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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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

Source: (God’s Love We Deliver, 2018)

GOD'S LOVE WE DELIV

n ..,-~for 

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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. 
Source: (Project Open Hand, 2019) 

March 2019 Wellness Menu

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

Source: (Food is Medicine Coalition (FIMC), 2018)

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 

MTM 

are a low-<»SV" h~intcrvcntion 

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 

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 

~ 

morenke~to 

be d lsehar,ed 

to home 

inCteaSe in 

a<lheranoe 

0 -

~

;.,.,..,ed patient 

satisfoction 

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

The Solution
Appendix C: Sample Workflow 

Source: MIFA No Hungry Senior program

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).
Appendix D: Sample Referral Form 

Source: (“Application for Project Angel Heart meals - Project Angel Heart,” n.d.)