When Food Becomes Medicine: Closing the Last Mile of Interoperability

What if the most effective prescription for heart failure or diabetes wasn’t a pill, but a meal?

That’s the promise of medically tailored meals (MTMs) — fully prepared, dietitian-designed meals delivered to people with serious, diet-sensitive illnesses. Over the past decade, MTMs have moved from the fringes of community nutrition programs into the mainstream of healthcare reform. The evidence is clear: they improve diet quality, strengthen outpatient engagement, and have the potential to reduce costly hospitalizations. But the big question remains: how do we move from promising pilots to sustainable, scalable programs?

The answer lies in the last mile of interoperability — the data connections that ensure MTMs are not just delivered, but also measured, reimbursed, and integrated into the broader health system.

California: A State Ahead of the Curve

California has been a national leader in “Food is Medicine” programs. Its Medi-Cal MTM Pilot Program (2018–2021) targeted beneficiaries with congestive heart failure and paired twelve weeks of home-delivered meals with nutrition therapy and case management. Evaluators found that participants filled 6.6% more prescriptions, had 13% more outpatient visits, and among those with heart failure, spent 53% fewer hospital days in the first six months compared to controls. Full evaluation: Evaluation of the Medically Tailored Meals Pilot Program – DHCS/Mathematica (2023)

More recently, Mama’s Kitchen in San Diego ran a “Shipped MTM” pilot (2023–2024) that provided 55 clients with 21 meals per week for 12 weeks, plus nutrition counseling. The results were telling:

• Participants increased their vegetable intake and ate more meals per day.

• Nearly 60% reported fewer hospital or emergency visits during the program.

• Satisfaction was sky-high, with 95% rating meals as good, very good, or excellent.

At the same time, challenges surfaced: only 38% completed the program, with attrition linked to freezer space, food preferences, or hospitalization. Clinical outcomes like A1C or weight showed no statistically significant changes, likely due to small sample sizes and short duration. Report: Mama’s Kitchen Shipped Medically Tailored Meals Pilot Report (2024)

California’s broader policy push through CalAIM has cemented MTMs as an optional reimbursable Community Support. Plans can provide up to two meals per day for 12 weeks, extendable when medically necessary, and must align with clinical needs rather than simply addressing food insecurity. Overview: CalAIM Community Supports – Medically Tailored Meals

National Evidence: The Big Numbers

On a national scale, the potential is enormous. A 2022 JAMA Network Open study modeled what would happen if MTMs were covered by Medicare, Medicaid, and private insurance for eligible adults with diet-sensitive chronic disease. The projections:

• 1.6 million hospitalizations averted annually,

• $38.7 billion in reduced expenditures,

• $13.6 billion in net annual savings.

Over a decade, that adds up to more than 18 million avoided hospitalizations and $185 billion in net savings. Study: Hager K, et al. JAMA Network Open (2022)

Beyond California: Lessons from Other States

California isn’t the only one experimenting. Across the country, states are weaving MTMs into Medicaid through Section 1115 waivers and demonstration projects.

• North Carolina: The Healthy Opportunities Pilots (HOP) launched in 2022 and now serve more than 13,000 individuals. Through managed care and regional “Network Leads,” the program covers medically tailored home-delivered meals, groceries, produce prescriptions, and nutrition education. Program overview: NC DHHS – Healthy Opportunities Pilots Spotlight: Food Is Medicine Center – North Carolina HOP

  
  

• Massachusetts: MassHealth has incorporated MTMs and food prescriptions into its Medicaid strategy, supporting fruit and vegetable vouchers, protein boxes, and other nutrition supports. Policy summary: ODPHP – Food Is Medicine Policy Pathways

  
  

• Oregon: Through its Medicaid waiver, Oregon Health Plan offers medically supportive food and nutrition services, including MTMs. Evidence roundup: Better Care Playbook – Medically Tailored Meals

  
  

• Other states: New York, Pennsylvania, Washington, and Illinois have waivers that include MTMs or supportive food services. These programs are newer, but they reflect a national shift toward embedding food into healthcare. Example: McDermott+ – NY 1115 Medicaid Waiver Summary

The Last Mile Problem

Despite all this momentum, one critical barrier keeps surfacing: data silos.

• Referrals are often faxed or emailed.

• Intake forms live in PDFs on nonprofit servers.

• Outcomes are measured by self-report surveys.

• Clinical data like lab values rarely flow back to the food providers.

Without interoperability, health plans can’t track whether MTMs reduce utilization, providers don’t know if their patients are completing programs, and community organizations struggle with reporting.

It’s the digital equivalent of delivering meals to the front porch but never ringing the doorbell.

What the Last Mile of Interoperability Looks Like

For MTMs to become a core part of whole-person care, the last mile of interoperability must be built. That means:

• Closed-loop referrals: Electronic referrals from EHRs, with confirmation of enrollment and program completion.

• Standardized coding: Using Gravity Project SDOH codes, SNOMED, and LOINC so MTM data integrates seamlessly with labs, meds, and encounters.

• Claims and outcomes integration: Linking MTM participation data with hospitalizations, ED visits, and medication adherence to prove impact.

• Equity dashboards: Tracking who receives MTMs, by geography and demographics, to identify gaps and disparities.

• Operational analytics: Monitoring referral patterns, program attrition, and patient satisfaction to improve delivery.

Conclusion

Medically tailored meals are no longer a fringe idea. They are evidence-based, patient-loved, and increasingly policy-backed. California has led the way, but states from North Carolina to Massachusetts to Oregon are proving that MTMs can fit into Medicaid and broader healthcare reform.

The evidence is there. The policy momentum is there. What’s missing is the data infrastructure to make it all work at scale. That’s the last mile of interoperability — the connections that allow food to be treated like any other medical intervention, visible in the care record, reimbursed by payers, and evaluated for outcomes.

When food flows through the same pipes as prescriptions and lab results, MTMs move from pilot projects to a standard of care. And when that happens, patients won’t just be fed — they’ll be healthier, healthcare will be more sustainable, and the system as a whole will finally recognize what we’ve known all along: food is medicine.