Delivering Whole-Person Care, One Meal at a Time

Man unpacks prepared meals in kitchen
Brett Perkinson opens his weekly supply of medically tailored meals delivered from a community-based organization to his mobile home in Aptos, just outside of the city of Santa Cruz. Photo: Shmuel Thaler

Every Wednesday afternoon, Brett Perkinson eagerly awaits a delivery of customized meals that keep him healthy and help make ends meet. The 51-year-old Santa Cruz gardener has had diabetes for years and began receiving prepared meals after he was hospitalized for a severe hand injury that left him unable to care for himself. Doctors feared that his diabetes would worsen once discharged, so they referred him to a medically tailored meal program.

“My diabetes has gotten better with the meals,” said Perkinson. “I’ve kept my weight down, and I feel much better now than I have in a long time. I’m one of the people this program is meant for.”

Perkinson’s meals are a benefit provided to Medi-Cal enrollees by the Central California Alliance for Health, a Medi-Cal managed care plan for Santa Cruz, Merced, and Monterey Counties. Eligible participants are people with chronic conditions who have been recently discharged from a hospital and are at high risk of needing to be readmitted.

For three months, eligible members receive a supply of 14 meals per week along with recipe cards to teach them how to prepare healthier meals at home. The Alliance assigns a case manager and offers consultations with a nutritionist to help participants make healthy food choices.

In Santa Cruz County, the medically tailored meals are delivered by Teen Kitchen Project, a community-based organization. A registered dietitian works with staff chefs to create meals that meet the dietary needs of people with diabetes, congestive heart failure, and other chronic health problems. The organization, which employs paid staff including teens, is one of two partners working with the Alliance to provide the meal service.

“I enjoy the variety of the meals, and I really appreciate the fruits and vegetables. Fresh produce is hard to get at food pantries,” said Perkinson, who used to rely on his church’s garden to supplement his groceries.

My diabetes has gotten better with the meals. . . . I’ve kept my weight down, and I feel much better now than I have in long time. I’m one of the people this program is meant for.

—Brett Perkinson

The Alliance began offering medically tailored meals in 2018 through a two-year pilot program developed and funded through its Medi-Cal Capacity Grant Program. The project enrolled more than 495 Medi-Cal enrollees with chronic health issues, and more than 72,000 meals were delivered to them.

Evaluation of the pilot found that medically tailored meals have helped reduce hospital stays and health care costs by $676 per member per month. These findings echoed national research showing that medically tailored meal programs reduce emergency and hospital care while improving health outcomes and helping people make healthier food choices.

“The pilot was very successful and resulted in better health outcomes for our members, lower health care costs, and high satisfaction among participants,” said Kathleen McCarthy, strategic development director at the Alliance. “This prompted us to continue offering this service as a benefit to all eligible members.”

Person walking near a car, carrying bags of prepared meals
Ali McCargo delivers meals prepared by the Teen Kitchen Project to Brett Perkinson at his home in Santa Cruz County, California. Within the community-based organization, McCargo and other drivers are referred to as “delivery angels.” Photo: Shmuel Thaler

Medically tailored meals are an outgrowth of community response to the AIDS epidemic in the 1980s. Today, there are medically tailored meal programs around the country that serve people living with serious illness paired with food deprivation.

“Access to healthy food is an important factor in disease prevention and overall well-being,” said Michelle Schneidermann, MD, director of CHCF’s People-Centered Care team. “People who experience poverty and food insecurity may choose high-calorie, nutrient-poor foods or forgo meals altogether, which can in turn lead to or worsen medical conditions. We know from rigorous studies that interventions like medically tailored meals can reduce stress, improve nutrition, and ultimately improve health outcomes.”

CalAIM Brings Medically Tailored Meals Statewide

In January, the state is launching CalAIM, an initiative to revamp its Medicaid program, which enables plans to offer medically tailored meals and 13 other approved community supports. These services were selected on the basis of evidence that they are cost-effective (PDF) and are integral to the state’s plan to offer comprehensive, whole-person care for patients with the greatest medical and social needs. Starting in January 2022, the state will allow health plans to offer these services as alternatives to traditional medical services.

An important part of the pilot was helping Teen Kitchen Project learn how to operate like a provider in a managed health plan provider network, and for the Alliance to work with a provider that was new to managed care.

—Kathleen McCarthy, Central California Alliance for Health

The state is encouraging plans to offer a range of community supports to fully address patients’ complex health needs, reduce health care costs, and produce better outcomes for enrollees. In fact, medically tailored meals are the most commonly offered community support service and will be available in January in 45 of California’s 58 counties, according to a list published by the California Department of Health Care Services. Almost all managed care plans are expected to begin offering at least one service in January, and many will offer more robust services by summer. To deliver these services at scale, health plans will have to work with community organizations that have never been part of the health care delivery system. While this approach presents new funding opportunities for local organizations, working in the Medi-Cal system presents challenges.

From Opportunity to Implementation

Community organizations need technology infrastructure, training, and ongoing support (PDF) to work with managed care plans. Navigating claims systems to properly bill and get paid in a timely manner is critical for local organizations that often lack cash reserves. Anticipating these challenges, the state has held webinars, created resources, and announced incentive payments to build capacity and encourage participation (PDF).

“An important part of the pilot was helping Teen Kitchen Project learn how to operate like a provider in a managed health plan provider network, and for the Alliance to work with a provider that was new to managed care,” said McCarthy. “We all needed to invest time and resources to ensure a successful transition.”

The managed care plan added Teen Kitchen Project as a provider in its claims system and guided the organization to use a claims clearinghouse that enabled it to bill the Alliance for services rendered. Teen Kitchen Project implemented Office Ally, a free web-based billing service, to handle claims transactions and set up an electronic interface to submit invoices.

For three months, the health plan conducted extensive training to build the organization’s capacity for billing. The Alliance required  Teen Kitchen Project to apply for a National Provider Identifier number, assigned by the US Centers for Medicare & Medicaid Services, to qualify for reimbursement.

The Alliance also partnered with an additional meals provider to cover its entire three-county service area. A national for-profit company, Mom’s Meals, is servicing Merced and Monterey Counties, which fall outside of Teen Kitchen Project’s coverage area.

“The whole experience has been seamless for us,” said Angela Farley, executive director of Teen Kitchen. “We couldn’t have done this without the Alliance’s support.”

Farley says she is grateful for the opportunity to provide a life-saving service to the community. Her organization plans to broaden its services to include meals tailored for patients with kidney failure.

For Perkinson, the help came just in time.

“When I was younger, I saw my father pass away from diabetes,” he said. “It’s a horrible way to die. I swore that I would do everything I could to be healthy and live as long as possible. I’m getting help to do that now.”

Shmuel Thaler

The 2016 Santa Cruz County Artist of the year, Shmuel Thaler has been a staff photographer at the Santa Cruz Sentinel since 1987. His photographs have appeared in every major newspaper in the United States. He spent much of 2020 documenting the Black Lives Matter actions, the election, the CZU August Lightning Complex fires, and the pandemic for the Sentinel. His photograph of Santa Cruz Police Chief Andy Mills and Mayor Justin Cummings was seen by millions when it went viral, aired on every major TV network, and was shared by Octavia Spencer, Katie Couric, George Conway, and thousands of others on social media.

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