Today, there is huge opportunity to bridge the continuum of care. In a recent NYSHealth-funded report, prepared by researchers at Weill Cornell Medical College, researchers examined hospitals’ involvement in community-based population health programs to address non-medical health determinants.

Strong evidence shows that community-level social and environmental factors can affect health significantly. As hospitals assume greater risk for their patients, some argue that they should focus not only on the medical care of their attributed patients, but also on improving non-medical health determinants—such as access to healthy foods, housing, and employment. The report finds that New York State hospitals’ involvement in programs to address community non-medical health determinants is not widespread, owing to a perceived lack of incentives and resources for such programs.

At God’s Love, we know that our medically appropriate meals and personal nutrition counseling improve patients’ health and wellbeing, while helping to reduce health care costs. We already partner with 34 Medicaid managed long term care plans to do so through our Community Partners Program. We are also deeply involved in the statewide push to reduce hospital admissions by 25% through DSRIP (the Delivery System Reform Incentive Payment model). All of our hospital partners have recognized the efficacy of our services and are now navigating ways to include them in discharge planning for vulnerable individuals.

Changing the paradigm takes time, but as we educate and elucidate how medically tailored home-delivered meals are a low-cost, effective strategy for hospitals to prevent recidivism, we believe the investment is worth it for our clients. Identifying and treating malnourished patients upon admission and supporting them through discharge go beyond the hospitals four walls.