Meals on Wheels People’s Medically Tailored Meals program provides essential nutritional support to individuals leaving the hospital, enhancing their recovery journey and overall health management right in their own homes. Partnering with health care systems, Meals on Wheels People is redefining patient care through tailored nutrition.
When an older woman returned to her home after being discharged from Providence St. Vincent Medical Center in Portland, she faced a common yet daunting challenge: how to manage her recovery alone, especially when it came to nutrition. Thanks to Meals on Wheels People’s Medically Tailored Meals program, she didn’t have to worry about grocery shopping, paying for quality ingredients on her fixed income, or standing in her kitchen to cook.
Launched in 2021, the Medically Tailored Meals (MTM) program by Meals on Wheels People (MOWP) partners with health systems to ensure that individuals who are at risk for food insecurity receive tailored meals to meet specific health care needs delivered right to their doorstep. Research shows that medically tailored meals lead to fewer emergency department visits and hospitalizations, savings on health care costs, and improved quality of life and ability to manage chronic disease.
“We know how critical it is that someone has their food and nutrition needs met to be able to heal appropriately,” says Shelley Yoder, director of population health program integration at Providence. “We started this program at one of our hospitals. It was so successful, we’ve since expanded to four hospitals.”
In fiscal year 2023, Meals on Wheels People partnered with three health care partners to serve 226,369 meals to 298 people of all ages who were discharged from the hospital and self-reported food insecurity. For the woman who returned home from Providence St. Vincent, and many others like her, the Medically Tailored Meals program offers more than just food; it provides a foundation for recovery and ongoing health management, delivered right to her doorstep.
Food Is Medicine
Providing nutritional support for older adults is the core mission of our organization. Medically tailored meals go further — offering dynamic support for individuals who are medically vulnerable, have chronic health conditions, or face other risk factors for hospitalization. In 2021, MOWP leadership completed the Food Is Medicine Coalition Accelerator Program, which works to scale the medically tailored meal model, and launched its MTM program later that year.
A medically tailored meal does not simply mean putting someone on a diet. Our participants’ medical lives are complex — many are living with multiple serious illnesses at once — and they require an equally complex nutrition intervention. Our current MTM offerings include meals tailored to folks living with chronic heart disease and kidney disease. Meals are served with fresh fruit, milk, and bread.
“Individuals who have been in the hospital are at high risk for readmission if they’re not well-nourished,” says Liz Cattin, director of community health at PeaceHealth and a registered dietician. “Meals on Wheels People focuses on high-quality nutrition. We fund Meals on Wheels People to provide two meals a day for 90 days after discharge to patients who are referred by our hospitals when they’re leaving – people who may have a need for higher-quality nutrition for healing in order to help them continue to heal when they leave and to help prevent unnecessary hospital visits.”
Connie Gilfillan, director of business development for MOWP, says the MTM program not only addresses the immediate need for nutritious meals but also plays a vital role in post-hospitalization care. “Our trained volunteers serve as the eyes and ears on someone after they’ve left the care of the hospital,” Connie says. “If a volunteer notes a change in an individual’s condition, like they take longer to answer the door week over week or complain that something is ailing them, we can be the conduit to funnel that feedback back to their health care provider.”
Liz says the impact on PeaceHealth’s patients has been more significant than she expected: “It makes all the difference for someone who is trying to heal and doesn’t have the physical or emotional capacity or support to take care of their own needs. This takes something off the list of have-tos to allow them more time and the ability to recuperate and not have to worry about where their next meal is coming from or how they’re going to prepare it or even plan or think about what it’s going to be. It helps them care for themselves. They can get into care faster, too, if they’re struggling because of the social connection and check-in that comes with MOWP. They notify us if they see a change in someone. We’ve seen a significant decrease in the number of times patients enrolled in the MTM program were being admitted and coming to the ER.”
Providence has integrated the MTM program into its safe and secure discharge program as well. Last year, an individual in his late 30s, struggling significantly with walking due to orthostasis and other health issues, enrolled in the MTM program before he was discharged from Providence St. Vincent Medical Center. Previously, he had been walking to a food bank about half a mile from his home, but continuing this routine immediately after discharge was not feasible. His care management social worker noted that the MTM program was critically important in his recovery process.
“His concerns about getting food for the weeks following his discharge were eliminated after we got Meals on Wheels set up,” the social worker says. “The service filled a crucial role in having a safe discharge plan, allowing a young person with great potential for independence avoid further escalation in needs and disability.”
MOWP’s Expanding MTM Offerings
To meet the ever-growing needs of patients across the Pacific Northwest, we are expanding our MTM service into regions outside our three counties served by our traditional program to support patients living in rural settings in need of nutritional supports post-discharge. This includes testing and piloting a frozen meal shipping program.
“Without access to healthy foods, it’s really hard to be healthy,” PeaceHealth’s Liz Cattin says. “We see that a lot in areas where access to food is scarce. Our relationship with Meals on Wheels People has allowed us to serve the rural service areas in southwest Washington and to do home-delivered meals in a different way.”
In addition to regional expansion, we are focusing on growing our MTM offerings. Our dieticians, compliance, and Central Kitchen leadership are diligently working to diversify and expand our menu by focusing on plant-based, culturally responsive, and renal diets in tandem with launching a new food management software system that allows for better ingredient and diet-type management. Up next is creating additional standards and reviewing recipes for wound care, prenatal, COPD, and diabetes diets.
“Meals on Wheels People is constantly bringing new research and best practices and thinking about new and different ways to expand and improve what they’re providing to the community,” says Providence’s Shelley Yoder. “They have been so flexible in working with us to design things that work well for our patients, for our front-line staff. They’ve been nimble and flexible and also really patient. The culture of MOWP is collaboration and partnership.”
Join the Movement
As we continue to witness the impact of the Medically Tailored Meals program, we invite health insurers, health care providers, and advocates to join us in this meaningful journey. If you’re interested in learning how you can connect your members and patients with this life-changing service, reach out to our team. Together, we can make a significant difference in the lives of those recovering and managing their health, one meal at a time.
