Partnership with health care providers results in decreased hospital readmissions

When it comes to health, the quality of your health care matters. But research shows that your medical care accounts for only a small fraction (10 to 20 percent) of overall health. Other factors, like the neighborhood you live in, the air you breathe, and the food you eat, can have far greater impact.

That’s why some health care providers and payers (such as Medicare/Medicaid) are considering non-traditional programs and partnerships as one way to improve the health of patients and customers. Could addressing nonmedical challenges—often referred to as the social determinants of health—be a more economical way to improve the health of people living with diabetes, chronic obstructive pulmonary disease (COPD), and other chronic diseases?

Last year, Project Angel Heart launched Meals for Care Transitions, a program in which health care providers and payers can partner with us to address the nutritional needs of patients after they’re released from a hospital or other care facility.

Initial results of the program, piloted with a small number of COPD and congestive heart failure (CHF) patients released from North Suburban Medical Center, a HealthONE hospital in Thornton, are positive. Of the 15 people who have completed the program, there have been zero readmissions within 30 days.

Sixty-seven percent of patients said that the meals contributed to their ability to remain at home after the hospitalization, and 56 percent said the meals made a difference in their ability to afford health care. Eighty-three percent of patients reported an improvement in their overall health and/or energy – moving from a rating of poor/fair to a rating of good/very good by the end of the program.

“Many of the patients who received these meals were malnourished prior to coming to the hospital and had verbalized an inability to afford quality foods,” said Ann-Marie Estes, supervisor of case management at North Suburban Medical Center. “The pilot provided these chronically ill individuals with the nutritious meals necessary to promote healing and good health.”

Meals for Care Transitions meals are tailored to meet the specific dietary needs of program participants.

Meals for Care Transitions meals are tailored to meet the specific dietary needs of program participants.

Meals for Care Transitions participants receive up to three healthy, medically tailored meals per day, free of charge, for a length of time prescribed by the health care provider. The meals are made using fresh ingredients, then delivered frozen to patients’ homes so that they have ready-to-eat meals available as they recover. The cost of the meals is reimbursed by the health care provider, with the aim of helping the provider achieve a specific, desired outcome (for example, helping patients remain independent in their homes or preventing weight loss during cancer treatments).

For many health care providers, the goal is preventing patients from being readmitted to the hospital within 30 days of being discharged. Readmissions are a costly problem in the U.S. On average, 23 percent of patients released after a COPD-related hospitalization are readmitted within 30 days, often due to complications related to malnutrition. For patients with CHF, 25 percent are readmitted within 30 days. The cost of each readmission averages between $8,400 and $13,000.

Based on Meal for Care Transitions initial success, the program will expand to Rose Medical Center and Medical Center of Aurora this year, and HealthONE officials hope to secure additional funding to expand it at other facilities. A variety of other health care providers are exploring partnership opportunities, as well. 

“Meals for Care Transitions is proving that that when community-based organizations and health care organizations work together to address the social determinants of health–like nutrition–it’s possible to greatly improve health outcomes while reducing health care costs,” said Leslie Scotland-Stewart, director of business development for the program.

Learn more about Meals for Care Transitions


Amy Daly is Project Angel Heart’s director of marketing and communications. While the majority of her professional experience is in nonprofit fundraising and communications, she’s also a bit of a nutrition geek, which led her to pursue a certification in holistic nutrition from Bauman College in 2011. She loves being able to combine her experience in marketing and fundraising with her passion for nutrition. Amy has a BA in journalism from Colorado State University and an MBA from the University of Denver’s Daniels College of Business. In her spare time, she enjoys inventing wild and silly stories for her 3-year-old daughter, reading (and occasionally finishing) a good novel, and exploring Colorado.