi-Cal utilization and claims data. Outcomes include changes in hemoglobin A1C, 

health care utilization (ex: emergency department visits), skilled nursing use, readmissions, overall costs of care, 

and other measures.

Costs Costs range, for example Mama’s Kitchen was $2.92 per meal.

Distribution 

Methodology

The multi-centered approach allows for a wide distribution of services to multiple counties in California. This 

project specifically works with Medi-Cal recipients, but is intended to stand as an example that other projects can 

imitate.

Sources (Food et al., n.d.), (Medi-Cal Medically Tailored Meal Pilot Project, 1996), (Medicine, n.d.), (Food is Medicine 

Coalition (FIMC), 2018), (Free / Medi-Cal Covered Medically Tailored Meals and Medical Nutrition Therapy for 

Discharged CHF Patients Scope of Intervention How to Refer, n.d.)

MANNA (Philadelphia)

Overview MANNA began as a church-affiliated meal delivery program for Philadelphia residents with AIDS. MANNA expanded 

its services to anyone at nutritional risk due to critical illness in 2006. The program includes medically-tailored, inhouse cooked meals and nutritional counselling.

Goals Providing nourishment to critically ill neighbors.

Funding Source(s) MANNA is a non-profit organization funded by donations from individuals, foundations and corporations, special 

events, and insurance coverage for some services. 

Target Population Residents of Philadelphia suffering from AIDS and other critical illness at risk for undernutrition and isolation.

“MANNA clients must currently be battling or in care for a serious illness and, due to that illness, are at acute 

nutritional risk. Some nutrition indicators include:

 Recent unintentional weight loss
 Recent, extended hospitalization

 Start of new medical treatment (ex. chemotherapy, radiation, or hemodialysis)

 Recovery from surgery

 Wound care” (“Apply for MANNA Services - MANNA,” n.d.-a) (Apply for MANNA Services, n.d.)

Meal Types Fully-prepared, frozen meals, delivered once a week: 7 breakfasts, 7 lunches, 7 dinners, desserts, and fresh fruit. 

Meals are high in protein, and moderate in carbohydrate, sodium and fat. Offers 11 different dietary 

modifications, including kidney friendly (low potassium low phosphorous, low sodium), diabetic/heart healthy 

(carbohydrate and sodium controlled), low lactose, GI friendly (low fiber, mild spice), no pork, no beef, no seafood, 

mechanical soft, pureed, high protein/high calorie, and children’s menu. Adaptations for personal or religious 

requirements. Can combine up to 3 modifications.

Outcomes MANNA patients who received medically-tailored meals and medical nutrition therapy (MNT) experienced 50% 

fewer hospital admissions, were 23% more likely to be discharged to their homes rather than another facility, and 

had 28% lower monthly health care costs. 

Costs ~$4.40 per meal.

For the 2017 fiscal year MANNA spent $4,390,043 on meals and services. In their IRS Form 990, MANNA reported 

serving 995,270 meals in FY 2017. This comes to about $4.40 per meal.

Distribution 

Methodology

Meals are provided for the greater Philadelphia area, participants are referred to the program.

Sources (“Apply for MANNA Services - MANNA,” n.d.-b), (Mccarron, 2017), (Gurvey et al., 2013), (Daugherty, HoskinsBrown, & Laverty, n.d.), (MANNA, 2017)

Southern Maine Agency on Aging (SMAA) – Simply Delivered Meals Pilot Study

Overview This agency is focused on improving social determinants of health by providing corresponding services and support. 

SMAA conducted a 2-year pilot of home delivered meals with 622 patients at high risk of readmission called 

“Simply Delivered Meals” in affiliation with Maine Medical Center.

Goals Reducing 30-day readmission rates post-acute care. Improving emergency department usage and hospital 

admission rates.

Funding Source(s) Hospital partners and grant funding.

Target Population Elderly and Medicare patients (for pilot study).

Meal Types Meals are frozen, prepared and no bread or milk is given. No information indicates that meals were tailored to be 

culturally appropriate beyond the different varieties of meals (i.e. vegetarian, gluten-free). Meals were given based 

on indicated preferences and diagnosis. Meals were specialized (e.g. vegetarian, pureed, regular, gluten free, low 

sodium, diabetic, renal, other/allergies) and could be packaged to meet multiple needs.

Outcomes The 2-year pilot conducted at SMAA demonstrated a 387% return on investment, and a 2-point reduction in 

admission rates. The pilot provided a minimum of 7 meals, with the option to join Meals on Wheels at the end of 

the 7-day period.

Costs ~$7 per meal.

For the pilot study, the costs of providing 7 meals to 622 patients was $43,530. 

Distribution 

Methodology

The pilot was limited to hospital patients being discharged from Maine Medical Center.

Sources (Martin, Connelly, Parsons, & Blackstone, 2018b), (Martin, Connelly, Parsons, & Blackstone, 2018a), (“Order Simply 

Delivered Meals,” n.d.), (“Southern Maine Agency on Aging,” n.d.), (“SMAA/MMC Simply Delivered Meals (SDM) 

Pilot,” n.d.), (Braveman, n.d.)

Flavor Harvest @Home

Overview This project was an extension of an existing intervention at Lee Health in Southwest Florida into the primary care 

setting. Dietitians were trained to identify malnutrition risk in a primary care setting and patients who were at-risk 

received 4 weeks of medically-tailored meals along with a clinical dietetic consultation.

Goals Improvement in long-term health status (reduced hospital length of stay, lower readmission rates, improved 

reimbursement opportunities, reduced operational costs) and quicker recovery for recently discharged patients.

Improved clinical status was indicated by measures such as weight gain, grip strength, and functional status.

Funding Source(s) Grants from Bank of America and The Allen Foundation funded the meals. Funding was for 2 years and supported 

60 patients.

Target Population Patients being discharged from Cape Coral Hospital and Gulf Coast Medical Center that were identified as at-risk for 

malnutrition. Specifically targeting frail elderly patients with chronic conditions (especially congestive heart failure, 

chronic obstructive pulmonary disease, acute myocardial infarction, or pneumonia).
Meal Types Meal options were individualized and approved by a RDN based on the patient’s medical condition. Meals were 

provided for a 7-day period and included 3 meals per day and snacks. Meals were a mix of fresh produce, shelfstable items and frozen prepared meals.

Outcomes Patients participating in the program were found to have a reduced length of stay in the hospital, improved fluid 

status and strength, and reduced readmission rates.

Costs ~$10 per meal.

The program estimated that meals would cost an average of $840 per person for 4 weeks. Based on 3 meals per 

day for 28 days, the cost came to about $10 per meal.

Distribution 

Methodology

Patients eligible for this program were identified from two area hospitals (Cape Coral Hospital and Gulf Coast 

Medical Center) using the Flavor Harvest Assessment Screening Tool (FHAST) and a physical exam to identify 

malnutrition risk. After discharge, Flavor Harvest @Home coordinated the home delivery of meals, using their 

existing vehicle delivery structure.

Sources (“Flavor Harvest@HOME - AARP Foundation,” n.d.), (Flavor-Harvest-at-HOME.pdf, n.d.), (“Lee Health – Flavor 

Harvest@Home | AHA,” n.d.)

Maintaining Active Citizens Maryland’s Malnutrition Model (MDMM)

Overview Maintaining Active Citizens (MAC) is the Area Agency on Aging (AAA) in Salisbury, MD, and serves surrounding 

counties. Clients receive home visits to establish them for home nutrition services and then are screened for 

malnutrition risk, food insecurity, and other social determinants of health. Appropriate interventions are put into 

place based on areas of concern identified in the screening and the client is followed by a community health 

worker through home visits and follow up calls. Meal packages are provided based on malnutrition and food 

security risk, and also can be given as “emergency” bags when recently discharged from the hospital.

Goals Collaborative and encompassing approach to combat malnutrition.

Funding Source(s) Grant funding.

Target Population Seniors at-risk for malnutrition. 

Meal Types The program offers different types of meals based on client needs. There are fresh fully-prepared meals, soups, 

shelf-stable emergency food bags, and shelf-stable snack bags. Meal bags were designed with input from 

community members about what would be acceptable to members of the population being served. The RDN meets 

with each participant to determine the best meal package plan for that person. Food items in the meal packages 

are low in sodium, fat, and added sugar, and are high in fiber. All meals meet the nutritional standards set by the 

Maryland Department of Aging and provide one-third of the RDI for older adults and 30 grams of protein.

Outcomes Project is still underway.

Costs ~$3 per meal.

Emergency meal bags provide meals for about $3 per meal, coming to about $10 per bag (three meals).

Distribution 

Methodology

MAC is responsible for packaging and distributing the meal packages to participants homes.

Sources (Simon, Beardsley, Davidson, Lachenmayr, & Eagle, 2018)

Metropolitan Interfaith Association (MIFA) No Hungry Senior

Overview The Metropolitan Inter-Faith Association (MIFA) serves the Memphis, Tennessee metropolitan area with programs 

for seniors and families. In 2014 MIFA initiated the No Hungry Senior program in partnership with the Aging 

Commission of the Mid-South (ACMS), Mid-South Food Bank, Catholic Charities of West Tennessee, the Memphis 

Jewish Federation, the Common Table Health Alliance, Baptist Memorial Health Care, and Methodist Le Bonheur 

Healthcare. The program began with a pilot in 2014 with 20 clients and was expanded to 35 in 2015 with the 

receipt of a new grant from the H. W. Durham Foundation.

Goals The goals of the program are to reduce the number of food-insecure seniors in Shelby County, improve and

maintain seniors’ overall health, and reduce hospitalizations and emergency room utilization.

Funding Source(s) Initially, a three-year, $3.98 million grant from the Plough Foundation funded the program. A subsequent $50,000 

grant came from the H. W. Durham Foundation for FY2015. Funding also came from the Wal-Mart Foundation and 

the Jewish Federations.

Target Population Shelby County residents in Tennessee, 60 years or older. Specifically focusing on those that are homebound, 

recently discharged from hospitals, or particularly challenged by a lack of transportation. Clients were identified 

from the agency’s Meals on Wheels waiting list.

Meal Types  5 home delivered hot/frozen meals delivered M-F by MIFA (for highest need clients)

 7 shelf-stable meal box delivered weekly by MIFA and Catholic Charities (for those who can do some light 

meal preparation)

 5 home delivered hot/frozen kosher meals per week provided by Memphis Jewish Federation
 7 shelf-stable meal box given at discharge by Baptist Memorial Health Care and Methodist Le Bonheur 

Healthcare

Outcomes Outcomes from 1-year post-enrollment compared with 1-year pre-enrollment found an overall reduction of 

healthcare utilization, including a 34% reduction in inpatient admissions. Participants also experienced a significant 

reduction in feelings of loneliness. There was also a high acceptability of the food and meals.

Some of the lessons learned from this program were:

 Food waste was an issue; the quantity of food delivered was sometimes too much for the seniors to consume.

 The Food Bank had difficulty sourcing low sugar and low salt foods that fit into their meal plans because they 

were high cost and harder to find.

 Effective communication with collaborators required having a dedicated point of contact/team.

 Having a 6-month planning period and regular meetings with project partners lead to greater success with 

project implementation.

Costs ~$7 per meal.

Average cost per client (including food costs, delivery, admin) came to less than $7 per day ($1,800 per client per 

year, one meal per day). 

Distribution 

Methodology

Meals are distributed by volunteers. MIFA produces the meals, Mid-South Food Bank sources the foods, and 

Catholic Charities manages meal deliveries.

Sources (Member Partnership Guide: Keys To Greater Collaboration and Impact to Better the Lives of Older Adults, 2016), 

(MIFA, n.d.), (“MIFA - Metropolitan Inter-Faith Association - Home,” n.d.)

Humana Dine Well

Overview This program provides nutritious meals to eligible Medicare Advantage members recovering from an inpatient stay 

in a hospital or skilled nursing facility. Meals also are available for some Humana Medicare members who are 

enrolled in a qualified chronic-condition special needs plan. The chronic conditions supported by this program 

include diabetes, chronic obstructive pulmonary disorder (COPD), congestive heart failure (CHF) and some other 

cardiovascular disorders.

Goals Overall goal is to improve member health and wellbeing. Meals are intended to provide proper nutrition after a 

long-term illness or condition that may have caused loss of important vitamins and proteins. The program doesn't 

just serve meals, they keep track of patients and know all about their well-being, so that they can provide the 

proper meals to their door.

Funding Source(s) Health plans/membership.

Target Population Seniors who are Medicare Advantage members.

Meal Types There are several diets a Humana Member could choose from such as regular, pork-free, fish-free, pureed, diabetic, 

vegetarian, pureed, renal supportive options and kosher meals. 

Patients who have been discharged from a hospital or skilled nursing facility (SNF) receive 10 frozen, packaged, 

low-sodium meals. Patients can receive meals in conjunction with up to four hospital/SNF admissions per year.

Patients who are eligible for the chronic condition meals program receive 20 frozen, packaged meals that support 

the special dietary needs of that chronic condition. Patients with multiple conditions can receive multiple benefits.

Outcomes Humana Medicare Advantage members who participate in the Well Dine delivery program have fewer hospital 

readmissions, shorter hospital stays and fewer emergency-room visits.

Costs No cost to the recipients, cost per meal unreported.

Distribution 

Methodology

Via health care providers; health care providers send a referral and Humana arranges meal delivery.

Sources (“Humana and Well Dine Deliver Program’s One Millionth Meal in Knoxville | Humana Healthcare,” 2010), (Humana 

Inc., 2019)

Better Meals (Vancouver)

Overview Established in 1993, Better Meals offers a wide selection of nutritious meals and à la carte food items including 

breakfast, homemade pies, side dishes, and 3 course dinners (soup, entree, and dessert), fresh sandwiches and 

wraps, snacks, and à la carte individual dinners. Meals are delivered in the service area of Greater Vancouver, 

Fraser Valley, Greater Victoria, Mid Vancouver Island and into the Okanagan and Interior.

Goals Providing natural, tasty and beneficial meals with nutritional value conveniently delivered. They strive to provide 

meals made from scratch that are: 

 Cooked using healthy fats and minimal added salt

 Provide adequate calories and protein to support health during illness and healing

 Evocative of warm memories and feelings of comfort

 Culturally appropriate
 Designed to provide 50-67% of daily nutrition

 Tailored to meet the medical and nutritional needs of each client

Funding Source(s) Money collected for the meals; individuals place orders online and weekly delivery is free. 

Target Population Seniors in the service area of Greater Vancouver, Fraser Valley, Greater Victoria, Mid Vancouver Island and into the 

Okanagan and Interior.

Meal Types Regular, diabetic, low sodium, minced, and à la carte. Meals are made with: 

 No MSG or preservatives are added

 Natural spices are used to reduce sodium

 Full course and à la carte meals are blast frozen to maintain freshness and preserve nutrients

 Salads and sandwiches are prepared shortly before their arrival for a refreshing taste

Outcomes Not reported.

Costs ~$6.75 per meal.

Varies based on type of meal (i.e. regular, special, etc.) and full course dinner and à la carte options; Cost of full 

course dinner including soup, entrée, and dessert is $6.75. Minimum order per delivery is $30.

Distribution 

Methodology

Home delivered meals; delivered weekly (free); orders may be placed online. 

Sources (“Better Meals,” 2019)

Community Servings

Overview Community Servings is a Boston-based not-for-profit organization with a 27-year history of providing medicallytailored meals and nutrition services to individuals and their families coping with critical and chronic illnesses. They 

provide 2 meals per day for 5 days per week to provide 50-67% of daily needs. Eligibility is based on extent of 

illness, clients’ lack of mobility, and factors that make it difficult to cook and shop (food desert, wheelchair, not 

able to carry groceries). The program also provides nutrition education and counseling for clients who are no longer 

in need of delivered meals. 

Goals Improve health outcomes for critically ill clients and reduce health care costs.

Funding Source(s) Funding from charitable financial, in-kind donations from corporations, foundations and individuals.

Target Population Critically ill individuals including adults and children.

Meal Types 17 medical diets with up to three combinations per patient including bland – mild and low in sodium, children’s 

menu, chopped/soft, diabetic, heart-healthy, low-fat/low cholesterol, low fiber, no citrus/tomatoes, no dairy, no 

eggs, no fish/shellfish, no nuts, no poultry, no red meat, low vitamin K, renal, vegetarian, and nausea care 

packages. 

Outcomes Study to look at role of medically-tailored meals on health of clients from the perspective of healthcare workers 

(case managers, nurses, physicians) who referred patients to Community Servings’ services through qualitative 

interviews and online surveys found improved psychosocial well-being (relieved anxiety so that energy can be 

focused on treatment); promoted healthy weight (stabilize or gain weight); provided high-quality, holistic care (care 

for the whole patient); improved adherence to medications and treatments (reduces side effects).

96% reported that the meal program improved their clients’ health; 65% believed the program resulted in 

decreased hospitalizations; 94% believed the program significantly improved patients’ access to healthy food; 16% 

net reduction in average monthly health care costs for patients who received the Community Serving home

delivered, medically-tailored meals.

Costs $350 monthly per person.

Distribution 

Methodology

Home delivered meals. They deliver to 20 different cities or 300 square miles; clients outside of delivery area can 

pick up meals.

Sources (Berkowitz et al., 2018), (“Community Servings Food Heals,” 2019), (“Financials | Community Servings,” n.d.)

Diabetes Initiative Food Box – Feeding America

Overview Feeding America Diabetes Initiative provides diabetes-appropriate food to clients through monthly or bi-monthly 

food distributions. The Feeding America Diabetes Initiative was piloted at three member food banks that offered 

tailored services to people with diabetes. These services included nutrition education, blood sugar monitoring, 

healthy food and referrals to primary care providers.

Goals Improve diabetes outcomes and reduce food insecurity.

Funding Source(s) Funding from the Bristol-Myers Squibb Foundation, the Food Bank of Corpus Christi (Corpus Christi, TX), the MidOhio Foodbank (Columbus, OH) and the Redwood Empire Food Bank (Santa Rosa, CA).

Target Population Individuals with diabetes struggling with food insecurity.
Meal Types Diabetes-friendly diet box. Food items provided include whole and unrefined grain products, fresh fruits and 

vegetables, canned fruits in own juice, low-sodium vegetables, sauces, soups, low-fat dairy, lean meats, and beans. 

Outcomes Individuals with diabetes showed improvements in pre-post analyses of glycemic control (hemoglobin A1c 

decreased from 8.11% to 7.96%), fruit and vegetable intake (which increased from 2.8 to 3.1 servings per day), 

self-efficacy, and medication adherence. Among participants with elevated HbA1c (at least 7.5%) at baseline, 

HbA1c improved from 9.52% to 9.04%.

Lessons learned from this pilot include:

 Clients requested utensils, spices and cooking oil needed to cook items in the food boxes.

 Providing recipes and tips was found to be valuable.

Costs ~$0.38 - $0.94 per meal.

On average, boxes cost $16 and are intended to support meals for 1-2 weeks. If recipients are averaging 3 meals 

per day from the contents of these boxes, this comes to approximately $0.38 - $0.94 per meal.

Distribution 

Methodology

Two general methods of distribution: 

 Clients coming to food pantries are screened for diabetes, then offered a diabetes-friendly box to help them 

make good choices for their meals. 

 Provider referral. Clients without a doctor are referred to a local provider who can make sure they get the 

healthcare services, including medication and blood sugar testing supplies that they need to manage their 

disease.

Sources (Prendergast, 2014), (Seligman, Bindman, Vittinghoff, Kanaya, & Kushel, 2007), (Seligman et al., 2015) (Feeding 

America, 2019), (Feeding America, n.d.)

Food & Friends

Overview Food & Friends provides meals, groceries, nutrition counseling and a two hour cooking class called CHEW to people 

living with life-challenging illnesses such as HIV/AIDS and cancer. Determination of eligibility is entirely healthbased. Food & Friends has no requirements for income or insurance coverage. 

Goals To improve the lives and health of people with HIV/AIDS, cancer and other serious illnesses that limit their ability to 

provide nourishment for themselves.

Funding Source(s) Financial support comes from individuals, corporations/foundations, public funding and in-kind donations from 

corporations and individuals.

Target Population To be eligible for services, one must have AIDS, cancer, poorly-controlled diabetes or be receiving hospice care, 

have a compromised nutritional status and a limited ability to prepare his/her own meals. Food & Friends’ clients 

must be referred by a healthcare provider.

Meal Types 11 different meal plans including regular, pureed, diabetic, shelf-stable, renal, no diary, heart-healthy, soft, 

vegetarian, no fish, and gastrointestinal friendly. Each Food & Friends meal delivery contains 2 days-worth of food 

including a variety of fresh and frozen components. Each delivery includes food for breakfast, lunch and dinner, 

along with liquid nutritional supplements, as needed.

Outcomes 858,021 meals served to 2,624 clients in 2017. Health outcomes improved – 72% reported improved health, 76% 

felt better able to follow their doctor’s orders, 73% reported being better able to manage the side effects of their 

treatment or medications, 66% reported fewer hospitalizations after receiving services, 88% found it less stressful 

to provide food for themselves and their family. 

Costs No cost/fee for services to clients.

Distribution 

Methodology

Meals are delivered by volunteers and staff.

Sources (“Food & Friends,” n.d.)

New Opportunities, Inc.

Overview New Opportunities, a senior nutrition services provider, partnered with Care Transitions, a care management 

coordination provider to provide high risk hospital patients meals for 30-90 days and nutrition counseling and

education. 

Goals To prevent readmission for high risk seniors recently transitioning from hospital to home. 

Funding Source(s) The CT Community Foundation and Meals on Wheels.

Target Population High risk seniors recently transitioning from hospital to home. For the pilot, 4 individuals were selected from a 

partner health provider. 

Meal Types 2 medically appropriate meals per day.
Outcomes In a five-month period the program showed a 100% success rate keeping four patients referred to the program at 

home for 60 days or more. 

Costs The program spent $1,500 for four patients over 60 days.

Distribution 

Methodology

Home delivered meals. Drivers deliver the meals. The program trained drivers to track health status and send 

report back to Senior Nutrition Services and they would contact cardiologist if there were red flags. 

Sources (American Society on Aging, 2017)

God’s Love We Deliver (GLWD) –New York

Overview The program prepares and delivers nutritious, high quality meals to people who, because of their illness, are unable 

to provide or prepare meals for themselves. GLWD also provides illness-specific nutrition education and counseling 

to clients, families, care providers and other service organizations. All services are provided free of charge without 

regard to income.

The program provides home delivered meals determined by an RDN and executive chef. Each week clients receive 

10 meals, as well as nutrition counseling and education. Clients get their first meal within 1-4 days of signing up. 

The program also provides nutrition tip guides for HIV, breast cancer, colorectal cancer, and prostate cancer as well 

as older adults and caregivers.

Goals GLWDs aim is to improve the health and well-being of men, women and children living with HIV/AIDS, cancer and 

other serious illnesses by alleviating hunger and malnutrition.

Funding Source(s) Funding includes government, private including corporations and foundations, and individual giving.

Target Population Men, women, and children living with HIV/AIDS, cancer, Alzheimer’s disease, ALS, Parkinson’s disease and other 

life-altering illnesses throughout the five boroughs of New York City, Westchester and Nassau Counties, and 

Hudson County, NJ.

Meal Types Medically-tailored meals with choices that include regular, modified, children’s and vegetarian. They follow a fourweek menu cycle with each meal containing a soup, entrée, bread and dessert. Clients with special needs work 

with a RDN.

Outcomes 7000 served annually; 1.2 million home delivered meals; 90% of clients live below the poverty line.

Costs Free to clients.

Distribution 

Methodology

Home delivered to 5 boroughs of NYC, Hudson County, and 2 congregate sites in Newark, NJ.

Sources (“How It Works | God’s Love We Deliver,” n.d.), (“Menu | God’s Love We Deliver,” n.d.), (“Our Impact | God’s Love 

We Deliver,” n.d.)

Home Plate Meal Program

Overview The Home Plate Meal Program (HPMP) is administered by the Johnson County Area Agency on Aging. The program 

is supported by the Older Americans Act and provides short-term meal service to seniors and retired veterans post 

hospital discharge.

Once a patient is discharged from the hospital, they are referred to the HPMP by a discharge planner or social work 

staff member. Following referrals, staff member at the Johnson County Area Agency on Aging contacts patient 

within 72 hours of hospital discharge to make arrangements to deliver a meal package.

A nutrition assessment is completed within 3 days of discharge and follow-up calls are made to evaluate additional 

service needs such as a home-visiting nurse, ongoing nutrition services, etc.

Goals The program goal is to assist seniors and retired veterans in their recuperation, decreasing the incidence of hospital 

readmission.

Funding Source(s): Government and clients (donations).

Target Population Patients age 60+, homebound, and discharging to a home in Johnson County from a participating 

hospital/rehabilitation facility.

Meal Types Microwavable 7-day frozen meal package (meat entree, vegetable, fruit, dessert, and whole wheat bread or

cornbread, and milk).

Outcomes Program is currently suspended.

Costs Donations accepted as payment.

Distribution 

Methodology

Following a referral to the HPMP, a staff member with the Johnson County Area Agency on Aging will contact the 

patient to make arrangements to deliver the 7-day frozen meal pack to the patient at home within 72 hours of 

hospital discharge.

Sources (“Home Plate Meal Program | Johnson County Kansas,” n.d.)
Independent Living Systems (ILS)

Overview Independent Living Community Services Inc. (ILS) is a non-profit organization in Miami-Dade County, Florida. ILS 

aims to deliver meals, community-based services that improve the daily living experience for special needs 

populations from children to the elderly as well as rebalancing costs across the healthcare system. The program 

offers home delivered meals, nutrition counseling and care coordination. ILS currently delivers 800,000 meals per

month through Care Delectable meal delivery.

Goals The program seeks to improve community-based care transitions, outcomes, and reduce readmissions and overall 

cost. 

Funding Source(s) Government sponsored and private insurance plans. 

Target Population The elderly, special needs, and at risk-populations in Miami with qualifying health plans.

Meal Types Offer 10 frozen home delivered meals (regular heart friendly, fish free, pork free, diabetic, gluten free, renal, 

vegetarian, puree, kosher).

Outcomes Florida’s Experience: Expanding the CMS Care Transition

 Community readmission rate: 22.1%

 30-day readmission rate: 13.5% (meals only)

 30-day readmission rate: 7.6% (meals and nurse visit)

 Post discharge 10 frozen meal packages, data shows reduced readmission rates 

 From June 2015- April 2015: readmission rate decreased by 65%

Costs ~$8.90 per meal.

The service used is Care Delectables. After discount, Care Delectables meals cost $89.00 for a 10-pack excluding 

applicable taxes.

Distribution 

Methodology

Meals are delivered to the home immediately upon discharge from a hospital or nursing home. Care Delectables 

delivers via 2nd day air freight in dry ice in specially designed packaging. Meals can be heated in a conventional 

oven or microwave by following simple instructions.

Sources (Suazo, n.d.), (“Independent Living Systems Launches New "Care Delectables" Nationwide HomeDelivered Meals Service,” n.d.), (“Care Delectables - Home Delivered Meals,” n.d.)

Carer Gateway (Australia)

Overview Carer Gateway provides meal assistance, including but not limited to the following: provisions of meals at a 

community center or at home, help preparing meals at home, help with shopping for food, help with making meals 

and storing food in the home, help with learning to cook, and delivering meals to the home. The starting point to 

accessing the service is My Aged Care, a service funded by the Australian Government.

Goals To help older people live as independently as possible.

Funding Source(s) Australian government. The National Disability Insurance Scheme (NDIS) can be used to fund assistance with meal 

planning, preparation, and cooking as well as delivered meals. 

Target Population Individuals 65 years or older (50 years or older and identify as Aboriginal or Torres Strait Islander person) or 50 

years or older (45 or older for Aboriginal and Torres Strait Islander people) and low income, homeless or at risk of 

being homeless. 

Meal Types Help with shopping for food, help with making meals and storing food in the home, help with learning to cook, 

delivering meals to the home, and providing meals at a community center.

Outcomes None available at this time.

Costs Varies.

Distribution

Methodology

Meals can be home delivered and many programs rely on non-government organizations to deliver services. 

Sources (“Meals Assistance | Carer Gateway | Australian Government,” 2018)

Seniors Community Care (Australia)

Overview The Seniors Community Care program offers clients prepared meals that are delivered to the home. The program 

has an extensive menu that provides both fresh chilled and frozen meals. The nutritious and healthy meals are 

prepared and home delivered twice a week.

Goals Seniors Community Care aims to offer services of the highest standard and support independent living for 

individuals.

Funding Source(s) Cost of meals paid for by individual(s) ordering the food/meals. 
Target Population Seniors or aged persons; disabled persons; individuals managing at home after an illness, injury or hospital stay or, 

any individual who likes the convenience of prepared meals. 

Meal Types Meal options include diabetic, low sodium, low fat, vitamised, diced, gluten free or vegetarian options, within the 

selection of fresh meals also available upon request.

Outcomes None available.

Costs ~$10.30 - $12.90 per meal.

Fresh cooked chilled dinner size small is $10.30 and medium is $12.90. 

Distribution 

Methodology

Meals are delivered fresh, chilled, and frozen on a regular or as needed basis. 

Sources (“Home Delivered Meals | Seniors Community Care,” n.d.), (Home Delivered Meals, 2017)

Maryann’s Kitchen (Australia)

Overview Maryann’s Kitchen offers fresh, healthy and home delivered meals for people who are elderly, disabled, and

recovering from illness and surgery.

Goals Meal delivery is their primary goal.

Funding Source(s) Fee for meals.

Target Population Elderly, disabled, and those recovering from illness and surgery. 

Meal Types They offer a different meal each day, over a 28 day period, with menus changing every 6 months. They offer a 

special weekend menu. Meals consist of a main course, with choice of dessert or soup or salad. Meal types include 

regular and diabetes. They cater to special dietary needs on an individual basis. 

Outcomes None available.

Costs ~$7 per meal.

$14.00 per day per 2 course meal or $70.00 per week. 

Distribution 

Methodology

Meals can be delivered daily hot or cold. Daily, weekday and weekend meal plans available. Extra surcharges may 

apply if ordering less than 5 meals per week.

Sources (“Home - MARYANN’S KITCHEN,” 2019), (Maryann’s Kitchen, 2018)

Tender Loving Cuisine (Australia)

Overview Tender Loving Cuisine (TLC) was established in 1995 and provides meals with a homemade taste at an affordable 

price. TLC delivers meals frozen.

Goals TLC aims to improve the quality of life for older people and individuals in need by providing the highest quality 

meals.

Funding Source(s) Fee for meals.

Target Population All ages.

Meal Types Regular, diabetes friendly, gluten-free, heart friendly, dairy-free, low salt, textured soft, minced moist. 

Outcomes None available.

Costs ~$8.40 to $13.75 per meal.

Saver menu cost starts at $8.40 per meal, premium meals start at $13.75; bundle packages can further reduce meal 

prices. 

Distribution 

Methodology

Delivered to the home, business or senior village. 

Sources (“Our Mission - Tender Loving Cuisine,” n.d.)

Swedish Municipal Food Distribution

Overview The program offers two key services, including: (1) The municipal Food Distribution service (FD) which provides 

services targeting individuals who are unable to do their own grocery shopping, and prepare their own meals and 

(2) home delivered meals.

Goals The goal of the program is help elderly people and those with disabilities age in place.

Funding Source(s) Elder care in Sweden is funded by municipal taxes and government grants. In 2014, the total cost of elderly care in 

Sweden was SEK 109.2 billion (USD 12.7 billion, EUR 11.7 billion), but patient charges were only 4% of the cost. 

Healthcare costs paid by the elderly are subsidized; the degree of subsidization is based on specified rate 

schedules.

Target Population Persons who are unable to do their own shopping, and prepare their own meals.
Meal Types Various types – meal boxes which are hot, chilled or frozen with different delivery frequencies.

Outcomes 360,000 meals are served within elderly care.

Costs Variable – low as government and welfare system covers.

Distribution 

Methodology

Home delivery with different delivery options. 

Sources (“Elderly care in Sweden,” n.d.), (Pajalic, 2013), (Josefsson, 2018)

Impact on the MDMP 

Meal Packages

Review of previous and ongoing meal package programs from this report have informed the 

development of the MDMP meal packages’ menu and design. An example of two menus from programs 

profiled in this report is found in Appendix A. Familiarity and recognizability of the food items in the 

meal packages was an important aspect of the menu design. This way, once the meal packages run out

participants can recognize and find replacement food items to purchase that also fit their nutritional 

needs. For example, a patient with heart failure might leave the hospital with an order to follow a lowsodium diet. When they are given the CC/HH meal packages and the accompanying menu they will 

know that they are eating a low-sodium diet and they will get a better idea of what it is like to follow this

type of diet. Once they have consumed all of the MDMP meals, they can then purchase foods that are 

similar to those found in the meal packages, such as low-sodium soups.

The cost of meals in other programs was scrutinized for reference. Meals from the programs profiled in 

this report tended to cost an average of $10 or less, with some as low as $3 per meal. The MDMP 

packages aim to meet or exceed the cost effectiveness of these meals. Many of the food items can be 

purchased at discount stores such as Walmart and Dollar Tree. These stores are also usually accessible 

in most locations, even those considered to be “food deserts.” This way, once the participant has 

consumed the meal packages, they will be able to find replacement items easily and affordably.

The flexibility and cost-effectiveness of prepackaged, shelf-stable foods was determined to be useful for 

the MDMP. The MDMP meal package food items are entirely shelf-stable, require minimal preparation, 

and are easy to open. Almost all of the other programs profiled in this report included a component of 

fresh or frozen, fully-prepared meals. As the MDMP progresses through and beyond the pilot period, it 

will be important to assess whether including a fully-cooked meal option in the program will be costeffective, viable and appealing to clients.

Educational Materials

Evaluating other programs illuminated the need for effective educational materials to inform 

participants as well as staff. A sample of an educational handout can be found in Appendix B. 

Educational materials are designed to accompany the MDMP meal packages and also to inform the 

hospital staff/healthcare workers that are providing the meal packages. Other programs’ materials also 

informed MDMP workflow, including a patient selection flowsheet, ordering protocol, and additional 

resources for patients who do not meet the criteria or need additional help to access assistance. A 

sample of workflow and patient selection can be found in Appendix C. Some programs had specific 

referral forms (seen in Appendix D). The MDMP does not use referral forms but a patient selection 

flowchart to determine patient eligibility as well as a consent form for the patient to sign. 
Target Population

The MDMP is specifically intended to address malnutrition risk in older adults. The program further 

focuses in on chronic conditions that have the highest rate of readmissions for the pilot hospitals. Many 

of the other programs that were reviewed were not specific to senior populations, but addressed

malnutrition risk for specific sub-populations based on income, disease, or insurance type. Malnutrition 

risk was sometimes identified using an assessment tool either developed by the program or an 

established verified tool. However, almost every program focused on specific medical conditions that 

are highly associated with malnutrition risk. Almost invariably, programs did not approach participant 

identification using a diagnosis of malnutrition as an eligibility criterion. The MDMP quickly discovered 

through review of similar programs and through collaborations with pilot hospitals that eligibility 

assessments needed to focus on specific medical conditions and risk-assessment tools to determine 

eligibility rather than relying on a diagnosis of malnutrition or referral for malnutrition treatment.

Other Impacts & Considerations

One theme that frequently emerged in this review of similar programs was the importance of interinstitutional collaboration and effective communication between partners. A report on the progress of 

the MIFA No Hungry Senior initiative (Member Partnership Guide: Keys To Greater Collaboration and 

Impact to Better the Lives of Older Adults, 2016) stated that one of the challenges for the program was 

the great number of collaborators involved. They found that effective communication would be a key to 

success for similar programs. As MDMP moves forward and more partner organizations get on board, 

setting up frequent meetings and having communication platforms to keep everyone apprised and 

engaged in ongoing efforts will be paramount.

Funding for these programs came from a variety of sources. The meals cost on average $10 or less for 

the programs profiled in this report. The packages currently being designed for the MDMP pilot average 

about $11.50 for a full day (3 meals, 2 snacks) or $2.30 per meal/snack (for food costs alone). Although 

this cost is on par with or less than these other programs, it will still require adequate and ongoing 

funding to be effective. Federal and State grants can provide financial support from the public sector, 

but the program can also look to private-sector and healthcare funding sources. For example, if 

partnering with a non-profit organization the program could take a note from MANNA in Philadelphia 

and utilize philanthropic donations from individuals and organizations. MDMP can also look to funding 

from private pay, insurance reimbursement, etc.

Many of these programs relied on volunteers to distribute and package food. Transportation will be 

required while meals are being distributed to clients in the community and while procuring items for the 

meal packages. This transportation requires vehicles, gas, and drivers. MDMP is addressing this through 

several different avenues. In some cases, participant hospitals have community health workers who are 

visiting discharged patients at home as part of their transitional care. This will provide an opportunity 

for the packages to be delivered during these visits. In other scenarios, the patient will be returning to 

the hospital’s transitional care clinic for a follow up visit and they will receive the packages there. This 

has an added advantage of providing an additional incentive to the patient to return for their follow-up 

visits. However, the issue of transportation and accompanying costs and required resources will be an 

ongoing issue area to look at while expanding the program.
Continual Network Support and Feedback 

As the MDMP pilot progresses, continued support and feedback from a network of groups working on 

similar initiatives will be essential. As much as previous projects have impacted the MDMP design and 

process, groups around the US and abroad are concurrently working on initiatives or evaluating results 

from projects that can continue to help to inform the MDMP pilot and ultimately the expansion of the 

larger Maryland implementation. 

Slack Network

The MDoA has brought together representatives from a variety of programs and initiatives around the 

country virtually using a Slack network (www.slack.com) to share materials, information and 

perspectives. Slack is an online networking tool that provides a shared collaborative workspace that 

combines communication through chat and instant messaging with sharing documents and other 

resources. MDoA intends to use this online network of collaborators to support the MDMP initiative 

and, in turn, provide support to other similar ongoing and future programs.

Quarterly Phone Meetings

Once a quarter, members are invited to a telephone conference call hosted by the MDoA MDMP 

representatives. Members range across acute, post-acute and community-based providers and are from 

20 different states across the United States. Each quarter 1-2 programs are highlighted to share details 

about their initiative, outcomes, and ongoing processes. This collaborative space is yet another way to 

share ideas, provide feedback, and learn from other programs to provide ongoing support to the MDMP 

and other initiatives around the country.

Conclusion and Acknowledgements 

Maryland, and all states across the US, have an exciting and challenging opportunity to address senior 

malnutrition and chronic illness with post-discharge meal package programs. The MDMP is a unique

example for others to consider, given it is entirely shelf-stable, medically-tailored, and connects patients 

discharged from hospitals to resources in the community and resources in their doctor’s office. 

The authors wish to thank and acknowledge similar programs and initiatives around the country and 

around the globe which have informed the development of the MDMP. We also thank the Maryland 

Department of Aging’s staff, Laura Sena, MSPH, RD, LDN and Judy Simon, MS, RD, LDN for their 

contributions by editing this material and compiling much of the foundational information presented in 

this document. The Maryland Department of Aging’s work coordinating the national peer network has 

facilitated cross-organizational discussions and will continue to impact the program as MDMP is 

implemented and eventually grows to a larger initiative. 
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(2016). (September). Retrieved from http://alliancetoendhunger.org/wpcontent/uploads/2018/05/TOWNS_FA-and-MOWA-Partnership-Guide.pdf

Menu | God’s Love We Deliver. (n.d.). Retrieved January 29, 2019, from https://www.glwd.org/getmeals/menu/

MIFA. (n.d.). No Hungry Senior: A three year grant funded by the Plough Foundation.

MIFA - Metropolitan Inter-Faith Association - Home. (n.d.). Retrieved March 6, 2019, from 

https://www.mifa.org/

Order Simply Delivered Meals. (n.d.). Retrieved March 6, 2019, from 

https://smaaa.wufoo.com/forms/x10kswqr1jbqlms/

Our Impact | God’s Love We Deliver. (n.d.). Retrieved January 29, 2019, from 

https://www.glwd.org/about-us/our-impact/

Our Mission - Tender Loving Cuisine. (n.d.). Retrieved February 25, 2019, from 

https://www.tlc.org.au/about-us/our-mission

Pajalic, Z. (2013). The Swedish Municipal Food Distribution Service to the Elderly Living at Home as 

Experienced by the Recipient’s Relatives. Global Journal of Health Science, 5(6), 12–18. 

https://doi.org/10.5539/gjhs.v5n6p12

Prendergast, K. (2014). Feeding America’s Diabetes Initiative - Helping Clients Manage their Health | 

Feeding America. Retrieved from https://www.feedingamerica.org/hunger-blog/feeding-americae2-80-99s-diabetes-initiative-helping-clients-manage-their-health
Project Open Hand. (2019). March 2019 Wellness Menu. Retrieved from 

https://www.openhand.org/sites/openhand.org/files/POH Wellness Menu March 2019.pdf

Seligman, H. K., Bindman, A. B., Vittinghoff, E., Kanaya, A. M., & Kushel, M. B. (2007). Food insecurity is 

associated with diabetes mellitus: Results from the National Health Examination and Nutrition 

Examination Survey (NHANES) 1999-2002. Journal of General Internal Medicine, 22(7), 1018–1023. 

https://doi.org/10.1007/s11606-007-0192-6

Seligman, H. K., Lyles, C., Marshall, M. B., Prendergast, K., Smith, M. C., Headings, A., ... Waxman, E. 

(2015). A pilot food bank intervention featuring diabetes-appropriate food improved glycemic 

control among clients in three states. Health Affairs. https://doi.org/10.1377/hlthaff.2015.0641

Sharma, Y., Miller, M., Kaambwa, B., Shahi, R., Hakendorf, P., Horwood, C., & Thompson, C. (2017). 

Malnutrition and its association with readmission and death within 7 days and 8-180 days 

postdischarge in older patients: A prospective observational study. BMJ Open, 7(11), 1–8. 

https://doi.org/10.1136/bmjopen-2017-018443

Simon, J. R., Beardsley, K., Davidson, T., Lachenmayr, S., & Eagle, L. A. (2018). Malnutrition Care Planning 

Post Hospital Discharge: Community-Based Senior Nutrition Programs and Social Services Can 

Effectively Support Older Adults. The Spectrum, (Special Edition), 42–49.

SMAA/MMC Simply Delivered Meals (SDM) Pilot. (n.d.). Retrieved March 6, 2019, from 

http://www.smaaacbo.org/healthcare/healthcare-study-results.html

Southern Maine Agency on Aging. (n.d.). Retrieved March 6, 2019, from 

http://www.smaaacbo.org/healthcare/healthcare-survey-results.html

Suazo, L. (n.d.). Role of Nutrition in an Integrated Care Coordination Model. Retrieved from 

https://www.eiseverywhere.com/file_uploads/9f4628702c0d7cf0afe2b32018f53699_DINE.pdf

Trust, T. H., & Food, A. (2017). Medi-Cal Medically Tailored Meal ( MTM ) Pilot Program Frequently 

Asked Questions. 3–4. https://doi.org/10.1177/21500131913490737

World’s older population grows dramatically | National Institutes of Health (NIH). (n.d.). Retrieved 

February 15, 2019, from https://www.nih.gov/news-events/news-releases/worlds-olderpopulation-grows-dramatically
Appendix A: Sample Menus

GOD'S LOVE WE DELIV

n ..,-~for 

)fON:r>AVS· 

YM-,,r

TtlESJlAl'S: 'Wlim.

..... aioo ~Soillp 

otatonltso,.p 

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.til Vllglltllblt SOfap 

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lbd:E}W~SO.., T« \"~

Mo;~Sorlip ~C

Wbila•-1:.-SOII(> ~-•...,

v. _,,_.., 

- ER MODIFIED MENU 2018 

v .. 

nrtlRSDAVS' 

a.-PHSoup 

H..._,Moo .SO.. c.o,a.o.,,i., P

MiNo:;llO• 

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nn

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t

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tiot-\$nti 

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~Sabo, \\'bJtt~ .. 

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\'~ble 

n1- Bmd.FclicUlew/ld l'dOPda&Hi:cd 

Ve:tdable 

OU?y dliidra w/ BJbt aoei~•fP~• 

Cta:lots, ~. 

0.-

r-J Mmd.Vog:~ 

- S...,Piw•rtllow~ ---"""' co.on, .......... Ton~--• ..,..,.._ Cl.ea~· -,~.Milolld\'~ Wbo Yo~ Ptiail 

~~Wulleast. lkocoolifi<~hlli "'"""'""""""""' """"""" Moa.doGw~Gnl\,., - camit:; r.. Gl- lk!iaa:; 

P.uuw) ~Puh$CIO& """""" °'""""""""'""' ....,v........, ~Ve:r;,rtable:Cbih 

Oauld-.. Broocoit 

- Kot:aa Gl-.4 <.llida ......,...,,_ Gt\'CO.hu.Wl'uioc,fft. 

<hda ~-r,.- wfn,l::.ol« Rotalt • M.-d uw1 D.J we ~ PJOe: Cv,,c -•"""'""- v- ~¥tllowSqwdl.• n.a a-1t1i:ie ...... Chc:bow/1Wa.rpebo.oc,-

Bro-11,11.ed:~&. 

.._,,M""'-' -. ... ...,_, - ..,..,,, - l)e,en; 

/!Wit Cno~ c.- ~libC.- (>......, ..... ..._. ..... Or-uc:~1-cz.diioilr-i. 

--- --- ~- OolS-. 

~Gio:a-Cut 

\'...U. 

---

J'oaa,I Cuii: --- ~et-b ~ -- --

Source: (God’s Love We Deliver, 2018)

Mondays: Soups: Onion barley, Potatoes Kale, Garbanzo bean barley, lentil 

vegetable. Entrees: Ginger glazed salmon with Asian slaw, friend brown 

rice, and mixed vegetables; roasted tilapia with black bean salsa, white rice 

and mixed vegetable; baked fishcake with basil pesto pasta and mixed 

vegetables. Dessert: apple cranberry cake, peach cake, zucchini bread, 

vanilla pound cake

Tuesdays: Soup: vegetable chowder, black eyed pea soup, white bean kale 

soup. Entrees: Curry chicken with rice, carrots, zucchinis, and pearl onions, 

chicken casserole, coconut chicken stew. Desserts: Pineapple bits cake, 

apple cornmeal cake, pear spice cake

Wednesdays: Soups: potatoes leek, vegetable noodle, curried carrot. 

Entrees: beef Bolognese with pasta and mixed vegetable, coconut braised 

beef, meatloaf. Dessert: cranberry scone, mixed berry cake, coconut cake. 

Thursdays: Soup: green pea, mushroom miso, corn chowder. Entrees: Lentil 

vegetable stew and rice, tofu eggplant caponata, vegetable chili. Desserts: 

Seasonable fruit. 

Fridays: Soups: black bean, spinach lentil, pasta white bean. Entrees: 

chicken with mushroom gravy, snap peas and yellow squash bow tie pasta, 

hoisin glazed chicken, green peas, red peppers, carrots and fried brown 

rice. Desserts: orange lemon cake, oat scone, apple ginger cake. 
March 2019 Wellness Menu

Source: (Project Open Hand, 2019) 

March 2019 Wellness Menu: 

March 1, roasted pork loin, mushroom and herb 

gravy; bulgur; broccoli and cauliflower

March 4th- roasted chicken tinga/mushroom sage 

gravy, penne, and peas and carrots.

March 5th: Mongolian beef, brown rice, and green 

beans.

March 6th: baked tilapia, Basque sauce, bulgur and 

glazed carrots

March 7: chicken tetrazzini stew, penne, broccoli 

and cauliflower

Different iterations occur throughout the month, 

with some having turkey meatloaf, or Tukey 

Bolognese and various sides. 
Appendix B: Sample Educational Material

FOOD IS MEDICINE '" - COALITION -

Food Is Medicine Coalition (FIMC) 

FIMC is a an as.soaation ot nonptotits across the naoon 

that pfOlide a complete. evidence,based. mecic-al food 

and nutrition intl!rVCntion to critical~ and chronicalty ill 

people in their comrrurvties 

The Need W )'OU ore siek ond hu...::,Y rl the United SU,tes. I.here iS no fedcml nutrition 

support fOf )'Ou. unless you have HIV. and even I.Nt iS r.ot aoe<auate to cover 

all v.hO are In need. To mee. this need, FIMC aitelldes raise most ot their 

budQets. and some are torceo to create wai;tln&IISJs, because the need In their 

corrwnunlbe9 1sso.-eat. As more and more people are d~ osedwrth chronic 

ilncs"Scs that require &pOCif\c ciots. Un need wil orly f}ON. 

i 57% --86% 092% ttt 1 in 3

57% 77% 

Prechcted rise in 

chronic illnesses~ 

2020(WHOI 

Portion of healtheare 

spending attributed to 

n:tMduats with chronic 

health conditions (CDC] 

Older adu Its with 

at IN,t • "• chroric disease 

Older adu Its withat least two

ati--.t..-o(NCoAJ 

1 in 3 

Peopleenter 

tho hospital 

malnourished 

Our dients are a complicated population. often living with multiple co-mortlid illnesses. They require nutrition counsei ng and 

tailored meats not avai able from trooitional meal or food providers. 

The InterYentiou Medical¥ tailorc,d meals {MTM) arc meals apptCMXI ~ a Rc-gJstercd Dietitian 

f\'\.rttitionist (RON) that rcllcct appropriate dictory lhffllP/ based on evidence,. 

ba.sed nwition pr&etiee guidelines tO adefress a medieal <lizlgnOS.iS.. S)'mPtoms, 

a11er.,es.. medlcaUOn manaae,nent a net sioe ettects to ensure tne beSt 

posSible nutntion.related health outcomes. MTM are often patred with medical 

nutnt1on therapy (MNT). an evtden~sed appl1C8b0n of the Nutrition Care 

A-ocess(Acadeny d M.Jttitjon and Diererics) focused on p~n. delirf or 

management of cisca.ses and conditions. and i~ an in-depth 

assessment periodic rcas.sessment end irtervention. 

8y making mecllcaly 1aik>red nutnnon a reimbursable serv10e in OU' healthcare 

system for this high risk. high need, l'i.gh cost pol)l.Aation. we can produce: 

® 

w J,

0 0 ofcare 

,owe«ost 0 -

~

;.,.,..,ed patient 

satisfoction 

MTM 

are a low-<»SV" h~intcrvcntion 

The Solution 

The Solution

~©~ 'J(r"'bette<health 

outcomes 

The Outco1nesThe Outcomes

J,@ i~ J,[Qo]] 

16'!< 28o/. 23o/. 50% 11 16% 28% 23% 50% 11

net healhoe8re 

cost S81J1n,s reduction in tmoltal!Zatlons 

~ 

morenke~to 

be d lsehar,ed 

to home 

inCteaSe in 

a<lheranoe 

la 

new studieS on~ .npac:t.CI MTM 

are In pro(ress across the count,y 

at flMC agencies 

e FIMCoalirion.o,g - e FlMCo::ii tion 

Food is Medicine Coalition (FIMC)

The Need

86%

92% at least one

77%

The Intervention

MTM

Source: (Food is Medicine Coalition (FIMC), 2018)
Appendix C: Sample Workflow 

STOP

STOP

STOP

Sample flowchart

1.Assess Nutrition Consult Triggers for

Patients greater than or equal to 60 years.

(Qualifying triggers: Shelby County

resident, unplanned weight loss, poor oral

intake, chewing/swallowing problems,

pressure ulcer). (Disqualifying triggers:

home tube feeding, home TPN, pureed

diet).

a. If no, Stop.

2.If yes, [Hospital] conduct nutrition

screening-Coaction Net.

3.If the score is less than 10, STOP.

4.If the score is greater than or equal to

10, decide if the patient should be

discharged to home.

1. If No: Stop.

5.If yes, enroll in No Hungry Senior and

send patient home with 7-meal/7 snack

box at discharge.

MIFA: If patient enrolled in No Hungry

Senior and send patient home with 7-

meal/7 snack box at discharge, determine

type of nutrition support and conduct 30-

day reassessment (phone).

Source: MIFA No Hungry Senior program
Appendix D: Sample Referral Form 

Source: (“Application for Project Angel Heart meals - Project Angel Heart,” n.d.)
Summary Brief

Snapshot of project and findings.
MARYLAND’S INNOVATIONS IN NUTRITION 

PROGRAMS AND SERVICES

ABOUT US

The Maryland Department of Aging helps establish Maryland as an attractive location for all older adults through 

vibrant communities and supportive services that offer the opportunity to live healthy and meaningful lives.

PROJECT PURPOSE

• To transform the Maryland Department of Aging’s Senior Nutrition Program using the epidemic of older

adult malnutrition as the catalyst to introduce evidence based practices, cost-cutting measures, innovative

meal products, and efficient service delivery methods to forge new health care linkages and expand service

to older adults in the community.

PROJECT LENGTH

• Two years

KEY PARAMETERS

• Population targeted: Age 60 and older, persons at risk of hospital readmission, and/or malnutrition

• Geographic setting: Urban, suburban, and rural settings (statewide)

• Service delivery setting: Community settings; initial distribution site of meal packages was in the hospital,

at discharge

• Services offered: Innovative post-hospital discharge meal package services, and development of a malnutrition

care pathway approach

• Number of staff/FTEs dedicated to innovation project: (paid/unpaid, FTEs): Maryland Department of Aging:

0.75 FTE Project Coordinator, with in-kind support of senior staff, and involvement of Older Americans Act

(OAA Nutrition Program Manager (in-kind not counted since the OAA is a federal program and could not be

applied for budget purposes)

• Consulting Registered Dietitian Firm: procured to assist with specific components

• Subgrantees: Maintaining Active Citizens, Inc. (MAC Inc.), a Maryland Area Agency on Aging (AAA) and the

Maryland Food Bank. Both were engaged and paid for time and expertise devoted to the project based on

executed agreements

• Total grant funds received: $245,975

• Total project period: Two years (2017 – 2019)

• Total funding leveraged from organization (cash/in-kind): $85,236 (State funding)

PROJECT COMPONENTS

• A replicable model for a hospital post-discharge community-based malnutrition care pathway.

• Medically-tailored, shelf-stable meal packages for older adults transitioning from hospital to home.

• University-led cognitive- and validation-testing of the Maryland Home Delivered Meal Screening tool.

• Community malnutrition awareness workshops for seniors at risk for falls entitled, “Stepping Up Your Nutrition”.

ORGANIZATION: 

Maryland Department 

on Aging

ADMINISTRATION FOR COMMUNITY LIVING INNOVATIONS IN NUTRITION PROGRAMS AND SERVICES CAPSTONE 

SERIES

1
nutritionandaging.org 2

SUCCESSES AND LESSONS LEARNED

Community Based Malnutrition Pathways Toolkit 

• Successes: A Community-Based Malnutrition Pathways Toolkit was created and was found to be of value to Area

Agencies on Aging across the nation.

• Lessons Learned: Plan sufficient time for project staff to manage and be significantly engaged in projects that

involve Area Agencies on Aging training, since consultants often will not have the context to develop special

needs plan (SNP) applicable materials and trainings independently, even if they are content experts.

Meal Packages

• Successes: The meal package project received excellent acceptance and usage by patients and succeeded

in its client-centered goals. The project team was able to create the first medically-tailored, shelf-stable meal

package for older adults in our state and possibly for the nation.

• Lessons Learned: Anticipate delays in the learning curve, capturing data and receiving outcomes. Do not

allow subgrantees to put project work plan timeline at risk. Intervene early to address problems.

Home Delivered Meal Screening Tool 

• Successes: Local AAAs in Maryland now have an “app” for their use and a current manual for implementation

of this screening procedure.

• Lessons Learned: Universities and the aging network work at different paces. This can affect deliverable

timeliness.

Stepping Up Your Nutrition 

• Successes: Met or exceeded programmatic and health outcomes. The workshops are sustainable and offered

nationally via steppingupyournutrition.com.

• Lessons Learned: Use of a proven, award winning tool can strengthen a new project’s outcomes and success.

PROJECT IMPACT

The department partnered closely with a number of healthcare and AAA partners to fulfill this grant. These 

relationships continue and enhance each organization’s ability to serve clients effectively. Examples of the 

project’s Impact:

• One AAA has received funding to hire a dietitian and implement the malnutrition pathway.

• The Consulting Registered Dietitian Firm will continue offering the meal packages to healthcare providers

and AAAs.

• A number of pilot projects have stemmed from our partnership with the hospitals.

• Another Department grant will be implementing the meal packages with subgrantees.

ADVICE TO PEERS

This grant project was very ambitious. The recommendation would be not to put too many projects into one 

grant proposal and consider what is absolutely critical to achieve project goals and what is manageable within 

the project’s timeframe. The important thing to remember when preparing grant proposals is that they are 

reviewed and scored based upon clearly defined project goals and objectives and the demonstration of a 

methodology/approach that is reasonable to achieve them within the project timeframe.

This project was supported, in part by grant number 90PPNU0001 from the U.S. Administration for 

Community Living, Department of Health and Human Services, Washington, D.C. 20201