Clinical Nutrition Services in Medically Tailored Meals
One element common to Medically Tailored Meals programs is linking food-based treatments to an individual patient’s health history and treatment plans. Registered Dietitian (RD), or equivalent licensed provider, services are utilized at multiple steps. These include designing meal options, assessing an individual patient & creating their meal plan, and checking in with patients over the course of treatment. Access to different levels of nutrition services and education is a component of most food as medicine interventions, although not always requiring the close engagement of licensed providers the way MTM programs do.
The role of RDs and clinical nutrition services in MTM programs is defined as part of payer reimbursement structures, and as part of the Food Is Medicine Coalition (FIMC) work on demonstrating program impacts and scaling the model to more regions. Some ways that MTM programs engage this expertise:
Research and developing clinical evidence for MTM efficacy
Designing meal plans in individual MTM programs
Individual counseling with patients to build and monitor a dietary plan
Counseling for sustainable lifestyle modifications and transition to other services, especially when accessing a limited-duration MTM benefit
Health / care plan coordination with primary care provider
Availability to answer participant questions
The FIMC overview of the MTM model overview is here and here. Components relevant to nutrition services include:
Overall meal standards are set by RDs (see this example from their national clinical committee), patients are individually assessed and their meal plans developed with an RD after referral from a medical provider, there is a closed loop for supportive services and health outcomes monitoring between community organization and health care provider.
MTMs are for patients with a serious illness that has a clinically-recognized dietary regimen connected to its treatment, and who experience complications that prevent them from shopping or cooking for themselves.
Complications might include co-morbidities, disabilities, need for acute services following a hospital stay that impacted mobility, and the level of complexity of the required diet.
Another example of describing nutrition services as part of MTMs comes from the North Carolina Healthy Opportunities Medicaid pilot:
Medically Tailored Meal Definition: Home delivered meal which is medically tailored for a specific disease or condition. This service includes an initial evaluation with a Registered Dietitian Nutritionist (RD/RDN) or Licensed Dietitian Nutritionist (LDN) to assess and develop a medically-appropriate nutrition care plan, the preparation and delivery of the prescribed nutrition care regimen, and regular reassessment at least once every 3 months. Meals must be in accordance with nutritional guidelines established by the National Food Is Medicine Coalition (FIMC) or other appropriate guidelines. Meals may be tailored to meet cultural preferences. For health conditions not outlined in the Food Is Medicine Coalition standards above, an organization must follow a widely recognized nutrition guideline approved by the Network Lead organization.
The North Carolina model also includes Network Lead organizations who offer care management services to integrate medical and social services for targeted health-related social needs.
Details on the primary coverage pathway for meals as a Supplemental Benefit through Medicare Advantage is found in the MA Advantage Plan Manual Chapter 4, Sections 30.1 & 30.3. Per this guidance, home delivery of meals may be offered as a supplemental benefit if the services are:
1) Needed due to an illness;
2) Consistent with established medical treatment of the illness; and
3) Offered for a short duration.
Social factors, by themselves, do not qualify an enrollee for meal services.
Additional details on clinical connections for diet-related services include the following:
Service must be primarily health related; that is, the primary purpose of the item or service is to prevent, cure or diminish an illness or injury.
The MA plan must incur a non-zero direct medical cost in providing the benefit. If the MA plan only incurs an administrative cost, this requirement is not met.
Meals must be ordered by a physician or non-physician practitioner. For chronic conditions, must be part of a supervised program designed to transition the enrollee to lifestyle modifications.
Although there are a few payer options with greater flexibility in linking meals to direct medical services, these are relatively rare. One example is Special Supplemental Benefits for the Chronically Ill (SSBCI) within Medicare Advantage plans. Here, CMS explicitly allows providing meals, food, and produce when there is a “reasonable expectation” they will promote health, which is a more permissive standard than requiring a direct link to treatment for a medical condition. The prescription cannot be based solely on social drivers of health, but those can be a significant focus and used as part of determining elgibility. This flexibility supports community partnerships to provide healthy food bur not necessarily based on a nutrition professional’s work tailoring an individual diet to reach clinical goals. See this 2020 letter of explanation:
“For example, an MA plan could elect to offer, as a SSBCI, the provision of meals or food/produce and pay a community-based organization for furnishing the covered benefit. Community-based organizations can also help determine whether an individual meets the eligibility requirements for SSBCI.” (pg 19)
Details on food-related benefits around SSBCI, including produce prescriptions, are available from the Center for Heath Law and Policy Innovation.
In the 2021-2022 planning for Vermont rural health systems’ capacity to add clinically-integrated food programs, the VT FAHC identified availability of relevant nutrition services as a potential barrier. The 2022 Overview of Nutrition Services in Vermont provides more information on current resources and gaps in these services. This one-page handout describes reimbursement for Medical Nutrition Therapy (clinical RD services) in Vermont in 2022.