Community Based Organization Finalists

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Q1 Please provide your contact information below.

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Q2 Please describe your company or organizations overall goals and mission.

God´s Love We Deliver ("God´s Love") is a non–profit community–based organization (CBO) located in New York City. Guided by the principle that food is medicine, our mission is to improve the health and well–being of men, women and children living with serious illnesses by alleviating hunger and malnutrition. We prepare and home–deliver nutritious, high–quality medically tailored meals to people who, because of their illness, are unable to provide or prepare meals for themselves. We also provide medical nutrition therapy—illness– specific nutrition education and counseling—to our clients, families, care providers and other service organizations.

Medically tailored meals are meals approved by a Registered Dietitian Nutritionist (RDN) that reflect appropriate dietary therapy according to evidence–based nutrition practice guidelines to address medical diagnoses, symptoms, allergies, medication management, and side effects to ensure the best possible nutrition–related health outcomes. Medical nutrition therapy is integral to medically tailored meals and includes nutritional diagnostic, therapy, and counseling services focused on prevention, delay, or management of diseases and conditions. Medical nutrition therapy involves an in–depth assessment, periodic reassessment, and intervention provided by an RDN outside of a primary care visit.

Today, God´s Love is the New York metropolitan area´s leading provider of medically tailored home–delivered meals and medical nutrition therapy for people living with serious illness. God´s Love cooks and home delivers 1.8 million medically tailored meals annually to more than 7,000 people living with more than 200 individual diagnoses—such as heart disease, diabetes, hypertension, chronic obstructive pulmonary disease (COPD), renal failure, cancer, HIV/AIDS and many more—in all five boroughs of New York City and in Westchester and Nassau Counties. Our clients live with an average of three co–occurring, complex illnesses that together require a specialized diet, tailored according to each individual´s dietary needs, including texture restrictions (e.g., minced, pureed, etc.). Illness knows no boundaries and the diversity of our client population bears that out: we serve every demographic and 90% of our clients live at or below the Federal Poverty Level. A significant majority of our clients are enrolled in Medicaid or are Medicaid–eligible.

In 2005, through the benefits made possible by New York State´s 1115 Medicaid waiver, Medicaid Managed Long Term Care (MLTC), PACE, MAP and FIDA plans began contracting with God´s Love to provide medically tailored home–delivered meals and medical nutrition therapy to their highest–risk enrollees. In the more than ten years since, God´s Love has prepared and delivered over 2.1 million medically–tailored meals to MLTC and other long–term care plan enrollees. God´s Love currently contracts with 24 long–term care plans and serves more than 330,000 meals to almost 1,500 long–term care enrollees annually.

In addition, God´s Love was chosen as an Outstanding Project by the New York State Department of Health, through their Balancing Incentive Program (BIP), which ended in 2016. Our BIP project facilitated the expansion of our services to Nassau and Westchester Counties and led the development of a simplified referral tool that uses the Uniform Assessment System (UAS) to help care managers identify enrollees in need of medically tailored meals.

God´s Love is the proud recipient of the New York Times Nonprofit Excellence Award, a recipient of Charity Navigator´s highest (4–star) rating and is a Better Business Bureau–accredited charity. God´s Love also leads The Food Is Medicine Coalition, a national provider coalition of peer medically tailored meal providers.

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Q4 Innovation Executive Summary. Please describe the innovation, and how it addresses the social determinants of health. Please identify how the innovation addresses the 6 innovation criteria (i.e. ROI, scalability, feasibility, evidence–based support for innovation, relevance to the Medicaid population and speed to market).

Innovation: To expand and enhance the delivery of medically tailored meals and medical nutrition therapy to more rural and other high– need populations by (1) using a food–safe shipping carrier, rather than a refrigerated van, to transport meals and (2) incorporating telemedicine to deliver in–depth nutritional assessment and counseling to individuals.

Today, God´s Love uses a refrigerated van delivery model to efficiently deliver medically tailored meals to individuals´ homes in densely– populated service areas. Meals are prepared and cooked in our New York City kitchen, flash frozen to preserve nutrients and freshness and contain no starters, fillers, or preservatives. Meal deliveries by van contain up to three well–balanced meals per day (breakfast, lunch, and dinner) for an entire week. In areas with lower population density, however, the van delivery model is prohibitively expensive. Using a food–safe shipping carrier to transport medically–tailored meals to individuals in need would enable the expansion to rural areas of New York State, whose residents are equally in need of high–quality, medically tailored meals. Along similar lines, there are many enrollees in mainstream Medicaid managed care who are living with serious illness(es) and at risk for hunger and malnutrition. Offering medically tailored home–delivered meals and medical nutrition therapy to this population would address food insecurity and poor access to healthy food and needed healthcare that exists among this population and may reduce their need for institutionalized care or even enrollment in MLTC and other long–term care programs. These gaps in service delivery are a missed opportunity to address critical social determinants of health relating to access to healthy foods and food security. Our innovation seeks to remedy this.

In addition to adapting the delivery of medically tailored meals, our innovation seeks to adapt the mode of conducting nutritional assessments and medical nutrition therapy, leveraging modern telemedicine technology to the maximum extent possible. While today, our seven Registered Dietitian Nutritionists primarily engage individuals through telephone calls, God´s Love seeks to implement video– conferencing to increase the effectiveness of and make even more personal the medical nutritional therapy delivered to clients, as well as to create new ways to connect with individuals in the community. Using telemedicine to deliver medical nutrition therapy to individuals in more rural areas will also allow these individuals to feel closer to their meal provider, since they will not have the face–to–face contact with a God´s Love meal deliverer as individuals in the New York City area do.

How the Innovation Addresses Social Determinants of Health
The services provided by God´s Love aim to improve the health and well–being of individuals with serious illness by hunger and malnutrition. In home–delivering medically tailored meals, the God´s Love meal delivery team can also provide much–needed social interaction for individuals who often feel isolated and lonely. In our carrier–based model, the telemedicine component supplies this connection. The expansion of medically tailored home–delivered meals and medical nutrition therapy, while keeping with the high standards that the God´s Love service model ensures, will address critical social needs–including poor access to healthy food, poor access to needed healthcare, food insecurity, and even lack of social interaction–for harder to reach, more isolated populations across the state.

Evidenced–Base Support for the Innovation
A growing body of research indicates that providing medically tailored meals to people who are severely or chronically ill is an effective strategy for achieving the "triple aim" healthcare goals of improving health care quality and health outcomes, lowering costs, and improving patient experience of care–especially for seriously or chronically ill enrollees.

While proper nutrition is critical to overall health for all populations, it is particularly important for individuals experiencing serious or chronic illness. Poor nutrition is associated with reduced control of chronic conditions. Medically tailored meals and nutrition therapy can play a key role in both preventing and managing some of the most costly and pervasive chronic diseases, such as heart disease, diabetes, hypertension, COPD, renal failure, cancer and HIV/AIDS. By improving medication adherence and engagement in care, medically tailored meals and nutrition therapy can help improve the effectiveness of treatment plans developed by providers and care managers.

High–risk and chronically ill enrollees, such as those with multiple co–morbidities, nutrition–sensitive illnesses or those returning home after an acute inpatient episode, may not have the ability to shop and cook for themselves or to obtain and eat food from other sources in their community (e.g., food banks, pantry programs or congregate meal programs). Ongoing illness and isolation, added to poor nutrition, can create stresses that negatively affect enrollees´ treatment and recovery, prevent enrollees from staying in their own homes, and reduce enrollee satisfaction with their care and overall health condition. Importantly, recipients of medically tailored meals report a decrease in stress, more independent living, better management of their medical treatment, and learning how to eat more nutritiously (1).

Research shows that poor nutrition is associated with a host of negative health outcomes and costly healthcare utilization trends, including longer lengths of hospital stays and higher rates of hospital readmissions. One in three hospitalized patients is malnourished on admission (2). Malnourished adults are 50% more likely to be readmitted and malnutrition is a factor in almost two million hospital stays annually (3). Malnourished patients are also twice as likely to be discharged to a facility than to their home (4). Medically tailored meals can reduce hospitalizations and emergency room visits and increase the likelihood that an enrollee will be discharged to their home, not an institution (5, 6, 7).

Return on Investment
Medically tailored meals and medical nutrition therapy are an inexpensive, but effective, intervention: you can feed someone for half a year for the cost of one day in a hospital (8). A new research study from Health Affairs has found that, for individuals with severe and chronic illness, medically tailored meals can decrease healthcare costs by up to 16% and reduce other healthcare cost–factors, such as inpatient costs, length of stay, and number of hospital admissions (9). This study also demonstrated the delivery of medically tailored meals results in cost savings that were not achievable through non–medically tailored meal programs. Furthermore, results like these can be seen in as little as 30 days. Offering medically tailored meals to enrollees can reduce the need for institutionalization and other long–term care services, such as personal care services, leading to cost–savings (for the state, plans or Value Based Payment contractors, and potentially, the enrollee and their family), and keeping enrollees in their homes where they want to be.

Relevance to Medicaid Population
New York State Medicaid enrollees living with serious illness are confronted with multiple competing needs. All enrollees are low– income and their physical health – and often mental health – needs are complex. Individuals caught in these situations often make the tradeoff between food and medication (i.e., to treat or to eat). Poor access to healthy food and food insecurity can be sources of chronic stress that have effects on individuals´ mental and emotional health and can lead to reduced adherence to medical treatments (10, 11). Something as simple as a medically tailored meal can turn this situation around for many of New York State´s Medicaid enrollees.

Feasibility and Scalability
Defining features of this innovation are feasibility and scalability–adapting the food delivery model in a feasible way to drastically increase scale, with the overarching goal of addressing the social needs of Medicaid enrollees across the state. God´s Love has already begun testing feasibility and scalability by executing a carrier pilot with a small group of MLTC enrollees in Westchester and Nassau Counties. (These counties are within our geographic delivery area, allowing us to address any concerns that surfaced in person, if needed.) Meals were custom–packed by God´s Love staff and volunteers in insulated boxes and delivered once a week via Priority Overnight delivery, which ensured individuals received meals within a short delivery window of time (i.e., guaranteed next day delivery by 10:30 AM).

The pilot has had significant success, indicating strong potential for scalability. Through careful planning we identified constraints, risks and potential pushback from the individuals receiving the medically tailored meals, to effectively design an operational framework and supporting controls that streamline meal packaging, carrier integration, client servicing and communication and reporting.

As part of this innovation to expand and enhance the delivery of medically tailored meals and medical nutrition therapy, God´s Love seeks to leverage its strong existing relationships with MLTC and mainstream Medicaid plans to build this new program in farther regions of the state. Because of the efforts of this initial pilot–and the fact that medically tailored meals and medical nutrition therapy are already reimbursable benefits in the MLTC program that God´s Love has provided to Medicaid enrollees for more than 10 years– the programmatic infrastructure, plan relationships and client–facing services are already in place, paving the way for successful implementation of our innovation in the near future.

Speed to Market
God´s Love has a robust history of managing change and growth. Over the last 10 years, we have grown our medically tailored meal delivery by more than 150%. We have renovated and expanded our home in New York City to allow us to more than double the number of meals that we can cook and home–deliver. And importantly, we have grown our volunteer corps, now 10,000 individuals strong, ensuring that we are connected to the communities we serve. In addition, God´s Love has developed a new Program Strategy Department tasked with managing projects of increased size and scale. And, as noted above, we have already completed a pilot of our innovation–to test the operational framework, carrier servicing standards, end–to–end consumer experience and overall quality assurance–with excellent results. The intervention is ready to be implemented.

Call for Social Determinants of Health Innovations

Citations

1. Palar et al (2017). Community Servings: Food Is Medicine: Medically Tailored Home–Delivered Meals Can Improve Health Outcomes For People with Critical and Chronic Disease. Client satisfaction surveys from Food Is Medicine Coalition agencies.
2. Su Lin Lim, Kian Chung Benjamin Ong, Yiong Huak Chan, Wai Chiong Loke, Maree Ferguson, Lynne Daniels. Malnutrition and its impact on cost of hospitalization, length of stay, readmission and 3–year mortality. Clinical Nutrition 31 (2012) 345–350. 345
3. Weiss, AJ, et al. Characteristics of Hospital Stays Involving Malnutrition, 2013. HCUP Statistical Brief #210. September 2016. Agency for Healthcare Research and Quality, Rockville, MD. http://www.hcup–us.ahrq.gov/reports/statbriefs/sb210–Malnutrition– Hospital–Stays–2013.pdf.
4. Corkins MR et al., Malnutrition Diagnosis in Hospitalized Patients: United States 2010, J. Parenteral and Enteral Nutrition (2013)
5. Jill Gurvey et al., Examining Health Care Costs Among MANNA Clients and a Comparison Group, 4 J. of Primary Care & Cmty. Health 311, 313–15 (2013).
6. Palar, K., Napoles, T., Hufstedler, L.L. et al. J Urban Health (2017) 94: 87. doi:10.1007/s11524–016–0129–7
7. Berkowitz, B., Terranova, J., Hill, C., Ajayi, T., Linsky, T., Tishler, L., and DeWalt, D. Meal Delivery Programs Reduce The Use Of Costly Health Care In Dually Eligible Medicare And Medicaid Beneficiaries. HEALTH AFFAIRS 37, NO. 4 (2018): 535–542
8. Based on average daily cost of a medically tailored meal program compared to average hospital cost per day in the US: International Federation of Health Plans 2015 Comparative Price Report Variation in Medical and Hospital Prices by Country
9. Berkowitz, S. Terranova, J. Hill, C. Ajayi, T. Linsky, T. Tishler, W. DeWalt, D. Meal Delivery Programs Reduce The Use Of Costly Health Care In Dually Eligible Medicare And Medicaid Beneficiaries. HEALTH AFFAIRSVOL. 37, NO. 4: CULTURE OF HEALTH, THE ACA & MORE. April 2018
10. Berkowitz SA, Seligman HK, Choudhry NK. Treat or eat: food insecurity, cost–related medication underuse, and unmet needs. Am J Med. 2014 Apr;127(4):303–310.e3. doi: 10.1016/j.amjmed.2014.01.002. Epub 2014 Jan 1
11. Aidala A., Yomogida M., and the HIV Food & Nutrition Study Team (2011). HIV/AIDS, Food & Nutrition Service Needs: Community Health Advisory Fact Sheet. New York: Mailman School of Public Health, Columbia University: 1.

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