What Works: How Howard County, Maryland is 

Addressing the Health and Well-being of its Seniors

Q&A with the Howard County Office on Aging & Independence (OAI)

The national Senior Nutrition Program often receives questions about how other local programs are

meeting the nutritional and social needs of older adults. That’s why we’re raising up the work that real 

programs are doing every day across the country. With our “What Works” articles, we hope to help 

programs share their experiences and spark ideas for others to use in their communities. In addition to the 

resources in this article, learn more and find tools by visiting the Nutrition and Aging Resource Center. 

ACL: How is your senior nutrition program promoting health and well-being, including helping 

participants to manage, prevent, or delay the onset of health conditions?

OAI: Our agency is strategic in our efforts to promote health and well-being through our nutrition 

services. Beginning in 2020, we brought nutrition and health promotion services together under one 

division. Program managers meet regularly to discuss ways they can continue to improve service 

delivery and outreach to those in the community. We also have a health and wellness coordinator who

helps manage workshops and ensures outreach efforts are customized to clients within our programs. 

But, as we all saw, the COVID-19 pandemic changed everything — we had to shut down our 50+ center 

operations for a while. When it was safe to resume in-person operations, we worked hard to bring 

seniors back into our centers. One of the first steps we took was to reexamine our existing programs to

determine whether their needs and interests changed. That action had a positive effect because it 

resulted in us identifying new opportunities to connect nutrition and health promotion. 

One example is that we’ve paired both the Chronic Disease Self-Management Program (CDSMP) and the 

Diabetes Self-Management Program (DSMP) with a healthy meal, which is paid for through Title III-C1 

for eligible participants. The meal reflects what we’re 

teaching in our workshops. It also offers an opportunity to 

socialize, which we know is so important as people age. 

We’ve found that participants often meet outside of class 

to walk, exercise, or just spend time together. 

One of our new initiatives under this structure is a medically tailored meal program, and we were 

approved to use American Rescue Plan Act (ARPA) funds to launch this service. The program offers three 

types of tailored meals — heart-healthy, diabetic, and renal-friendly. 

When participants are homebound, meals are delivered to them. And while this doesn’t provide the 

same social interaction as congregate meals, delivering meals to their homes is still a great opportunity 

to build a connection and make sure they know about the services we offer. 

For those with chronic health conditions who can’t make it to a class in person, CDSMP and DSMP are 

offered virtually. That also enables us to help educate caregivers, connecting them to health promotion 

programming. 

CDSMP and DSMP are 6-week workshops 

that build skills and confidence to help 

participants manage their health. Learn

more: National CDSME Resource Center. 
ACL: How do you identify participants’ health needs and ensure appropriate services are offered? 

OAI: The entry point for our programs is our “No 

Wrong Door” Maryland Access Point (MAP). MAP 

staff do an initial screening with clients, and if a 

nutrition risk is identified, they are referred to a 

meal program.

If the person can get to a congregate meal site, MAP will refer them to a congregate meal program at 

one of our centers. If someone cannot leave the house, an additional screening process identifies 

whether traditional home-delivered meals or medically tailored home-delivered meals are appropriate. 

Generally, staff can identify participants’ needs and make appropriate referrals.

For several years now, we’ve contracted a registered dietitian. We 

also have an exercise specialist on staff to provide one-on-one 

nutrition and exercise consultations to people in our centers. The 

service is advertised in our newsletter and other marketing. 

When people sign up, they meet one-on-one with the registered 

dietitian or exercise specialist to set goals and receive guidance 

specific to their goals and abilities. Staff identifies options for 

clients during the action planning process, and health promotion 

programs are often a key service referral. The connection goes 

both ways, as many CDSMP participants identify nutrition and 

exercise as key topics for goal setting. 

In addition, we work closely with our Senior Care Program to refer 

clients for medically tailored meals. Senior Care is a statewide program that provides essential services 

for people at risk for nursing home placement. 

We have Senior Care clients who didn’t want to continue with home-delivered meals because they had a 

condition that required a specific diet. Those who qualify for the new program are now able to switch 

and continue receiving meals. Those who do not qualify for medically tailored home-delivered meals 

would continue with the traditional home-delivered meals program. To date, all Senior Care clients 

referred to the medically tailored meals program have qualified.

When it comes to evidence-based health promotion programs, we partner with our area health 

department and hospital to determine where programs should take place based on the prevalence of 

chronic conditions in the county. By working collaboratively, we can switch participants between classes 

as they fill up so that no one gets left out. The hospital hosts an online portal where each organization 

posts upcoming workshops. If a workshop fills up, the individual is directed to the portal for other 

available workshops. 

MAP is Maryland’s Aging and Disability Resource 

Center (ADRC). ADRCs provide person-centered 

counseling to empower people to make informed 

decisions about long-term services and supports. 

ACL: How does your agency blend and braid funding streams to address health and well-being?

OAI: We keep the funding streams for nutrition and health promotion programming separate. We use 

our OAA Title III-D funds to pay for instructors for our Arthritis Foundation Exercise and Better Balance 

fitness classes. The OAA Title III-C funds are used for Senior Nutrition Program supplies, salary, and 

contractual costs for the registered dietitian and food. ARPA has allowed us to be creative and come up 

with new initiatives. We did not have sufficient funding through our nutrition funds alone — Title III-C, 

state, or the Nutrition Services Incentive Program — to start the medically tailored meals pilot. 
When the ARPA funding stream runs out, we will need to be strategic in determining our next steps. We 

have a good relationship with our hospital, which contributes funds to our low-impact Age Well exercise 

program, which provides a low-cost option for seniors. If we prove that our medically tailored meals 

model is successful, we aim to approach the hospital to see if it aligns with its strategic initiatives. 

ACL: What are the most significant gaps in available services to improve the health and well-being of 

participants, and how are you addressing them in your community?

OAI: We are a diverse community and therefore need to expand our efforts to provide services to 

participants in their native languages so that we can attract even more people to our programs. For 

example, we hired a staff member who speaks Korean to provide nutrition education talks during meals

with members of our Korean community. We’re looking to hire a bilingual nutrition specialist to expand 

this service among the county’s Chinese residents. 

Recently, we created a new program in partnership with 

Roving Radish, a local market that provides fresh food from 

local farmers, and the University of Maryland Cooperative 

Extension. We had a registered dietitian give a talk on farmto-fork, using seasonal vegetables and other produce to 

prepare meals. The program was paired with a congregate 

meal made with locally sourced ingredients. The market 

provides a subsidy for low-income residents, so it’s a great 

resource for the community.

Participants received a voucher for the market, so even if they didn’t qualify for the subsidy, they 

received a discount that day. We advertised through our online newsletter and had people who had 

never participated in a congregate meal attend because they were interested in the topic. We also 

targeted senior living buildings within walking distance of the market and saw many people come in that 

way.

You may also be interested in these resources...

• Evidence Based Programs Compendium (NCOA)

• National Falls Resource Center (NCOA)

• National CDSME Resource Center (NCOA)

• Health Leads Screening Toolkit

• Social Needs Screening: The EveryONE Project (AAFP)

• The Accountable Health Communities Health-Related Social Needs Screening Tool (CMS)

• Behavioral Health Resources (ACL)

• Resources for Serving Older Adults (SAMHSA)