Nourishing Seniors Through 

Medically Tailored Meals 

The National 

Resource Center on 

Nutrition & Aging 

August 8, 2019 Proceedings 

Convened by the 

National Resource Center on 

Nutrition and Aging 

Arlington, Virginia 

Written by: Elaine Furlow 
Introduction 

This event was hosted by the National Resource Center on Nutrition 

and Aging with support from the Administration for Community 

Living, Grant Number 90PPNU0001. 

National Resource Center on Nutrition and Aging (NRCNA) 

www.nutritionandaging.org 

1550 Crystal Drive, Suite 1004 

Arlington, Virginia 22202 

(888) 998-6325

About the National Resource Center on 

Nutrition and Aging 

Hosted by Meals on Wheels America as part of a 

cooperative agreement with the Administration for 

Community Living, the National Resource Center on 

Nutrition and Aging (NRCNA) is designed to build the 

capacity of the aging services network to provide nutrition 

services for current and future older adult populations 

integrated into a home and community-based service 

system. The NRCNA also provides training and technical 

assistance to the aging network regarding nutrition 

services. 

Event Overview 

For this convening, keynote speaker Katie Garfield, clinical 

instructor at the Center for Health Law and Policy Innovation 

of Harvard Law School, kicked off the day. Three speakers 

presented local success stories (Leslie Scotland-Stewart, Director 

of Health Care Innovation at Project Angel Heart, Colorado; 

Jean Terranova, leader of the Food is Medicine policy initiative, 

Massachusetts; and Alissa Wassung, Director of Policy and Planning 

at God’s Love We Deliver, New York City). Afterward, small group 

discussions were led by trained moderators and recorders. All findings in 

this Proceedings document have been generalized from transcripts and 

the groups’ observations. The graphic images were recorded on-site and 

reflect a quick summary of the discussions. The graphic images and ideas 

within them reflect the perceptions and experience of local program 

participants and are not the opinions or views of the funders or convener. 
Contents 

Executive Summary................................................................................................. 1 

1. The Opportunity................................................................................................... 3 

A. The Unmet Need .....................................................................................................4 

B. Research on What Works .......................................................................................5 

C. Opportunities for Integration with Health Care ..................................................5 

D. Research Gaps and Access Gaps...........................................................................5 

2. Different Service Models..................................................................................... 7 

A. Project Angel Heart (Colorado)..............................................................................7 

B. God’s Love We Deliver (New York City).................................................................7 

C. Community Servings (Massachusetts)..................................................................8 

3. Participants’ Insights........................................................................................... 10 

A. Reflections: What Holds Promise for Your Organization ...................................10 

B. Concerns and Questions........................................................................................10 

C. Opportunities/Challenges in Establishing MTM Programs ................................10 

4. Solutions for Building the Movement ............................................................... 13 

A. Developing a Local MTM Program........................................................................13 

B. Propelling MTMs at the National Level.................................................................14 

5. A Call to Action..................................................................................................... 15 

Appendix ................................................................................................................... 19 

Speaker Biographies ....................................................................................................19 

Endnotes........................................................................................................................20
Executive Summary 

For older Americans coping with 

chronic illness, part of the prescription 

for health just might be the right 

nutritious meal, tailored to special 

medical needs, delivered to one’s 

doorstep. A growing number of 

experts and healthcare professionals 

think that such medically tailored 

meals (MTMs) look like a promising 

solution to both boost quality of life 

and trim healthcare costs. 

That’s because the number of older 

adults in America is growing quickly, 

overwhelming the resources available 

to help them—especially the most 

vulnerable ones—and jeopardizing 

their health and well-being. For 

some older adults, the lack of access 

to nutritious food is a particular 

challenge. Food insecurity, meaning 

lack of consistent access to enough 

food because of a lack of resources, 

can lead to malnutrition, and both 

conditions are associated with high 

annual healthcare costs. 

Enter MTMs. MTMs “are delivered to 

individuals living with severe illness 

through a referral from a medical 

professional or healthcare plan. Meal 

plans are tailored to the medical 

needs of the recipient by a Registered 

Dietitian Nutritionist (RDN), and are 

designed to improve health outcomes, 

lower cost of care and increase patient 

satisfaction.” 

This is significant because recipients 

of MTMs can be some of the highest 

need and higher cost patients to 

treat. There is growing evidence that 

MTMs can lower healthcare costs. For 

instance, the Community Servings 

program in Massachusetts has led 

three clinical research studies that 

found a 16% net reduction in average 

monthly costs for patients who 

received their MTMs. 

To further explore the potential 

of MTMs, the National Resource 

Center on Nutrition and Aging 

(NRCNA) hosted a day-long session 

in Arlington, Virginia, on August 8, 

2019. Participants heard evidencebased research on the healthcare 

cost savings from MTM programs 

and firsthand accounts from three 

programs that employ different 

models to suit their differing local 

situations. 

In small groups, participants voiced 

initial reflections and concerns. They 

expressed interest in information 

on how to fund MTM services, 

talked about how to bridge the 

different worlds of social science and 

healthcare, and outlined needs for 

research and infrastructure. They 

discussed and better understood 

the operational impacts of these 

programs and how best to address 

them. Participants also explored ideas 

for “building the apparatus,” for how 

to start offering MTM services such 

as playbooks on reimbursement, 

referrals and stakeholder analysis. 

They saw a need for a comprehensive 

picture of the national competitive 

landscape, available data and cost 

range of MTMs. Currently there 

is a lack of national standards, 

requirements and capacity, (including 

varying access to registered dietitians). 

A diversity of programs are at work. 

Many local models have sprung up, 

shaped by each state’s different 

populations, needs, regulations, 

healthcare structures, culture and 

opportunities. Community-based 

organizations (CBOs) that shared 

success stories include Community 

Servings (Massachusetts), God’s Love 

We Deliver (New York City) and Project 

Angel Heart (Colorado). Launching 

such local programs, generally in 

public-private partnerships, can take 

time, yet a growing number of leaders 

are committed to finding what works 

and meets the concerns of payers 

and healthcare providers in their 

communities. 

The NRCNA is responding to a need 

for thinking strategically, setting 

priorities, building infrastructure and 

business development, nurturing 

continued regional/national 

conversations, identifying training 

needs and providing technical help 

on such challenges as strengthening 

referral systems. 

Participants heard that at the local 

level, proving that MTMs reduce 

healthcare costs and improve 

individuals’ health is a critical first 

step before exploring partnerships, 

launching pilots or expanding 

current programs. Practitioners 

must first have evidence-based data, 

characteristics of target populations, 

and proof of ROI in hand—all tailored 

to the needs and structure of potential 

payers. (A payer could be any entity, 

such as a hospital, a private health 

insurer or government healthcare 

provider such as the Centers for 

Medicare or Medicaid Services, for 

example.) Then as with any new 

business opportunity, leaders must 

identify best practices, understand 

the training needed, develop reliable 

business models, and create practical, 

strategic paths for practitioners. 

Many questions from participants 

were practical, such as how to price 

MTM services and how to determine 

which portion of a population to 

serve. Other issues require culture 

shifts and change management, such 

as bridging the different mindsets 

between the social service/aging 

services and medical worlds. 

By providing thought leadership 

on both the local and national 

levels, the NRCNA aims to support a 

sustained MTM movement, nurtured 

by convening such discussions and 

partnering with like-minded others. 

1 
2 

Nourishing Seniors Through Medically Tailored Meals:

Food is medicine -> 5.5 million people are food insecure (double since 2001) -> Domino Effect (I have to make a hard choice) -> Solution? -> 

Medicine Pyramid -> Showing Health Outcomes! -> Spectrum of Needs -> Food is love (Client as a whole family) -> 90% living with more than 1 

condition -> Collaboration & partnership -> Prayers, Providers Government -> Show where there is Impact -> Think like a Start-up (Planning, 

Referrals, Reimbursements, Methods, Capacity).

Opportunities: Leverage Existing Reimbursement Systems; HC Cost Environment; Desire to get in Home; CHS Center for Innovation/broader NIH 

Studies; Robust Hearth-Care System; More Data.

Challenges: Local Population & Need; Mindset/Culture Change; Competitive Landscape; Lack of National for Consistent Standards; Building the 

Apparatus. 

Ideas: ID funders of Select Population; Outreach to HC Professionals; Proactively Market Outreach; Tell Story; Access Data from Partnerships; 

Landscape Relationship; Layout Opportunities; Understand Funding. 
1. The Opportunity 

(Synthesized from remarks by keynote 

speaker Katie Garfield, JD, Clinical 

Instructor at the Center for Health Law 

and Policy Innovation of Harvard Law 

School.)

For people living with serious health 

conditions, health and food are linked. 

A growing number of older adults 

in America lack consistent access 

to quality food and also suffer from 

chronic diseases such as diabetes or 

renal failure. While the healthcare 

system has tended to their immediate 

medical needs, looking at “the whole 

person”—including meals at home 

and how meals can be tailored to 

medical needs—can uncover a new 

way of helping to address their 

problems. 

This new focus is medically tailored 

meals (MTMs). Medically tailored 

meals “are delivered to individuals 

living with severe illness through a 

referral from a medical professional 

or healthcare plan. Meal plans are 

tailored to the medical needs of the 

recipient by a Registered Dietitian 

Nutritionist (RDN), and are designed 

to improve health outcomes, lower 

cost of care and increase patient 

satisfaction.” 

As MTM programs are being 

integrated into the healthcare system, 

the need for evidence-based results 

and data has increased. In particular, 

payers are primarily interested in 

approaches that can show compelling 

evidence of how costs are trimmed— 

such as by reducing readmissions 

or emergency room visits—and how 

patient care improves. 

Community-based organizations 

(CBOs) have an opportunity to develop 

effective MTM programs, targeting 

some of their services to local needs 

as expressed by healthcare providers 

and payers. The road from idea to 

rollout may be bumpy. Yet armed with 

an understanding of research, ROI, 

innovative demonstration projects, 

and back-end basics like referral 

systems, the opportunities are vast. 

The rewards? Seeing better health 

results for individuals (particularly 

older adults), and bending the curve 

on healthcare costs downward. 

A. THE UNMET NEED

Nationally, 5.5 million older adults 

are food insecure, or more than 

double the number in 2001. Food 

insecure percentages of the older 

adult population range from 2.8% in 

Minnesota, the lowest, to Louisiana at 

12.3%, the highest. 

Further challenges include vision loss 

and cognitive and physical changes. 

When consistently needing quality 

food, such a person faces tough 

choices. He may choose between 

food and other basic needs such 

as utilities, or consume low-cost, 

energy dense foods like potato chips. 

She may delay medical care, save 

money by using less medication than 

prescribed, or go without food needed 

for special medical diets. 

These hard choices lead to a domino 

effect, particularly if an older person is 

dealing with a chronic disease such as 

diabetes at the same time. It is striking 

to see the result of some of these hard 

choices. For instance, Seligman and 

colleagues found that hospitalizations 

for low-income, diabetic patients rose 

at the end of the month when food, 

finances and nutrition benefits such 

as SNAP (Supplemental Nutrition 

Assistance Program) were low. 

Hospitalizations, in turn, remained 

stable for middle- and upper-income 

households. 

Meanwhile as the severity of food 

insecurity increases, health conditions 

can worsen and healthcare costs 

can increase. For instance, Craig and 

Gunderson found that food insecure 

older adults were 57% more likely to 

have congestive heart failure than 

those who were not food insecure. 

Various “nutrition interventions”— 

from prevention to treatment—can 

help keep the negative health effects 

under control. Basic programs like 

SNAP and emergency food programs 

can help forestall the domino effect. 

Still, for some people, a basic meal 

is not enough. Seeing the concept 

of “food as medicine” in a pyramid 

diagram demonstrates “basic” needs 

at the base and a narrower slice at 

the top for those who need the more 

specialized MTMs. 

MTMs can help this smaller, yet even 

more vulnerable, slice of the older 

population who deals with severe or 

chronic illness, and often with multiple 

conditions. Though this is a smaller 

percentage of overall individuals in 

3 
4 

Nourishing Seniors Through Medically Tailored Meals:

Keynote Speaker Katie Garfield - Today (1 Baseline Medicine Meals, 2Why?) -> Problem 5.5 million people food insecure (Double since 2001) -> I have to make a heard choice! -> 65% Diabetic, 57% Hearth Failure -> Project Open Hand -> Project Angel Heart (COPD, Diabetes, CHF) -> 13% Rate Admission ->Community Servings 2019 16% Health Care 

Cost -> Take aways (medically tailored meals decreased, health care cost. Real change Partners (Medicare, Medicaid, Older Americans Act) -> 2020 Special supplemental benefits -> Issues (Dosing, transition, triaging), Gaps (Rural areas, non-coastal states).

HIV AIDS Programs (Health, Housing, FOOD, OUR Roots...), Food is Medicine -> What does data looks like? (High quality research) -> Medicine Pyramid -> Study means on wheel (stability, less depression, less anxiety) -> Declined Positive health outcomes -> Spectrum of Need -> 5% - pop %50 % cost -> Medically Tailored Meal -> Meals delivered secure 

tailored by licensed nationalist. 
need, these individuals consume a 

greater percentage of healthcare costs 

than do patients without severe or 

chronic illness. 

A 2015 study commissioned by 

Meals on Wheels America showed 

how the provision of basic daily 

meals improved recipients’ health 

and life. Compared to the waitlist 

group, daily meal recipients reported 

better health, less likelihood of falls, 

reduced feelings of isolation, and 

decreased depression and worry 

about being able to remain at home. 

A 2017 analysis of Medicare claims 

showed that rates of hospitalization, 

emergency department use and 

nursing home use all dropped after 

recipients began getting Meals on 

Wheels deliveries. The declines in 

healthcare use held up over 180 days. 

Such interventions are at the base 

of the Food Is Medicine pyramid 

(see page x). The pyramid conveys a 

continuum of services. 

The advent of MTM programs calls for 

still more research on implications for 

individual health and whether such 

meals can help put the brake on rising 

healthcare costs across the nation. 

B. RESEARCH ON WHAT 

WORKS 

If they seek to be providing these 

services, the organizations that 

are delivering an MTM program or 

contemplating providing MTMs must 

make the case to prospective payers 

for how they are lowering healthcare 

costs. Without evidence, payers and 

healthcare providers will not be 

interested. A handful of research 

studies illustrate how to deliver that 

proof. 

In one study in Philadelphia, MANNA 

clients who were critically ill and 

nutritionally at-risk showed 50% fewer 

hospital admissions and 31% lower 

mean monthly healthcare costs after 

a year, compared to a control group. 

This was largely because MANNA 

clients were using fewer high-cost 

services. 

Project Open Hand in San Francisco 

took a look at how some hard 

choices faced by resource limited 

individuals described earlier played 

out when medically appropriate food 

was added. The program showed 

decreased trade-offs. While 34.6% 

of those served had sacrificed 

health care for food previously, for 

instance, only 15.4% did so after the 

intervention. 

Project Angel Heart in Colorado used 

health insurance claim data for a pre/ 

post-comparison. After a six-month 

intervention for adults diagnosed with 

diseases such as cancer, congestive 

heart failure, multiple sclerosis and 

diabetes, hospital readmissions 

showed a 13% decrease. For 

congestive heart failure, for instance, 

there was a $736.00 cost reduction 

per member, per month. 

Cost savings evidence takes on 

additional weight when data show 

the net savings after provision of 

the MTMs. A study from Community 

Servings in Boston did just that as 

it looked at patients dually-eligible 

for Medicare and Medicaid who had 

received MTMs. This group had 52% 

lower hospitalization rates and 16% 

lower healthcare costs after meals 

were paid for. A follow-up study, with 

a wider patient mix and larger sample 

size, found a similar 16% net reduction 

in healthcare costs after paying for the 

meals and delivery. 

C. OPPORTUNITIES FOR 

INTEGRATION WITH HEALTH 

CARE 

As interest in MTMs increases, 

there is opportunity and incentive 

for greater coordination with 

healthcare providers. One concrete 

opportunity comes in 2020, when 

Medicare Advantage plans will allow 

special supplemental benefits for 

the chronically ill. That can mean 

greater options for providing meals 

to chronically ill individuals, and 

a particular opportunity for CBOs 

to consider MTMs. Potential MTM 

providers might look at Medicaid 

waiver programs (1115, 1915[c]) for 

support. 

For senior nutrition program 

providers, it is increasingly important 

to integrate with healthcare structures 

and to prove ROI. Providers must 

demonstrate that:

• MTMs can help get the right 

nutrition intervention to the right 

client. 

• MTMs can help maximize health 

outcomes, quality of life, and save 

healthcare dollars. 

These critical considerations come 

up on the back end, as well as when 

making the initial referral of a patient 

to a meal provider. Evidence-based 

data matter in crafting proposals 

that could resonate with healthcare 

providers’ areas of greatest need for 

cost savings. 

D. RESEARCH GAPS AND 

ACCESS GAPS 

Getting the right individual connected 

to the right nutrition intervention will 

continue to be a priority, so additional 

research could be done on triage and 

which intervention makes sense. For 

instance, non-tailored meals might 

work better than MTMs for certain 

clients. Additionally, one intervention 

might be appropriate for the acute 

phase after hospital discharge, while a 

transition to other interventions could 

be appropriate several months later. 

The question of dosing also needs 

further study. How many meals per 

week, for how many weeks? How 

5 
personalized and tailored can MTMs 

be when a client has several medical 

conditions and resources may be 

limited? 

The national competitive landscape 

needs to be more thoroughly studied. 

As the MTM field expands, traditional 

social service meal providers will focus 

not only on their own ROI and valueadd proposition, but on how to stay 

competitive in the broader landscape. 

MTM programs so far have tended to 

be in urban areas or along the East 

and West Coasts. More work needs 

to be done in non-coastal states 

and in rural areas to ensure access 

and quality remain high for all older 

Americans who might benefit. Since 

the overall need is great, research 

also needs to explore which target 

populations will see the greatest 

benefit, both on health outcomes and 

healthcare costs. 

6 
2. Different Service Models 

While practices in MTMs are 

standardized, MTM programs 

have developed with flexibility and 

diversity. Every state is different in 

its needs, people, regulations, variety 

of healthcare providers and meal 

providers, and even the number 

of registered dietitians who could 

be tapped for such an endeavor. 

These models show a range of 

services, population needs/focus, 

and structures. Their very diversity 

illustrates the possibilities and 

promise of MTM programs. 

A. PROJECT ANGEL HEART 

(COLORADO) 

(Synthesized from remarks by 

Leslie Scotland-Stewart, Director of 

Health Care Innovation at Project 

Angel Heart) 

Approach. Project Angel Heart began 

in 1991 and now provides MTMs 

throughout the state of Colorado. 

While meals can be volunteerdelivered in urban centers such as 

Denver and Colorado Springs, much 

of the state is rural, so the program 

had to develop a reliable shipping 

model. Now frozen meals can be sent 

to towns on the state’s eastern and 

western edges, more than 200 miles 

from Denver. Having an efficient 

shipping model was key to being able 

to get Medicaid reimbursement. And 

having food within 24 hours after 

hospital discharge was another proof 

point getting healthcare providers and 

reimbursers interested. 

Challenges. The program was 

one of the first in Colorado to do 

a reimbursement contract with 

healthcare providers. But the road 

was not easy. Project Angel Heart 

leaders had to be able to say to 

providers, “If you invest a dollar in 

MTMs, here is what you’ll be getting.” 

It took two years of relationshipbuilding, showing the value-add and 

data, and advocating nonstop. 

Another challenge was transitioning 

from a meal-for-free mindset to 

getting reimbursed for referrals 

and meals. In many places, food is 

still seen as a charity, rather than 

as part of the healthcare regimen. 

One participant recalled a patient 

with congestive heart failure who 

was offered a tailored low-salt meal. 

“Oh, no,” replied the client,” give it 

to someone who really needs it.” 

The takeaway from that exchange 

was the need to better frame their 

MTM service, both to clients and to 

partners. 

Opportunities. Among the program’s 

eight partnerships: a hospital system 

and a “money follows the person” 

demonstration (Medicaid waiver). As 

a CBO, Project Angel Heart found it 

needed to up its game in terms of 

making referrals simple, easy and 

quick. Setting up a referral system 

was one thing, but actually getting the 

referral was another. Finding the right 

person in the hospital to make the 

referral, who also had the time to do 

so, made a difference. Project Angel 

Heart leaders focused on outcomes, 

who would care about the results, 

how they would get the necessary 

data, and how to relate it to money 

saved. For instance, by using health 

insurance claim data, 

Project Angel Heart found that after 

a six-month intervention for adults 

diagnosed with diseases such as 

cancer, congestive heart failure, 

multiple sclerosis and diabetes, 

hospital readmissions showed a 13% 

decrease in one project. Zeroing in on 

the costly components of health care, 

such as readmissions or emergency 

room visits, helped make the case for 

investing in MTMs. 

As they moved toward MTMs, 

program leaders had to start 

thinking like a start-up, and snap up 

opportunities when they arose. One 

innovative example: Paramedics now 

carry meals in their vans’ freezers, 

so when they encounter certain 

situations and needs, the nutritious 

food is right at hand. 

Looking back, Project Angel Heart 

compares its operations then and 

now, in the current day. “Then” was 

delivering meals and knowing the 

work was needed and good “because 

we got lovely stories.” Today is a more 

focused delivery of MTMs, based 

on medical needs, and the ability to 

concretely show impact. 

B. GOD’S LOVE WE DELIVER 

(NEW YORK CITY) 

(Synthesized from remarks by Alissa 

Wassung, Director of Policy and Planning 

at God’s Love We Deliver.)

Approach. This program delivers 

meals to people of all ages and 

incomes, but primarily low-income 

individuals. An average of 7,500 

meals are cooked and delivered each 

weekday, for a total of 1.9 million 

meals to 7,600 people each year. 

Cheerful red-and-white vans go to 

all five New York City boroughs and 

almost all the surrounding counties. 

The program started in 1986, and 

since 2005, the number of meals 

served has grown to 400,000 a year. 

The program started in 1985 as a 

service to people living with HIV, and 

later expanded to people with more 

than 200 different diagnoses. Some of 

the most common primary diagnoses 

now are cardiovascular disease, 

cancer, HIV and kidney disease. Yet 

it is important to note that 43% of 

recipients deal with more than five 

diagnoses at once, a statistic from 

God’s Love We Deliver’s proprietary 

database. 

A healthcare professional’s referral 

is key, and a team of seven RDNs 

makes nutrition assessments. The 

program can provide from 1-21 meals 

per week, plus ongoing, unlimited 

nutrition counseling. RDNs tailor 

7 the MTMs plans to a client’s unique 
8 

Panel Discussion: God Loves we Deliver (15,000 Volunteers), (we server all ages Income); Complex Medical Conditions (HIV, CFD, Cancer); 90% Over Living 

w/more than 1 condition; Value Prep keeping People at home; Capabilities (Know Policy, Start W/End, Valve Prep, Operations, Contracting Negotiation; Project 

Angel Hearth; Reimbursement/Tailor Meal Plan; Research THRU Healthcare Lens; Managed Care Plans; Medicate Advantage; Flexible Services; Food is 

Medicine State Plan.

Food is Love Food is Medicine; Meal Prep To Nourish their Soul; Every State looks different; Journey; 45% 65+ age show there is Impact; What can you offer?; 

Community Para medicine and Outcome, 71% Copying With more than 1 Values; Community Based Approach; Focused on Reimbursement; Medically Tailored 

Meals. 
medical situation, and they could 

range from high fiber/low fat for heart 

disease to pureed/minced for a cancer 

patient, in addition to multiple other 

combinations. For patients with such 

diseases, appetite is often one of the 

first things to falter, so the program 

works hard not to sacrifice flavor, 

choice or color. It starts with fresh 

ingredients with no preservatives, 

starters or fillers, and uses flash 

freezing for freshness and taste. 

The program also delivers a special 

cake on each client’s birthday, and 

emergency meals during blizzards or 

blackouts. 

MTMs are part of a high-quality 

continuum of care. So collaboration 

with a variety of stakeholders—from 

policy-makers to payers to providers— 

remains important. 

Because God’s Love has focused on 

breaking down the walls between 

hospitals and the community, it has 

several pilots with hospital systems. A 

sample:

• 30-day Care Transitions Pilot. 

Looks at efficacy of referral to

MTMs post-discharge within the 

30-day window. This is a focus in 

Medicare so that patients don’t 

rebound to the hospital. 

• Congestive Heart Failure Pilot. 

Tests efficacy of MTMs postdischarge using a validated tool 

against a randomized control. 

In building partnerships, God’s Love 

advises other CBOs to clearly craft 

their value proposition and know what 

they can do going in. 

Payers. God’s Love has 24 contracts 

with Medicaid Managed Long-Term 

Care. In mainstream Medicaid, 

there’s an emphasis on value-based 

payment as the prevalence of chronic 

illness grows. Like other programs, 

God’s Love looks forward to 2020, 

when home-delivered meals can be 

added to Medicare Advantage for 

chronically ill enrollees who are at risk 

for hospitalization or who need care 

coordination. 

The population will influence the 

service offered, and the policy 

in one’s state will help shape the 

scope. Different funding streams 

have different requirements and will 

determine the contracting target. 

For instance, the Ryan White federal 

funding stream changed to allow 

MTMs as a core medical service. 

C. COMMUNITY SERVINGS

(MASSACHUSETTS)

(Synthesized from remarks by Jean 

Terranova, who leads the Food is 

Medicine policy initiative.) 

Approach. Community Servings is a 

nonprofit organization with a 30-year 

history of providing scratch-made 

MTMs to chronically and critically ill 

individuals and their families. It was 

founded in 1990 to provide homedelivered meals to people living 

with HIV/AIDS. As those individuals 

survived, they also had chronic health 

conditions, and the program evolved 

with them. 

Today it provides MTMs to 2,300 

high-need people a year with 

multiple chronic conditions. The main 

diagnoses are HIV/AIDS (32%), cancer 

(20%) and renal failure (18%). About 

30% of clients are over age 60. 

MTMS are cooked with whole, fresh 

ingredients, home-delivered five 

days a week (lunch, dinner, snack) 

after an initial nutrition assessment. 

Menus are developed by an RDN and 

trained chefs, and assessed over time 

as needs evolve. Customization is 

important because when an individual 

has multiple chronic conditions, no 

single meal selection might fit.

Recipients of MTMs can be some of 

the highest need, higher cost patients 

to treat, so healthcare providers are 

increasingly interested in seeing how 

MTMs can improve outcomes and 

lower costs. Community Servings has 

led three clinical research studies that 

found a 16% net reduction in average 

monthly costs for patients who 

received their MTMs, and significant 

improvements in dietary quality and 

self-efficacy in disease management. 

Savings came primarily from areas 

like reduced emergency room use, 

reduced hospital admissions, and 

fewer admissions to skilled nursing 

facilities. 

Proving an ROI was eye-catching and 

launched Community Servings into 

collaborations with decision-makers 

at bigger institutions. “But the ROI 

by itself may not be enough,” said 

one leader. “It was important to be 

pertinent to a payer’s population, 

to understand the payer’s referral 

process and care structure, and tailor 

a proposal to each existing structure.”

Payers. Community Servings has six 

contracts with insurers, for the most 

part being reimbursed by managed 

care plans serving individuals dually 

eligible for Medicaid and Medicare. 

They also are piloting reimbursement 

through a Medicare Advantage plan. 

Understanding that payers likely will 

not provide MTMs forever, they also 

are working on a transition plan for 

long-term sustainability. 

Opportunities. On the local level, 

Community Servings includes 

nutrition education (workshops, 

web, counseling and assessments) 

and Teaching Kitchen, a 12-week 

foodservice job training program 

for individuals facing barriers to 

employment, with 80% of graduates 

finding meaningful employment.

On the state level, Community 

Servings and the Center for Health 

9 
Law and Policy Innovation of Harvard 

Law School co-lead the Massachusetts’ 

Food is Medicine plan, which assesses 

nutrition access and need on the 

broader level. Its aim is to make 

systemic changes: provider education 

and buy-in, screening incentives, 

stronger referral systems with a 

seamless technology integration, 

scaling and replication by CBOs, and 

sustainable funding. 

10 
3. Participants’ Insights 

A. REFLECTIONS: WHAT 

HOLDS PROMISE FOR YOUR

ORGANIZATION 

Participants represented varying 

locations, experience, organizations, 

and types of populations served. Each 

had varied interests in MTMs. After 

discussing questions and ideas in 

small groups, their reflections gave 

a range of reactions from on-theground providers of meal services, 

professionals and others. 

• “To know that people are 

out there having successful 

campaigns, they are doing the 

work already—that has been 

really helpful to know.” 

• “The idea that healthcare 

providers are actively looking to 

make referrals for MTMs, which 

is interesting because as a meal 

provider, we are actively looking 

to get the referrals to work on— 

there is clearly a disconnect in the 

system.” 

• “The national system for MTMs 

needs to be flexible to meet the

needs of local communities—the 

process needs to start at the local 

level.” 

Participants appreciated the idea 

that not every person needs homedelivered MTMs, and that being 

responsive to a variety of nutrition 

and medical needs would continue 

to be paramount for providers and 

healthcare partners. (See Food is 

Medicine Pyramid, page x). They 

stressed that individuals should be 

referred to the most appropriate 

program to best use the dollars, so 

finding the right level of intervention 

for each client is key and then 

transitioning them between these 

levels will be crucial. 

B. CONCERNS AND 

QUESTIONS 

Participants were quick with their 

questions and concerns, particularly 

homing in on issues related to the 

costs of MTMs and funding sources. 

Funding and Costs. MTMs seem like 

a productive idea, yet who would 

fund this and how would that work? 

Participants expressed needs for more 

information on costs compared to 

regular meals, a solid business model, 

reimbursement plan, referral plan, 

and more business experience and 

research to know which partnerships 

to pursue. 

• “I foresee the greatest challenge 

is finding innovation/start-up

funding. It’s hard to change 

service delivery when your 

program budget is already tight,”

said one observer. “It goes back 

to the challenge of how to fund 

innovation just to get started and

then long enough to show trends

and hard, lasting data.” 

• “MTM programs are nutritionist/ 

health professional heavy, which 

is expensive, and many senior 

nutrition programs/non-profits 

will never have the money to 

support this,” cautioned one 

observer. 

“Different Worlds” and Silos.

Participants pointed out that to be 

successful, MTMs must bridge two 

different worlds—healthcare and 

social services—and operational 

barriers generally exist between these 

two systems. Thinking strategically 

about how to remove such barriers 

was an important insight. 

• “The healthcare side and social 

services side speak different

languages—everyone wants to 

do the right thing, but it’s hard to 

get there, and this is not a new 

problem,” said one observer. 

• “Ryan White [federal funding 

stream] had a medical model; 

Older Americans Act came in with 

social model (“as long as they get 

food it doesn’t matter”) so [they 

are] working with the homedelivered meal providers around 

the country.” 

Research. Before some programs 

could start providing MTMs, 

more research needs to be done, 

particularly among populations and 

areas that have not yet been studied 

in sufficient detail.

Infrastructure. Technology, 

compliance, data gathering and 

sharing, and robust referral systems 

were commonly mentioned concerns. 

Many questions fell in the operational 

area, such as billing capabilities, HIPAA 

compliance and IT. 

Coordination among Different 

Programs. Participants pointed out 

that the duration of MTMs and dosing 

is highly variable, depending on the 

client. Some clients might stay on 

the program until the end, while 

others with less severe conditions 

should eventually be transitioned 

to another community program. So 

programs—from food assistance to 

OAA programs to medical assistance— 

need to work together. 

One participant also mentioned an 

underlying concern: “People have 

different needs, so MTMs will not be 

appropriate for everyone, and we 

don’t want to get to a point at which 

healthcare companies will pay for 

MTMs but not for regular Meals on 

Wheels.” 

C. OPPORTUNITIES/ 

CHALLENGES IN 

ESTABLISHING MTM

PROGRAMS

Opportunities at the local level 

include a desire to respond to the 

holistic needs of older adults— 

nutrition, medical situations, and 

11 
social determinants of health (SDOH) 

such as socioeconomic status and 

connections to one’s community 

and other people. MTM programs 

also offer an avenue to enhance 

current meal services, find new 

funding opportunities, and serve a 

new population as there is growing 

acceptance of the MTMs concept. 

Opportunities at the national level 

include the ability to leverage existing 

reimbursement structures and 

systems, and the potential for new 

or additional funding. Additionally, 

there is room for innovation, such 

as working with the Innovation 

Center at CMS (Centers for Medicare 

and Medicaid), or being involved in 

demonstration projects and other 

research. 

Local challenges include operating 

outside the traditional aging network, 

and perhaps losing a sense of 

ownership and the ability to control. In 

addition, participants mentioned:

• Identifying the most appropriate 

populations to work with: by age, 

disability status and other factors 

• Ensuring meals meet religious, 

ethnic, cultural and regional tastes 

of individuals receiving MTM 

services 

• Creating effective partnerships 

(using referral systems, through 

supplier networks, and with 

regulators) 

• Ensuring quality control, 

contracting (less control over food 

quality). Many nutrition providers 

to older adults are contracted 

agencies that have little or no 

decision-making power; MTM 

initiatives may be challenging in 

these circumstances. 

• Recognizing geography, including 

rural vs urban and variety in what 

is available 

Major national challenges include:

• Needing a comprehensive picture 

of the national competitive 

landscape, data and cost range 

of MTMs (while understanding 

local variability and proprietary 

information). Such a study 

could include: total older adults 

in need, medical diagnoses, 

location, socioeconomic status, 

and what proportion is being 

served currently with MTMs. 

Some commercial alternatives 

are available as well, targeted for 

older adults. 

• Finding funding options 

and leveraging existing 

reimbursement structures and 

systems. 

• Building the apparatus and 

understanding operational 

impacts. Participants saw the 

need for change management, 

playbooks on reimbursement, 

referral, and stakeholder analysis. 

coverage, requirements and 

standards (including limited RDs/ 

RDNs). This could limit scalability. 

A diversity of programs are at 

work; it’s challenging to partner 

and coalesce as a national, 

standardized network. 

• Understanding national capacity, 

• Needing technical assistance on 

determining local population and 

need, as well as strategic focus to 

mesh with healthcare provider or 

payers’ greatest needs. 

• Becoming part of the healthcare 

system. There will likely be the 

need for a mindset and culture 

change as organizations with 

a social service background 

intersect with the medical/ 

healthcare structure. 

• Other challenges include 

acknowledging that MTMs tend 

to be different (more “restaurant” 

quality) than the meal typically 

provided by programs serving 

older adults. Does this create 

a friction point with traditional 

providers? If a national movement 

toward MTMs became stronger, 

there was hope that the social 

service mission of providing 

“basic” meals not be lost or 

diminished. 

Participants also voiced concerns 

about needing more communication 

on multiple levels: with other leaders 

who are involved with MTMs, with 

professionals making the referrals, 

with boards and stakeholders, and 

eventually with consumers who would 

need to become aware of services 

available and eligibility. As MTMs 

continue to emerge as a promising 

solution, the need for continued 

communication came up often. “We 

also should be talking about this in 

Age-Friendly Network circles—this 

is a large movement that is working 

toward making cities more friendly for 

older Americans,” said one observer. 

12 
13 

Breakout 1: Ideas; Reflections/Takeaways?; Insights; Considerations?; -> Medically Driven Meal Model; Medicine Pyramid; Funding Funding 

Funding; Social Determination of Health; H2 Identity Need; Surprised by funding; The “Need”; Cage Studies; Measure; Importance of regulation; 

Referrals & Reimbursements; Operational Challenges; Coalition of Food of Medicine; Diverging History; Pyramid Stood out; Agencies/Disconnect; 

Transition Down to Different levels; Interconnectedness; Learning from others; Assess Organization; Local Opportunities; Resources for Training; 

Source of Funding; Entrepreneurial/flexible; Leadership Buy-In; Partnerships; Pyramid; Validation Value of Meal; Distinguish MTMS; Scale /

Volume Needed; Building Local; Consider Prog. Size Production Contracted -> Lens-Mow? What About Others?.

Cost Pyramid ROI

Breakout 2: Challenges?; Ideas?; Solutions?; Building & Movement; Opportunities? Action Ideas?.

Main Challenges: Local Population & Need; Lack of National For Consistent Requirements or Standby; Mindset/Culture Change; Building the 

Apparatus; Money.

Opportunities: Leverage Existing Reimbursement System; CMS Center for Innovation/Broader NIH Studies; Robust Health Care System; Desire to 

get in Home; HC Cost Environment; More/More Data. 

ID Funders of select population; Outreach to HC Professionals; Proactively; Maret Outreach; Research Evidence Based Tell Story; Get Access to 

Data From Partnerships; Landscape; Relationship; Layout Opportunities; Understanding ability to fund MNT. 
4. Solutions for Building the Movement 

Understandably, CBOs that want to 

offer MTMs will want to concentrate 

on local options. At the same 

time, a national movement will be 

gathering steam and each local 

effort contributes to that. With that 

framework in mind, here are action 

steps and solutions. 

A. DEVELOPING A LOCAL 

MTM PROGRAM

What would it take to establish a new 

MTM program? What would a current 

provider of meals to older adults need 

to consider? Participants mentioned 

that if in the early “I’m interested” 

stage, interested CBOs could partner 

with a mentor, engage online with the 

MTM community, participate in state 

or regional follow-up discussions and/ 

or training, or have initial discussions 

with boards, healthcare providers and 

other leaders to debrief and gauge 

interest. A senior nutrition program 

might contact one’s Area Agency on 

Aging (AAA) or State Unit on Aging 

to explore regulatory or operational 

implications of offering MTMs locally, 

and if not, discover why. 

Focus and Scalability. Participants 

appreciated the Food is Medicine 

Pyramid (see page x) and the 

visualization of a tiered system where 

one might focus at various places, 

depending on the local population, 

need, funding possibilities and 

opportunity. Having a way to discuss 

scalability and practical implications 

was helpful. 

new MTM program to ensure the best 

chances of success. 

one’s ROI case responsive to the 

needs expressed by payers. Without 

reliable and up-to-date technology, 

an otherwise good program could 

founder. So mastering information 

sharing, referral feedback loops, and 

interoperability would be essential. 

Organizational Self-Assessment. It 

would be important to undertake 

a clear-eyed organizational selfassessment early on to see if an 

existing program is a good fit to serve 

MTMs. Some social service programs 

are adverse or simply not yet ready 

to provide a medical service or 

work within the healthcare system, 

participants observed. Organizations 

would need to consider how MTMs 

would mesh with an established 

system. Some organizations are ready 

and able to expand now, while others 

may need additional time. 

Leadership buy-in would matter at this 

early stage. One leader mused, “I am 

thinking of my board right now, and 

imagining those faces and who would 

respond how, and who I would have 

the first conversations with.” Finding a 

champion would be a boon, as well as 

agreement among stakeholders about 

the way forward. 

Educational Resources, Business 

Acumen. Participants wanted a 

basic playbook. While resources 

are available to learn the business 

concepts to initiate a successful MTM 

program, such training needs to be 

available for business beginners 

as well, they advised, and easily 

accessible, with perhaps some type 

of pairing or mentorship among 

meal providers. Others mentioned 

training available through ACL’s 

Business Acumen Institute, MTM 

Root Cause Coalition, the Aging and 

Disability Business Institute and 

other organizations. “There is a lot at 

risk for this for a social agency and 

it would require staff training, such 

as compliance with sensitive health 

information,” noted one observer. 

For some programs, logistics such as 

shipping capability could be a deciding 

factor in getting a reimbursement 

contract. And for all locations, 

ensuring equitable access—despite 

geography or other challenges— 

should be a key consideration. 

Community and Healthcare Provider 

Outreach and Collaboration. It 

would be important to showcase 

the expertise of programs for older 

adult nutrition and then identify 

opportunities to collaborate. Being 

able to strategically pinpoint funders 

of select participants in need would 

help successfully launch an MTM 

program, since not all funders share 

an issue or constituency of interest. 

To consider MTMs, an organization— 

especially one that has traditionally 

been more mission driven—would 

need increased awareness of the 

business aspects of MTMs, and skill 

in developing and maintaining new 

business processes. Understanding 

the local referral system and 

reimbursement processes would be 

critical. 

Knowledge of the Local Client 

Population. Knowing the medical 

needs of the local client population 

would be a key first step, in concert 

with a healthcare provider or payer. 

Likewise, it would be important to 

understand the intersection between 

these needs and SDOH such as 

income and social connectedness. 

Only then would it be possible to 

strategically determine how to tailor a 

Reliable Funding and Partnership 

Skills. Participants felt that 

partnerships should be in place, 

with roles for each partner explicitly 

defined and reassessed as time goes 

on. When preparing for contract 

negotiation, leaders must be crystal 

clear about what their program can 

provide, and what they are expecting 

from the payer. Newcomers to the 

MTM field would need clear-headed 

Data collection is an important issue: 

what information to collect, how 

to collect it, how to communicate 

it, and how to build on it to make 

14 
thinking about long-term expectations 

as they develop business models and 

focus on particular client populations. 

B. PROPELLING MTMs AT 

THE NATIONAL LEVEL 

What would it take to support 

and sustain interest MTMs across 

the national network of aging 

services organizations? What would 

organizations with national reach and 

impact need to consider to support 

action at the local level? Participants 

identified next steps for consideration.

Research on the Competitive National

Landscape. At the national level, 

participants saw the need for a better 

understanding of the comprehensive 

competitive landscape, with an 

estimate of number of persons in 

need and persons being served, 

broken down by income level, age 

range, type of disease and location. 

Such an overview would include totals 

of existing providers (commercial, 

local Meals on Wheels and others). 

how to do projections and realistic 

business cases (recognizing that each 

local situation is different).

On-the-Ground Guidebook.

Participants valued hearing case 

studies of programs that have had 

success (see Different Service Models, 

page x), how to leverage existing 

systems—what the state does, how 

funds flow, Medicare/Medicaid system 

and waiver programs, preventiveservice reimbursement opportunities, 

successful referral systems and ideas, 

and a section on costs of MTMs and 

Operational/Compliance Advice. 

Local entities need concrete help on 

measuring ROI and outcomes. 

Broader Conversation. NRCNA 

intends to continue its leadership 

and convening role, facilitating 

conversations among members of 

Meal on Wheels America, anti-hunger 

organizations, healthcare entities 

and advocates to identify synergies 

and build on strengths. This includes 

nurturing and developing innovative 

partnerships. 

15 
https://www.chlpi.org/

massachusetts-food-medicine-stateplan/ 

5. A Call to Action 

As the number of older people with 

chronic diseases continues to grow, 

there is an urgency about rolling out 

MTMs as part of an overall plan to 

help people enjoy better health and 

to reduce healthcare costs nationally. 

Yet some locations may not have 

a registered dietitian, for instance, 

or others may have such a small 

target population that it may not be 

economical to use existing delivery 

systems. 

improves, and net healthcare costs 

shrink, then both older adults and 

payers are finding value. 

There may be chafing between 

cultures, since MTM programs 

sometimes operate outside the 

traditional “aging services network.” 

At the same time, one’s own 

organization may voice concerns 

about “getting away from our mission” 

or the “medicalization” of providing 

new services. Establishing an MTM 

program is beyond a policy shift. 

However, if in so doing the health of 

older individuals with chronic diseases 

On the national front, the NRCNA will 

continue to lead and shape MTMs 

and this promising new direction. 

Among the most pressing tasks: 

analyzing the national competitive 

landscape; sparking needed research, 

especially on costs; leading learning 

collaboratives, sharing case studies 

and success stories; providing 

operational/compliance advice and 

concrete help on measuring ROI 

and outcomes; and encouraging 

local programs to be focused and 

sustainable over the long haul, while 

operating with the energy and can-do 

spirit of a start-up. 

The to-do list is long: doing 

research on needs and population 

characteristics, establishing clear ROI 

on healthcare dollars saved, finding 

partners and payers, aligning with 

their most pressing needs, doggedly 

pursuing buy-in from stakeholders, 

strategizing on which population to 

focus on, ensuring effective referral 

systems and a feedback loop, building 

infrastructure and business acumen, 

and constantly communicating with all 

concerned. 

We invite you to join us in this journey! 

Key Resources 

Center for Health Law and Policy 

Innovation of Harvard Law School 

https://www.chlpi.org/

Community Servings https://www.

servings.org/ 

Food is Medicine Coalition (FIMC) 

www.fimcoalition.org 

Federal Aids Policy Partnership (FAPP) 

https://federalaidspolicy.org

God’s Love We Deliver https://glvd.org

Massachusetts Food is Medicine 

State Plan

Project Angel Heart https://www.

projectangelheart.org/ 

16 
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meals. 

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Intervention, Big Impact: Health Care 

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4 Food is Medicine Coalition (2019). 

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The State of Senior Hunger in America 

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America (2019). 

6 NS Weinfield et al., Hunger in 

America 2014. Prepared for Feeding 

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17