Across the athenahealth network and beyond, healthcare organizations are designing and implementing simple interventions with outsized impact on outcomes, satisfaction, and success. Here's another.

The problem

About 12 percent of U.S. households experience food insecurity, with adults in those households 40 percent more likely to be chronically ill.

That's a challenge when the most common chronic conditions — diabetes, hypertension, and congestive heart failure — require patients to follow restricted diets. And most of those patients have multiple conditions, making their diets even more complex, as glucose, potassium, vitamin K and other nutrients must be carefully monitored.

Making things more difficult, “five minutes before they leave the hospital, we tell people how to change their diets with a flier," says David Waters, CEO of Community Servings, a Massachusetts food and nutrition program serving the chronically and critically ill.

The solution

Founded in 1990, Community Servings views food as an affordable, high-impact medical intervention. What began as a high-calorie meal delivery service for AIDS patients has evolved to provide 15 different categories of medical diets — addressing up to three conditions in any individual meal — for 1,300 patients each day in Massachusetts and Rhode Island. Patients must see a doctor to register for the service, which means that taking part in the service keeps them connected to their physician.

Once a week, a driver delivers to housebound patients enough lunches, dinners, and snacks to last five days. The meals are intended to be delicious to entice patients to eat, even when their appetites are low. Everything is prepared from scratch by chefs from the same community as the patients, infusing dishes with flavors from their cultures.

To increase the impact of the visits, drivers visit with patients and do a "light touch wellness check," noting if patients seem more frail, are showing signs of dementia, or fail to come to the door. And all of that information is relayed to each patient's care manager.

Healthy diet tips come with each meal, and Community Servings offers disease-specific nutrition classes. Dietitians reach out to patients to prescribe a diet and provide coaching and help with the side effects of medications.

The outcome

A recent study compared claims data for 135 dually eligible Medicare/Medicaid Commonwealth Care Alliance health plan members fed by Community Servings with data on more than 200 patients receiving Meals on Wheels.

While both cohorts saw reduced emergency department visits compared to the general population, those receiving medically tailored meals also saw a 16 percent reduction in monthly healthcare costs: $220 per patient per month. One patient with diabetes used to call 911 every month when her HbA1c levels would spike. In her first 6 months with Community Servings, however, she had no visits to the emergency department.

Medically tailored meals, says Waters, should be a reimbursable component of treatment plans – and payers have been receptive to his argument. “If you can't control your glucose, it's going to lead to kidney failure, blindness and leg amputation – very expensive care," he says.

Next up: Community Servings is working to scale its "food as medicine" model nationally by creating its own accelerator – a program of teaching and mentoring to develop new healthcare solutions for food insecurity.

Lia Novotny is a contributing writer for athenaInsight.