Addressing Malnutrition in Community 

Living Older Adults

A Toolkit for Area Agencies on Aging 

Version 2 Issued July 2019

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

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

of the ACL or Department. 
1

Table of Contents

Acknowledgements 2

About this Project 3

Executive Summary 4

How to Use This Toolkit 6

Why Is Malnutrition Important? 7

Establish a Vision and Path to Success 15

Process Flow Planning

 Step 1: Implement Validated Screening Tools

 Step 2: Address Root Cause(s)

 Step 3: Monitor Client Progress and Quality of Services

18

19

20

23

Define Roles & Responsibilities 27

Engage Partners 31

Conclusion 40

Abbreviations and Acronyms 41

References 43

Appendices 45
2

Acknowledgements 

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

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

time and resources to generously assist with this project.

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

● Carroll County Bureau of Aging and Disabilities

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

Excellence

● Washington County Commission on Aging

We also are grateful to the following organizations:

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

document as well as contributed to and edited the content.

● Administration for Community Living - supported this project through grant 

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

the materials.
3

About this Project

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

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

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

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

improved health outcomes for senior meal program recipients by promoting higher 

service quality and increased program efficiency through innovative nutrition service 

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

funding unique initiatives, such as this grant project.

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

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

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

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

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

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

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

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

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

The Maryland Department of Aging and our grant partners recognize that 

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

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

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

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

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

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

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

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

facilitate active engagement by local aging network organizations.
4

Executive Summary 

Why Is Malnutrition Important? 

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

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

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

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

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

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

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

these deleterious outcomes. 

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

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

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

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

services that support nutritional well-being. 

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

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

Establish a Vision and Path to Success

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

establish a vision statement.

● Acknowledge that your organization provides services that address the social 

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

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

partnerships; learn about new programs and services. 

Process Flow Planning

Follow the “community-based malnutrition care pathway”:

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

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

counseling and provide appropriate and documented referrals. A sample referral 

table is provided.

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

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

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

Define Roles & Responsibilities

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

effectively address malnutrition, an interdisciplinary approach with cross-referrals 

to various services is required. 

Engage Partners

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

directly with hospitals, Care Transition Organizations, and primary care 

providers. 

● Review examples of successful healthcare-community partnerships including 

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

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

reimbursement with healthcare. Case studies are shared.

● Sample healthcare presentation and discussion tips are provided.
6

How to Use this Toolkit

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

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

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

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

partnership with a healthcare organization.

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

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

clients through providing resources that address the many risk factors.

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

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

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

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

your agency. 

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

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

5. To understand healthcare partnership models and billing reimbursement strategies 

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

and elsewhere. 
7

Why Is Malnutrition Important?

Community-Based Aging Network Mission

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

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

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

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

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

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

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

of thousands of people annually. 

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

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

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

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

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

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

addressing malnutrition aligns with the mission of the aging network.

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

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

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

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

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

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

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

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

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

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

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

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

appropriately can reduce future economic burden of healthcare costs and 

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

Everyday Examples of How Staff Identify Malnutrition 

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

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

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

significant change in behavior, medical condition or living situation. 

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

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

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

Coordinator.

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

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

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

-Senior Center/Congregate Meals Supervisor.

Malnutrition: What is it?

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

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

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

We can eat all the right foods, but if our 

hormones - insulin for example - or organs 

aren’t working properly, the good nutrients 

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

In fact, if nutrients don’t go where they 

belong, they can cause problems, often 

seen as chronic diseases including heart 

disease and diabetes.

Malnutrition or “poor nutrition” is 

defined as “the inadequate intake of 

nutrients, particularly protein, over time 

and may contribute to chronic illness 

and acute disease or illness and 

infection.” 1It is a hidden condition in the 

body that affects - and is affected by -

medical conditions as well as social 

determinants of health. Because 

malnutrition is an imbalance in the body 

related to nutrients, a person may be fat, 

thin or average build and still be at risk 

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

if a person has malnutrition just by 

looking at them.
9

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

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

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

reduced hand grip strength. 2

TRY THIS: What signs of malnutrition can you identify? 

1 2

3 4

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

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

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

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

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

including:

1. Hollow eye sockets, sunken temples, cheeks

2. Prominence of collarbone/clavicles 

3. Muscle loss in hands

4. Fat loss in upper arm
10

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

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

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

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

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

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

❏ Poor appetite

❏ Poor dental health

❏ Trouble chewing or swallowing

❏ Changing taste buds

❏ Chronic diseases

❏ Medication side effects

❏ Dementia

❏ Depression

❏ Social isolation

❏ Limited income

❏ Food insecurity

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

regularly see older adults at risk for malnutrition. 

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

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

referring to other services offered in the community.

Malnutrition has a number of consequences, including increased risk for 

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

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

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

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

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

more information about malnutrition. 

Source: http://www.mealsonwheelsnys.org/MQC_Blueprint_web.pdf
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Social Determinants of Health (SDOH)

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

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

behavioral and economic factors. 9

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

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

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

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

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

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

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

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

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

healthy as they could be.” 10

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

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

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

relate to malnutrition and SDOH.
12

Table 1: Social Determinants of Health and Malnutrition. 

Social Determinant Malnutrition Sample Scenarios

(causes and effects of malnutrition are IN BOLD)

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

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

dietary restrictions to avoid losing weight and strength needed for her 

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

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

She experiences weight loss, frailty and significant decline in 

ADLs.

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

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

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

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

frequent hospitalizations and ER visits.

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

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

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

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

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

daily calories.

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

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

despite medications and diet and medical counseling. These 

conditions increase inflammation and don’t allow the body to 

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

becomes weak, lose independence and chronic conditions

worsen.

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

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

go towards utilities and rent. Chronic conditions and nutrition 

decline.

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

for strength and to manage diabetes. Poor diabetes control results 

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

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

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

to medical appointments.

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

attend senior center activities. In-home assistance can improve 

confidence in social interactions and facilitate improved health and 

medication management.

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

often skips meals because sitting alone at the kitchen table is 

unappealing. Research shows that eating with others improves 

food intake. Congregate meals, volunteering and senior center 

activities provide this support and connection.
13

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

loss, dehydration and poor nutrition. Client becomes isolated and 

weakness results in a fall.

Health Care 

Referral

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

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

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

Employment Lack of profession or volunteer opportunities may lead to social 

isolation and depression. Depression can result in overeating 

and lack of exercise, worsening chronic conditions.

Health Education Chronic Disease self-management workshops, and other 

evidence-based programs, provide education and allows for clients 

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

proven positive impacts on healthcare costs and on individuals’ 

mental/physical health.

Addressing Malnutrition in the Community: Sustainable, PersonCentered Impact

Research and healthcare awareness about the impact of malnutrition on health 

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

acknowledging the critical importance of addressing individuals’ nutritional health prior 

to and after hospital admission.

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

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

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

address the complex social needs that often accompany malnutrition. They 

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

community. 

Healthcare organizations have monetary incentives and financial penalties which 

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

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

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

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

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

improve health and reduce healthcare costs. 9

Effective implementation of high quality AAA services can therefore reduce

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

at risk for malnutrition on a regular basis. 
14

Why should AAAs consider partnering with healthcare? Organizations may gain 

access to additional resources such as:

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

● Expanded referral options to appropriately assist older adult,

● Additional funding stream(s),

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

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

● Enhanced quality assurance of current and new programs,

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

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

justify funding.

Questions to Consider

1. Define malnutrition in your own words. 

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

seen or spoken to this past week?

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

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

successful?
15

Establish a Vision and Path to Success

What is your Vision?

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

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

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

● To improve staff collaboration to enhance efficiency and effectiveness of 

our staff and resources.

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

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

______________________________________________________________________

Aging Network “Owns” Social Determinants of Health!

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

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

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

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

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

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

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

Use Existing Staff and Programs Efficiently and Effectively

Executive Directors can 

establish uniform policies and 

procedures for staff within 

existing programs and services 

that can positively affect and 

even cure this and other 

conditions. As we pursue clinicalcommunity partnerships, the goal 

for local aging organizations -

where there often are no 

healthcare staff - will be to 

perform screenings for 

malnutrition and other conditions. 

Screening is a process for determining if there 

may be a problem. Screening differs from 

assessment and diagnosis, which often requires 

a medical expert. There are validated tools for 

screen for various conditions, including 

malnutrition. Validated tools have been tested for: 

11

1. reliability (the ability to produce consistent 

results), 

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

3. sensitivity (the probability of correctly identifying 

a patient with the condition).
16

There are a number of validated 

malnutrition risk screening tools, including the 

Malnutrition Screening Tool (MST), which is a 

quick and easy tool containing just two 

questions. 12

Should a “positive” screen occur, AAAs need 

to establish a process to notify the persons’ 

healthcare provider in order to:

• Facilitate the healthcare provider’s ordering of

further tests, referrals to specialists, physical

therapy, etc. and

• Communicate community-based interventions,

which will both demonstrate our organization’s

impact, potentially secure funding based on

effectiveness and allow for effective clinicalcommunity approaches to addressing the

illness(es).

Truly, only by working hand-in-hand 

“across care settings” (eg, between hospital 

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

and quality of life.

Consider Offering Additional Programs and Services

Stepping Up Your Nutrition (SUYN), one of 

the evidence-informed workshops offered by 

AAAs, is specifically focused on malnutrition 

related to falls risk. Participants identify their 

personal nutrition risk status and establish their 

own goals to improve nutritional status and 

muscle strength. SUYN could be an appropriate 

referral for an individual with malnutrition or 

could help identify a root cause for an 

individual referred for falls. See Appendix 2 for 

a list of evidence-based programs available 

across Maryland.

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

Are you at Nuritional Risk?

High Nutrition Risk: Score below 50

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

Moderate Nutrition Risk: Score 50-54

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

Low Nutrition Risk: Score above 54

Keep up the good work! Your eating habits are working to keep you healthy and strong.
17

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

Academy of Nutrition and Dietetics website here.

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

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

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

client education materials.

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

and/or new programs and services that address malnutrition.

Questions to Consider

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

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

address malnutrition risk among clients?

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

Process Flow Planning

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

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

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

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

Step 1: Implement validated screening tools

Step 2: Address root causes(s)

Step 3: Monitor client progress and quality of services 

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

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

Involved.

1. IMPLEMENT VALIDATED SCREENING TOOLS

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

outside organizations.

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

Tool: List of malnutrition and SDOH screening tools.

2. ADDRESS ROOT CAUSE(S)

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

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

screening results and service/program referrals.

Tool: Sample Referral Table.

3. MONITOR CLIENT PROGRESS AND QUALITY OF SERVICES

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

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

and assure the quality of services provided.

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

partners.

Tool: Sample Community Care Plan. 
19

Step 1: Implement Validated Screening Tools

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

Validated screening tools are processes that have been developed through extensive 

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

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

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

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

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

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

regarding Maryland screening tools. 

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

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

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

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

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

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

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

can be integrated into program or intake assessments, disease prevention 

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

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

such as social isolation, falls risk or depression. 

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

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

coordination with existing AAA databases and healthcare electronic medical 

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

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

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

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

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

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

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

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

population. 
20

Step 2: Address Root Cause(s)

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

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

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

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

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

more comprehensive care for the client.

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

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

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

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

and improve health; however...

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

ACTUALLY DO.

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

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

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

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

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

their health and independence. 

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

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

results and recommended services and programs. 

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

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

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

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

services.
21

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

Care Planning 

Components

AAA Referral Programs and Services

Food and Nutrition 

Z594

❏ Senior Center Congregate Meals

❏ Home-Delivered Meals

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

❏ Commodity Supplemental Food Program (CSFP)

❏ Community food resources (Food Bank, etc.)

❏ Senior Farmers Market Nutrition Program

❏ Stepping Up Your Nutrition

❏ Post-discharge, medically-tailored meals

Housing

Z590

❏ Assisted Living (including SALGHS)

❏ Ramp Assistance

❏ Home Modification

❏ Assistive Technology

❏ Durable Medical Equipment 

❏ Congregate Housing Services Program

Transportation

Z650

❏ County or Regional Transit

❏ Cab/Bus Vouchers

❏ Senior Village 

❏ Community for Life

Financial

Z590

Application assistance for financial aid: 

❏ SNAP

❏ Medicaid

❏ State Health Insurance Program (SHIP)

❏ Energy-assistance programs

❏ Income-tax assistance

❏ Medicare Part A, B, C, D

❏ Medicare Billing, Appeals, Denials, Grievances

❏ Medicare Fraud Assistance 

❏ Oral nutritional supplements (Ensure, etc) 

❏ Prescription assistance

❏ Assistance for dental, eye care, hearing aids

Utilities

Z590

❏ Low-Income Home Energy Assistance Program (LIHEAP)

❏ Electric Universal Service Program (EUSP) 

❏ Universal Service Protection Program (USPP)

❏ Utility Assistance (other)

Personal Safety

Z600 

❏ Elder Abuse

❏ Legal Assistance 

❏ Emergency Response Systems

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

Balance)
22

❏ Arthritis foundation classes (Walk with Ease)

In-Home Care

Z602

In-Home Care

Z602

(con’t)

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

❏ Home Care agencies

❏ Community First Choice

❏ Senior Care

❏ Home-delivered meals

❏ Dietitian referral

❏ Senior Village

Social Supports

Z600 or Z630

❏ Senior Center (exercise, socialization, Congregate Meals) 

❏ Telephone Reassurance 

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

❏ Adult Day Care

❏ Volunteer opportunities

Mental Health

Z640 or Z650

❏ PEARLS: Program to Encourage Active, Rewarding Lives

❏ Enhance Wellness

❏ Healthy IDEAS

❏ Behavioral Health Referral (Core Service Agency or Health 

Department)

Health Care Referral

ICD-10 code dependent on 

root cause

❏ Primary Care Physician

❏ Clinics: Dental, Eye, Physical Therapy

❏ Community Health Worker

❏ Adult Medical Day Care

❏ Local health department

❏ Home care agencies

❏ Medical supplies

Employment

Z560 

❏ Senior Employment 

❏ AAA volunteer coordinator

❏ Community volunteer opportunities

Health Education

Z550 

Self-management workshops: 

❏ Diabetes Self-Management (Spanish version available) 

❏ Chronic Disease Self-Management (Spanish version available)

❏ Chronic-Pain Self-Management

❏ Cancer Thriving and Surviving 

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

Balance) 

❏ SAIL (Stay Active and Independent for Life) 

❏ Aging Mastery 

❏ Enhance Fitness 

❏ Lifelong Learning 

❏ Medication Management

❏ Wellness Center Gym
23

Step 3: Monitor Client Progress and Quality of 

Services

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

Monitoring Progress: A Community Care Plan

A care plan outlines:

● individual assessed care needs, 

● the types of services provided to meet those needs, 

● who will provide the services and when. 

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

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

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

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

responsibilities established and documentation incorporated. 

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

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

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

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

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

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

checklist could be provided if desired. 

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

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

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

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

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

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

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

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

CLIENT NAME: Sally Jones DATE: January 1, 2019

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

ACHIEVE BY DATE: June 20, 2019

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

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

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

NOTES:

Referral made to Health Promotion Coordinator to enroll in Stepping 

On.

Contacted doctor regarding positive screens. Faxed referral table, care 

plan.

Assisted in getting a cab voucher for transportation.

 DATE: January 1, 2019

 STAFF SIGNATURE: Linda Johnson, MAP Program Coordinator

.

30 DAY FOLLOW UP: 

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

appointment scheduled with her doctor. Rescreened for social 

determinants of health. No changes, no new referrals made

DATE: February 4, 2019

STAFF SIGNATURE: Linda Johnson, MAP Program Coordinator

60 DAY FOLLOW UP: 

DATE:

STAFF SIGNATURE:

90 DAY FOLLOW UP: 

DATE:

STAFF SIGNATURE:
25

Quality Assurance 

Quality assurance may include client satisfaction, evidence based workshop 

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

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

for documentation and communicating with healthcare. Contracts with healthcare will 

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

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

in the future (assuming adequate funding and staffing).

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

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

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

contracting for AAA services.

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

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

resources, see Appendix 6.

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

control...

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

preferences

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

effective dependable and timely...

● Integrates healthcare and social services to promote 

well-being

● Promotes privacy, dignity, respect and 

independence....

● Ensures each individual can achieve the balance of 

personal safety and dignity of risk...

● Supplies and supports an appropriately skilled 

workforce...

● Supports family caregivers

● Engages individuals in the design, implementation, 

and evaluation of the system and its performance

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

linguistically appropriate

● Coordinates and integrates to best meet needs and maximize 

efficiency/affordability

● Delivers cost-effective services

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

data...

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

consumer outcomes
26

Chesapeake Regional Information System for Patients (CRISP)

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

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

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

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

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

contract with CRISP, AAAs could:

● Embed referrals to evidence-based programs and 

other non-clinical services

● Report patient engagement, enrollment, and 

completion of programs

● Document provisions of programs and services 

(including ICD-10 codes)

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

needed services through care alerts

In addition, CRISP could be utilized to track return on 

investment (ROI), including pre/post hospital and 

emergency department utilization and changes in cost of 

care. 

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

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

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

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

Questions to Consider

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

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

for all or select clients? 

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

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

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

not, what would it take to implement one?

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

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

Define Roles & Responsibilities

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

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

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

interdisciplinary team approach is required to adequately support an older adult 

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

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

SDOH domains previously discussed, including chronic conditions, financial limitations 

and social isolation need to be addressed. 

Executive Director

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

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

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

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

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

In order to foster organizational commitment:

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

feasible given your existing resources.

● Establish cross-departmental meetings to develop healthcare-community 

linkages.

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

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

potential partners, coalition members and funding opportunities.

In order to become involved:

● Initiate meetings with hospital administration (Medical Director, Population 

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

● Consider developing joint proposals with hospitals or health departments for 

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

preventive health approaches.

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

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

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

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

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

individuals discharged with malnutrition.

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

Consider starting with small changes or additions to services or assessment 

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

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

of the causes of malnutrition.

Program Directors 

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

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

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

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

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

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

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

issues.

In order to foster organizational commitment:

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

screening.

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

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

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

environmental causes of malnutrition.

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

which your organization can use to identify or treat malnutrition.

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

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

with presentation materials which summarize your current services and consider 

adjusting them, based on healthcare partner feedback.

In order to become involved:

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

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

needed services.

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

completion of documents.
29

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

status and assist with supporting care plans.

Cross-Referrals 

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

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

important that staff roles are established and streamlined documentation is 

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

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

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

Health.

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

Older Adult

MAP, SC, 

Nutrition

Housing MAP, SC

Transportation MAP

Financial MAP, SC, 

SHIP

Utilities MAP, SC

Personal 

Safety

HP, MAP, 

SC

In-Home 

Care

MAP, SC, 

SHIP

Social 

Supports

HP, MAP, 

SC

Mental 

Health

HP, MAP, 

SC

Health Care 

Needs MAP

Employment MAP

Health 

Education

HP, MAP, 

Nutrition

Nutrition

Food and 
30

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

underlying causes of malnutrition, and communicate with healthcare partners 

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

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

community-based malnutrition care pathway. 

Questions to Consider

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

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

process?
31

Engage Partners

Partnership Scenarios

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

prevent and address malnutrition in your AAA jurisdiction.

Community Partners and Food Resources

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

example:

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

class? 

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

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

organizations such as churches, soup kitchens or libraries? 

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

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

Agency?

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

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

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

to persons inquiring about food access. 

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

meals if they are homebound.

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

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

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

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

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

Insurance Companies 

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

supplemental benefits to Medicare beneficiaries enrolled in Medicare Advantage 

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

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

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

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

outcomes.” 

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

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

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

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

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

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

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

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

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

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

avoidable emergency and health care utilization. 

Figure 4: Expansion of Supplemental Benefits in 2019.

Not covered by Original Medicare.

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

• Diagnose an illness

• Compensate for physical impairments

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

• Reduces avoidable emergency and health care utilization

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

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

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

• Support for caregivers of enrollees

• Medically-approved non-opioid pain management

• Stand-alone memory fitness benefit

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

• Transportation

Plan must incur non-zero direct medical cost.

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

The Bipartisan Budget Act of 2018 further expanded supplemental benefits by 

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

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

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

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

transportation.
33

Figure 5: Further Expansion of Supplemental Benefits.

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

category of benefits, beginning in 2020.

Special Supplemental Benefits for the Chronically Ill (SSBCI)

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

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

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

increase its taxable value.

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

There are several commercial insurance companies in Maryland offering the 

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

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

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

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

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

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

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

can be found here. 

Regional AAA Partnerships 

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

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

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

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

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

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

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

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

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

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

million in savings.15
34

Hospitals, PCPs, and CTOs

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

Services Cost Review Commission (HSCRC) establishes uniform payment structures 

based on population health goals, which incentivizes cost reduction. 

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

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

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

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

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

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

social services connections, hospital care coordination and behavioral health 

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

Figure 6: The Maryland Primary Care Program Structure.

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

-%20Presentation%20Web.pdf

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

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

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

prevention and management of chronic disease and prevention of unnecessary hospital 

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

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

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

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

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

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

Another alternative could be partnering with area CTOs for specific 

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

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

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

perceived needs.

Examples of Success

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

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

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

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

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

resulted in reimbursement for these services. 

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

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

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

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

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

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

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

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

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

Billing Reimbursement Options 

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

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

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

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

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

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

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

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

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

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

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

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

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

individual is at for poor health outcomes. 

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

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

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

healthcare organizations to provide case management and document social needs with 

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

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

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

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

SDOH Sample ICD-10 Codes 

Living Situation 

(Housing, 

Utilities)

Z590 - Problems related to housing and economic circumstances

Z600 - Problems related to social environment

 Z602 - Problems related to living alone

Food Z590 - Problems related to housing and economic circumstances 

 Z594 - Lack of adequate food and safe drinking water 

Safety Z600 - Problems related to social environment 

Financial Strain Z590 - Problems related to housing and economic circumstances 

Employment Z560 - Problems related to employment and unemployment 

Family and 

Community 

Support

Z630 - Other problems related to primary support group, including 

family circumstances

Z600 - Problems related to social environment 

Education Z550 - Problems related to education and literacy 

Mental Health Z650 - Problems related to other psychosocial circumstances 
37

SDOH ICD-10 Code Case Studies 

SCENARIO ONE

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

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

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

caregivers from a private agency. 

Through the screening process by MAP, 

Suzy’s mother was identified at risk for:

➔ Living arrangements: Z599

➔ Financial: Z596

➔ Food and nutrition: Z594

➔ In Home care: Z602

➔ Social support: Z600

In addition, Suzy herself was identified 

with the following risk factors:

➔ Dependent needing care: Z636

➔ Burnout: Z730

➔ Lack of relaxation and leisure:

Z732

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

1. Respite care through the local ARC.

2. Caregiver program and support group.

3. Home-delivered meals 3 times per week.

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

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

times per week.

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

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

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

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

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

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

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

groups near her. 
38

SCENARIO TWO

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

multiple admissions to community hospital emergency room. The Emergency Room 

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

Barbara was struggling with anxiety. 

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

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

● There was almost no food in the refrigerator.

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

were dry. 

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

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

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

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

of the county. 

The following diagnosis codes were identified for this situation:

➔ Living arrangements: Z599

➔ Financial: Z596

➔ Food and nutrition: Z594

➔ Living alone: Z602

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

the hospital and PCP. 

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

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

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

*Names have been changed to protect privacy.
39

Initiating Conversations with Healthcare

Meetings with prospective healthcare partners should outline:

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

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

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

reduce their costs.

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

measures that will be transparent to both parties.

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

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

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

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

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

presentations you can customize for meetings with healthcare and Appendix 10

contains additional website resources. 

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

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

components of addressing malnutrition and health conditions in the community.

Questions to Consider

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

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

to manage these clients? 

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

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

resources do you need?

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

clients to? 
40

Conclusion 

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

Area Agencies on Aging” has shared:

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

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

older adults” 

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

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

malnutrition in community-residing older adults. 

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

mission and assigning staff roles, documenting processes, and embedding 

quality assurance. 

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

pathway.”

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

high quality process to expand resources and service offerings.

The toolkit also provided you with:

● Template forms that incorporate ICD-10 codes

● Internal and external cross-referral suggestions 

● Case studies

● Questions to consider as you develop your plans

● Sample healthcare presentations and discussion tips 

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

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

welcome you to join us in this emerging endeavor.
41

Abbreviations and Acronyms 

AAA Area Agency on Aging

ACL Administration for Community Living

ADL Activities of Daily Living

ADRC Aging and Disability Resource Center 

ALS Amyotrophic Lateral Sclerosis

APS Adult Protective Services

CBO Community-Based Organization

CDSME Chronic Disease Self-Management Education

CHF Congestive Heart Failure

CHW Community Health Worker 

CMF Case Management Fee

CMS Center for Medicare and Medicaid Services 

CRISP Chesapeake Regional Information System for Patients

CSFB Commodity Supplemental Food Program

CTO Care Transformation Organization 

EMR Electronic Medical Record

EMT Emergency Medical Technician

EUSP Electric Universal Service Program

ER Emergency Room

HDM Home-Delivered Meal

HIE Health Information Exchange

HP Health Promotion 

HSCRC Health Services Cost Review Commission 

ICD-10 International Statistical Classification of Disease and Related 

Health Problems, 10th Revision

IDEAS Identifying Depression, Empowering Activities for Seniors

IT Information Technology

LIHEAP Low-Income Home Energy Assistance Program

LTSS Long Term Services & Supports

LWCE Living Well Center of Excellence

MA Medicare Advantage 

MAC Maintaining Active Citizens

MAP Maryland Access Point 

MCO Managed Care Organization

MDH Maryland Department of Health

MDPCP Maryland Primary Care Program

MNT Medical Nutrition Therapy 

MQii Malnutrition Quality Improvement Initiative 
42

MST Malnutrition Screening Tool

NP Nurse Practitioner 

n4a National Association of Area Agencies on Aging 

PCP Primary Care Provider 

PEARLS Program to Encourage Active, Rewarding Lives 

RDN Registered Dietitian Nutritionist 

RD Registered Dietitian 

ROI Return on Investment 

SAIL Stay Active and Independent for Life

SALGHS Senior Assisted Living Group Home Subsidy 

SDOH Social Determinants of Health 

SHIP Senior Health Insurance Program

SIREN Social Interventions Research & Evaluation Network

SMAA Southern Maine Agency on Aging

SNAP Supplemental Nutrition Assistance Program

SUYN Stepping Up Your Nutrition

SW Social Worker 

USPP Universal Services Protection Program
43

References

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

Malnutrition Care. Retrieved from

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

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

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

Dietetics/American Society for Parenteral and Enteral Nutrition: indicators

recommended for the identification and documentation of pediatric malnutrition

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

1988-2000.

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

Opportunities for the Aging Services Network. Retrieved from

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

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

82(963), 2-8.

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

identification and impact on patients and the healthcare system. International

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

6. DefeatMalnutrition.Today. Retrieved from Malnutrition

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

Malnutrition_Info_Graphic_OnePage_Update_FA.pdf.

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

Quality Malnutrition Care for Older Adults. Retrieved from

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

_web.pdf.

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

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

e0161833.

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

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

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

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

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

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

screening tool for substance use. Retrieved from 

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

5.

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

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

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

Addressing Gaps in Performance Measurement Final Report, September 2016. 

National Quality Forum. Retrieved from 

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

nityBased_Services_to_Support_Community_Living__Addressing_Gaps_in_Perform

ance_Measurement.aspx.

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

Approach Nets Multiple Contracts. Retrieved from 

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

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

Bridging Community-Based Organizations and Health Care Organizations. 

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

Appendices

Appendix 1: Malnutrition Resources 

● Alliance for Aging Research-Malnutrition in Older Adults

● American Society for Parenteral and Enteral Nutrition Malnutrition Toolkit

● Defeat Malnutrition Today

● Malnutrition Quality Improvement Initiative (MQii) Toolkit

● National Council on Aging Community Malnutrition Resource Hub

● National Council on Aging Malnutrition Toolkit

● National Resource Center on Nutrition & Aging

● The Gerontological Society of America
46

Appendix 2: Evidence-Based Programs in Maryland

● Aging Mastery Program

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

Ease)

● Diabetes Prevention Program (Medicare, National)

● Enhance Fitness

● Enhance Wellness

● Healthy Eating for Successful Living in Older Adults

● HomeMeds

● Matter of Balance

● Move with Balance

● Otago

● Powerful Tools for Caregivers

● Program to Encourage Active and Rewarding Lives (PEARLS)

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

Surviving, Diabetes, Spanish versions)

● Stay Active and Independent for Life (SAIL)

● Stepping On

● Tai Ji Quan: Moving for Better Balance

● TimeSlips

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

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

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

Screening Tool Details Use

Level 1 Screen 

REQUIRED FOR 

ELIGIBILITY IN 

MEDICAID LONG 

TERM 

SUPPORTS AND 

SERVICES. 

Purpose: Screen and triage individuals 

for Medicaid community programs, 

including the Community Options 

waiver, Community First Choice, and 

Medical Assistance Personal Care.

Components:

● Instrumental Activities of Daily 

Living

● Activities of Daily Living

● Living Arrangement

● Health Status

● Communication, Cognition and 

Behavior

● Financial Questions

● Referral Questions

Length: Thirty one questions

Score: Priority category and referral 

recommendations generated 

● Determine functional eligibility for 

Medicaid community services

● Provide information, referrals, 

Options Counseling and access to 

home and community-based 

services 

DETERMINE 

Your Nutritional 

Health (Nutrition 

Screening 

Initiative) 

REQUIRED BY 

ACL FOR 

SENIOR 

NUTRITION 

PROGRAM USE 

(CONGREGATE 

AND HOME 

DELIVERED).

Purpose: Identify persons at risk for 

poor nutrition, based upon SDOH. 

Components:

● Disease

● Eating poorly

● Tooth loss/mouth pain

● Economic hardship

● Alcohol problems

● Reduced social contact

● Multiple medications

● Involuntary weight loss/gain

● Ability to shop, cook and/or feed 

self

Length: Ten questions

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

nutritional risk, 6 + high nutritional risk

● Home delivered or congregate meal 

program

● RDN counseling or nutrition 

education

● Social and exercise programming to 

address isolation

● Dental referral 

● Social services or community group 

if elevated alcohol intake noted

● Physician/pharmacy or medication 

management referral if multiple 

medications noted

● Financial assistance if unable to 

afford medications and/or food

Home Delivered 

Meals Priority 

Screening

REQUIRED BY 

MDoA FOR ALL 

HOME 

DELIVERED 

MEAL SERVICE 

PROVIDERS.

Purpose: Effectively identify persons 

most at need for meals and to 

determine other services which may 

best meet clients’ current needs.

Components: 

● Ability to acquire groceries and 

prepare meals

● Food insecurity assessment

Length: Eight questions

Score: A-E levels of priority 

Determine if client would benefit most 

from:

● Fully prepared home-delivered 

meals

● Income eligibility review and/or 

SNAP

● Grocery assistance, including the 

Commodity Supplemental Food 

Program 
48

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

Social Determinants of Health Screening Tool

Name:____________________________________________ Phone Number:_________________________

Preferred Language:_________________________________ Best time to call:________________________

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

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

____

____NO

YES NOTES:

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

your service for not paying your bills?

____YES

____NO

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

have stable housing?

____YES

____NO

Do you have difficulty in taking the medicine/prescriptions 

prescribed by your doctor?

____YES

____NO

Are you able to get/pay for your 

medicine? Do you understand what 

medicine to take when and what it 

is for?

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

but could not because of cost?

____YES

____NO

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

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

____YES

____NO

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

____NO

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

____NO

On a weekly basis I participate in social activities or 

attend organized groups, such as choirs, support groups, 

cultural performances, group meals, exercise classes, etc.

____YES

____NO

Do you ever need help reading or understanding hospital 

or other materials from your physician?

____YES

____NO

Are you afraid you might be hurt in your apartment 

building or house?

____YES

____NO

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

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

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

#_______

____YES

____NO

Do you worry about falling? 

____YES

____NO

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

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

hopeless?

____YES

____NO

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

to receive assistance with any of these needs?

____YES

____NO

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

place to sleep tonight)

____YES

____NO

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

Appendix 5: List of Malnutrition and Social Determinants of Health 

Screening Tools

Malnutrition 

● Malnutrition Screening Tool (MST)

● Mini Nutritional Assessment (MNA)

a. MNA-Short Form (MNA-SF)

● Malnutrition Universal Screening Tool (MUST)

● Nutrition Risk Screening (NRS-2002)

● Subjective Global Assessment (SGA)

● Patient Generated Subjective Global Assessment (PG-SGA)

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

and SCREEN II)

● Short Nutritional Assessment Questionnaire (SNAQ)

● Validated Malnutrition Screening and Assessment Tools: Comparison Guide

Social Determinants of Health

● Accountable Health Communities Health-Related Social Needs Screening Tool

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

and Experiences

● Health Leads Social Needs Screening Toolkit

● Institute of Medicine Social and Behavioral Domains and Measures

● WellRx Toolkit

● Total Health Assessment Questionnaire for Medicare Members

● Kaiser Permanente’s Your Current Life Situation Survey

● HealthBegins Upstream Risk Screening Tool

● Social Need Screening Tools Comparison Table
50

Appendix 6: Quality Assurance Resources

● Home and Community Based Services: Quality Management Roles and

Responsibilities

● Improving Quality of Services

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

Conversation about Strategic Directions for Research and Policy

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

Behavioral Health in Medicaid

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

Addressing Gaps in Performance Measurement

● Quality of Home- and Community-Based Services
51

Appendix 7: Suggested Professional Role Delineation 

MAP

Implement Screening Tools

● Level 1 Screen

● Malnutrition Screen

● SDOH Screen

Address Root Cause(s)

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

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

● Transportation to healthcare appointments and referral sites

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

Monitor Progress and Quality 

● Lead care plan implementation and documentation

● Track referrals

● Share client care plan goals with healthcare

● Assist with hospital messages and progress

Nutrition

Implement Screening Tools

● DETERMINE Checklist

● HDM PriorityScreen

● Malnutrition Screen

● SDOH Screen 

Address Root Cause(s)

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

● Person centered service/meal plan

● Provide social interaction

● Provide relevant nutrition education

● Nutritionally balanced food, hydration

● Reduce social isolation

● Manage chronic conditions 

Monitor Progress and Quality 

● Periodic screening, as appropriate, note in care plan

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

● Perform quality assurance related to respective service(s)

● Update care plan as client participates in programs

● Adjust care plan as information changes

● Assist with communicating hospital messages

SHIP 

Implement Screening Tools

● Benefits Checkup

● Malnutrition Screen 

● SDOH Screen

Address Root Cause(s)

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

● Address gaps in insurance coverage (income)
52

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

● Allows client to access affordable medical care and medications

Monitor Progress and Quality 

● Periodic screening, as appropriate, note in care plan

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

● Perform quality assurance related to respective service(s)

● Update care plan as client participates in programs

● Adjust care plan as information changes

● Assist with communicating hospital messages

Health Promotion 

Implement Screening Tools

● Varies based on program staff certifications

● Malnutrition Screen

● SDOH Screen

Address Root Cause(s)

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

● Chronic disease management

● Exercise to improve strength

● Improve nutrition/malnutrition

● Social isolation

● Address falls risk

● PEARLS to address depression

Monitor Progress and Quality 

● Periodic screening, as appropriate, note in care plan

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

● Perform quality assurance related to respective service(s)

● Update care plan as client participates in programs

● Adjust care plan as information changes

● Assist with communicating hospital messages

Senior Care

Implement Screening Tools

● Level 1 Screen

● Malnutrition Screen

● SDOH Screen

Address Root Cause(s)

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

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

● Provide PEARLS or refer to other mental health supports

Monitor Progress and Quality 

● Periodic screening, as appropriate, note in care plan

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

● Perform quality assurance related to respective service(s)

● Update care plan as client participates in programs

● Adjust care plan as information changes

● Assist with communicating hospital messages
53

Appendix 8: Sample Community Food Resource List

Food and Nutrition Assistance in Somerset County 2019

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

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

Food Needs Program 

Name

Number Contact Name Other Information

For 

homebound: 

Delivered 

meals & 

Grocery bags

Meals on 

Wheels by 

Somerset MAC 

Senior Services

410-651-3400 All staff Delivered meals 

Monday, Tuesday, 

Thursday, for 60 and 

older

Therapeutic 

Home 

Delivered 

Meals

Moveable 

Feast

410-327-3420

Ext. 12

All staff Delivered frozen 

meals for all ages

Senior Center 

Noon Meals

Westover and 

Deal Island 

MAC Senior 

Services 

Centers

410-651-3400 All staff Noon meal Tuesday 

and Thursday for 60 

and older

Dinner Friday 

& Saturday 

6-7:30 PM

H.O.P.E. 

Ministry

11724 

Somerset Ave, 

Princess Anne

410-726-7910

or

443-880-7871

Steve Milligan

Wayne Muir

Eat dinner and take 

home a bag lunch

Nutrition 

Education and 

Supplement 

Assistance

MAC 

Registered 

Dietitian

410-742-0505

Ext. 144

Karla 

Beardsley

Call for appointment 

or questions

Nutrition 

Counseling

McCready 

Hospital 

Dietitian

410-968-1801

Ext. 3250

Jeannette 

Jardin

Call for appointment

Food Stamps 

(SNAP)

Social Services

30397 Mt. 

Vernon Rd, 

Princess Anne

410-677-4330 All Staff Need proof of 

address, income, 

expenses, SS card, 

and picture ID

Emergency 

and monthly 

food pantry

Maryland Food 

Bank-Eastern 

Shore

410-742-0050 Teresa See

Jennifer Small

Find a food pantry 

close by

www.mdfoodbank.org

click “find food”

Emergency 

and monthly 

food pantry

“Food Share”

Seton Center 

Catholic 

Charities

410-651-9608 All Staff Need proof of 

address, income, 

food stamps, SS 

card, and picture ID

Grocery 

Shopping 

Online

Walmart 

Pocomoke City 

Supercenter

410-957-9600 All Staff Order at 

www.walmart.com

and pick up at store
54

Appendix 9: Sample Presentations for Healthcare
55
56
57

For access to this PowerPoint, please contact Judy Simon at 

judy.simon@maryland.gov. 
58

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

03/MealProgramValueProposition.pdf
59

Appendix 10: Healthcare-Community Partnership Resources

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

Organizations: Understand the Business Environment and Your Place Within It

● Aging and Disability Business Institute

● Chronic Care Management Information Resource

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

Diseases. A Practitioner's Guide

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

● HCBS Business Acumen Center

● HCBS Business Acumen Toolkit. 

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

Within It. 

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

Your Organization

● Healthcare Policy and Practice Opportunities for Senior Nutrition Programs. 

○ Part 1: The Evolving Healthcare Legislation Landscape. 

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

● Health Care and Community-Based Organizations Have Finally Begun 

Partnering to Integrate Health and Long-Term Care 

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

New Partnerships

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

and Healthcare Organizations

● Sustainability and Revenue Generation in an Evolving Senior Nutrition Business 

Environment

● The Aging Network in Transition: Hanging in the Balance

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