INNOVATIONS IN 

NUTRITION PROGRAMS 

AND SERVICES 
WELCOME AND 

INTRODUCTIONS 
ACL Innovation 

Grant Funding 

Opportunities 

3 
ACL INNOVATIONS IN NUTRITION GRANT OPPORTUNITIES 

Demonstration 

• Funding opportunity 

number: 

HHS-2020-ACL-AOA-INNU0404 

• Application closing date: 

May 26, 2020 

• Funding amount: $250,000 

for each year of the 3-year 

project period 

Research 

• Funding opportunity number: 

HHS-2020-ACL-AOA-INNU-0403 

• Application closing date: 

May 26, 2020 

• Funding amount: $300,000 for 

each year of the 3-year project 

period 

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ACL INNOVATION CALL FOR GRANT REVIEWERS 

What is the responsibility of a grant reviewer? 

• Reviewers will independently review and score each of their assigned 

applications from their home or office and be compensated for each 

application reviewed. 

• An individual review can take approximately 3 hours per application. 

• Each reviewer will have approximately two weeks to review all assigned 

applications. 

• Reviewers will also be compensated for participating in 1 reviewer training 

and 1 panel call. The panel call will be scheduled for 3 hours and include 

discussion of strengths and weaknesses from each reviewer 

• Selected reviewers should have nutrition programming experience in the 

aging network and resumes or CVs should be submitted to annotate 

experience. We will train all reviewers in being equipped to handle this 

task, so don’t worry if you have not previously served as a reviewer for a 

discretionary grant program. 

• Please contact Mr. Phantane Sprowls at phantane.sprowls@acl.hhs.gov by 

Monday, May 4, 2020 with your resume if interested in becoming a 

reviewer for this grant program. 

@NRCNA_engAging
 

POLL QUESTION 

• What brought you here today? 

• I want to be more innovative in my program. 

• I want to learn from my peers. 

• I want to get new programming ideas. 

• I want to do more with technology. 

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TAKING CHARGE OF DIABETES 

Presenter: Susan Hayes, RD, LDN

Clinical Program Manager, Nutrition and Active 

Living, Health Promotion Council

April 21, 2020 

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INNOVATION STORY 

• Taking Charge addresses the gap in care transitions for older 

adults (65 and older), by offering a multi-component, homebased intervention to improve health outcomes at the patient 

level and reduce health care costs at the system level for adults 

65+ with Type 2 Diabetes. 

• Project Partners: 

Health Promotion Council 

Thomas Jefferson University Center for Urban Health 

Family Food LLC 

Thomas Jefferson University Hospital Primary Care 

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th outcomes and quality of life of adults age

65+ with Type 2 diabetes by establishing an innovative and 

replicable community-clinical

IMPROVE HEALTH OUTCOMES AND QUALITY OF LIFE OF ADULTS AGE 65+ WITH TYPE 2 

DIABETES BY ESTABLISHING AN INNOVATIVE COMMUNITY-CLINICAL INTEGRATION MODEL 

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1.Jefferson primary care team identified patient, confirms eligibility and consent and refers to Family Food LLC. 2. FFLC verifies health 

insurance MNT coverage, contacts patient and scheduled RD and HC visit. RD and HC conduct dietary assessment and nutrition education. 4: 

HC conducts shopping/cooking skill building session. Repeated 2-3times. RD provides meal planning. 5. RD adjusts meal plan and provides 

support. 6. Ongoing JPCT, HPC, and FFLLC support/communication. 7. Case closure. 

Process outcomes: increased program satisfaction. Increased program retention. Patient-reported 

outcomes: increase knowledge, increase behavior, complete action plan. Clinical outcomes: decrease 

ER visits, decrease HbA1c, increase medication adherence. 

• Improve heal
 

ACL TAKING CHARGE OF DIABETES PROGRAM RESULTS 

2018 78 eligible patients # patients contacted 

# patients enrolled in 

program 

28 2019 167 eligible patients 105 Total 245 eligible patients 

❑ Completed RD MNT1 sessions: 

10 patients 36% 

❑ Completed RD MNT2 & 

Health Coach Nutrition sessions: 

7 patients 25% Completed ACL Taking Charge Program: ❑ Completed HC Cooking Shopping sessions: 3 patients 11% 3 patients 11% 

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PROGRAMMATIC OUTCOMES 

• 100% of JPCT, HPC and CUH reporting satisfaction with the care 

coordination system. 

• Among Taking Charge participants who completed the program, 

100% reported satisfaction with the overall program. 

• 80% of Taking Charge program participants attended 40% of 

scheduled sessions. 

• Utilizing the tracking tools, referral protocol and forms approved by 

IRB, 100% of Taking Charge participants seen by the Health Coach 

were offered referral services 

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PATIENT CENTERED OUTCOMES 

• Eight patients out of thirteen who received medical nutrition 

therapy through Taking Charge reported to visit the ED at least 

once after being enrolled in the program. 

• 100% of Taking Charge participants demonstrated increased 

knowledge and self-efficacy related to healthy eating and 

diabetes management. 

• 67% of Taking Charge participants reported positive behavior 

change related to healthy eating and diabetes management. 

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PATIENT CENTERED OUTCOMES CONT. 

• Due to restrictions and limitation in accessing medical records, 

Taking Charge was unable to assess medication adherence as 

prescribed. 

• 56% of Taking Charge patients (whose data was available to 

assess) showed a reduction in hemoglobin A1c within 12 

months as noted in their medical record. 

• Utilizing the tracking tool, protocol and instruments approved 

by IRB, 67% of Taking Charge participants achieved at least one 

of their personal action plan goals (included major dietary 

changes to better manage diabetes). 

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KEY CHALLENGES 

❖Participant Enrollment 

❖Patient Interest in Taking Charge 

❖Social Determinants of Health 

❖Data Access and Billing 

❖Partnerships 

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SUGGESTIONS FOR REPLICATION/ADVICE TO PEERS 

Funding: 

If justifying a budget to cover the planning period is an issue, factor into overall 

budget or consider applying for additional funding elsewhere. Start up time can 

be significantly long depending on legal, contracts, IRB and other institutional 

restrictions. 

Technology: 

Consider providing in-home health education using telehealth. Technology can 

potentially be used to do both individual and group activities/classes. 

Consider having a robust system to access medical records and billing system 

for all partners involved in the project to facilitate referral, scheduling and loop 

back to provider. 

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SUGGESTIONS FOR REPLICATION/ADVICE TO PEERS 

Partnership: 

Partner with an organization or health care institutions that has RDs who 

can provide MNT and capability for billing services already in place. 

Partner with a local community organization as they are deeply connected 

with the community and understand the needs, challenges, and resources 

available to patients. 

Staffing: 

Staffing would require a program coordinator to manage the 

communication needed for all the moving pieces and partnerships involved 

as well as ensuring services are provided as proposed. 

@NRCNA_engAging
THANK YOU 

Susan Hayes, RD, LDN 

suhayes@phmc.org 

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7 
LINN COUNTY INNOVATIONS IN NUTRITION 

PROGRAM 

ENCORE CAFÉ 

TIM GETTY, MBA

HERITAGE AREA AGENCY ON AGING

April 21, 2020 

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INNOVATION STORY 

Heritage AAA experienced 

Site Closures 74% decline in congregate 

meal participation 2011-

2017 

74% 

Lack of awareness of 

AAA in Iowa’s 2nd largest 

metro area 

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PROJECT DESCRIPTION 

A Second Call to Enhance Your Health 

• Four pop-up, catered sites in community buildings 

• Library, Senior Center, Church, and Parks Building 

• Salad Bars & Choice Menus 

• Flexible Serving time 11:30am-12:30pm 

• Evidence-Based Programming and Nutrition Education 

offered 

• 2.0 Total FTEs and 12 active volunteers 

• Successful Project Partners 

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KEY LEARNING(S) 

“The food has been tasty with generous portions. The ladies have

been very helpful and friendly. I appreciated the fresh produce to 

take home. Nice visit with Steve and his service dog Peyton. 

Eating is great at Encore Café. Catering by Hy-Vee has been 

exceptional.”

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DATA 

Congregate Participants Congregate Meals 

Linn County Linn County 

1400 12000 

Encore Café Participant Age 1200 

10000 0.83% 

4.72% 

1000 

8000 

800 

6000 

600 

4000 

400 

2000 

23.33% 

43.06% 

28.33% 

200 

Age 60-69 Age 70-79 Age 80-89 Age 90-99 Age 100+ 

0 0 

Participants Meals 

FY2017 FY2018 FY2019 FY2017 FY2018 FY2019 

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FY2018

FY2019

FY2018

FY2019

23.33% age 60-69

4.72% Age 90-99

43.06% Age 70-79

28.33% Age 80-89

.83% Age 100+
DATA 

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KEY CHALLENGES OVERCOME 

• Staff turnover 

• Catering through regional 

grocery store and nutrition 

requirements 

• Attendance outgrew sites 

• Meal site purpose confusion 

for participants and others 

• Chef demonstrations and 

the audience 

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PROJECT IMPACT 

• Increased participation 

• Increased 

awareness/community 

partnerships 

• Replicable service model 

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5 
SUGGESTIONS FOR REPLICATION 

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• Collaborate in 

unconventional ways 

• Grand Opening events and 

marketing 

• Quality and choice for 

different generations 
ADVICE TO PEERS 

• Allow for flexibility 

• Make project partners a 

priority 

@NRCNA_engAging
THANK YOU! 

TIM GETTY, MBA 

REGIONAL NUTRITION PROGRAM COORDINATOR 

HERITAGE AREA AGENCY ON AGING 

TIM.GETTY@KIRKLAND.EDU 

ALEXANDRA BAUMAN, RD LDN 

NUTRITION, HEALTH & WELLNESS DIRECTOR 

IOWA DEPARTMENT ON AGING 

ALEXANDRA.BAUMAN@IOWA.GOV 

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8 
MARYLAND INNOVATIONS IN NUTRITION 

PROJECT 

MARYLAND DEPARTMENT OF AGING

April 21, 2020 

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INNOVATION STORY 

Purpose: Transform 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. 

@NRCNA_engAging
 

PROJECT DESCRIPTION 

• Design a replicable model for a hospital post-discharge 

malnutrition care pathway. 

• Create meal packages for older adults transitioning from 

hospital to home. 

• Enhance an existing Home Delivered Meal Priority 

Screening tool. 

• Evaluate the effectiveness of a community malnutrition 

awareness workshop. 

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PROJECT DESCRIPTION 

Malnutrition Pathway Toolkit 

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PROJECT DESCRIPTION 

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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.

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.

Easy to prepare

These foods were chosen because they are single-serve, 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
 

PROJECT DESCRIPTION 

Nadine Sahyoun, PhD, RD 

Professor of Nutritional Epidemiology 

Department of Nutrition and Food Science 

University of Maryland 

nsahyoun@umd.edu 

Available at: https://nfsc.umd.edu/extension/expanded-food-security-screener 

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PROJECT DESCRIPTION 

Available at: http://www.mdlivingwell.org/programs/stepping-up-nutrition/ 

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KEY LEARNING(S) 

• Community Based Malnutrition Pathways Toolkit 

– useful as nationally-replicable model 

• Meal packages 

– highly accepted, feasible 

– may have impact on reducing readmissions 

• Revitalized products 

– valued by AAAs 

– impact on consistent training and implementation 

• Use of a proven, award winning tool can strengthen a 

new project’s outcomes and success

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KEY CHALLENGES OVERCOME 

• Working with consultants. 

• Greater than expected internal workload. 

• Delays in learning curve, capturing data and receiving 

outcomes. 

• Universities and the aging network work at different 

paces, affecting deliverable timeliness. 

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NUTRITION 

STEPPING UP YOUR NUTRITION 

Risk at baseline (n =429) 

SCREEN II - Nutritional Risk 

• Average risk score 44.1 (+8.4) 

• 70% high nutrition risk 

• 20% moderate nutrition risk 

• 10% no/low nutrition risk 

Fall-Related Risk

• 21 % reported a recent fall 

Nutrition Barriers and Meal Isolation 

· 17% "never/rarely" eat with someone daily 

· 17% "often/sometimes" ran out of food 

· 53% "often/sometimes" skipped meals 

• 48% of those who fell reported an injury 

• 16% fearful of falling "a lot" 

• 27% fearful of fall ing "somewhat"

on Nutrition • 

DATA 

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DATA 

POST-DISCHARGE, MEDICALLY-TAILORED SHELF STABLE MEALS 

• Health Care Utilization: 54% reduction in 30-day readmissions. 

• Client surveys: 

– 95% - packages helped them recover. 

– 92% - packages met their nutritional needs based on their health condition. 

– 89% - easy to get the packages at hospital discharge and at the follow-up 

visit 

– 85% - packages helped them manage their health condition. 

– 82% - packages provided them with food otherwise unable to buy or shop 

for. 

– 82% - packages provided food when they had difficulty preparing their own 

meals. 

– 86% - packages helped them eat healthier food. 

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PROJECT IMPACT 

• Promising healthcare impact data for meal packages. A 

separate Department grant (ADRC) is offering the meal 

packages with subgrantees. 

• All components of the grant are replicable across US. 

• Grant significantly impacted the spread of a malnutrition 

awareness Session 0 across the state. 

• AAA has received grant funding for consultant to implement 

the malnutrition pathway. 

• Post-discharge meal peer network group continues. 

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0 
 

 

 

 

 

SUGGESTIONS FOR REPLICATION 

• The RD consultants continue offering the meal packages. 

https://sites.google.com/bnws.co/bnws-meals/home. It is being 

used in projects with hospitals, physicians' offices and AAAs. 

• The Stepping Up Your Nutrition program is sustainable and is 

offered nationally via https://www.steppingupyournutrition.com/ 

• Toolkit: “Addressing Malnutrition in Community Living Older Adults: 

A Toolkit for Area Agencies on Aging.”

• HDM Priority Screening Tool: Training Manual, embedded excel, 

Paper screening tool, and instructions to access the “app” . Contact 

nsahyoun@umd.edu. 

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ADVICE TO PEERS 

• Limit the scope of projects, as each component 

requires oversight, management and data 

collection. Focus applications on grant 

requirements. 

• Ensure adequate personnel to run day-to-day 

tasks. 

• Don’t work in isolation - reach out to others. Many 

thanks to everyone who shared with us! 

@NRCNA_engAging
THANK YOU! 

JUDY SIMON, MS, RD, LDN 

JUDY.SIMON@MARYLAND.GOV 

4 

3 
ROUND ROBIN 

44 
 

 

 

 

 

 

ROUND ROBIN QUESTIONS 

• Describe how your project was in fact ‘ innovative’?

• How will your innovation project(s) be sustained? 

• What new partner(s) did your organization engage/does 

your organization plan to engage with going forward to 

grow or sustain the new nutrition programs/services you 

have established? 

• Discuss any COVID-19 changes to how your innovation 

project is being currently implemented. 

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4

6

QUESTIONS AND ANSWERS 

@NRCNA_engAging
POLL QUESTION 

• Please select the areas below that you feel it 

easiest for your organization to be innovative 

(select all that apply): 

• Partnerships 

• Technology 

• Service delivery 

• Marketing 

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2017 

ACL INNOVATIONS IN 

NUTRITION PROGRAMS 

AND SERVICES HUB 

48 
RESOURCE HUB OVERVIEW 

Website: https://nutritionandaging.org/innovation-services-hub/ 

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RESOURCE HUB OVERVIEW 

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AVAILABLE NRCNA/COVID-19 RESOURCES 

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• Title Text

THANK YOU 

– Body Level Five

PLEASE COMPLETE 

THE EVALUATION