Linda: Improving Chronic Outcomes by Addressing Food Insecurity

Connecting members to the care and support they need, wherever they are.

Linda, a 67-year-old living alone with diabetes and hypertension, struggled to maintain a consistent, healthy diet due to financial and mobility constraints.

01. Challanges

Food insecurity created a direct barrier to managing her chronic conditions effectively.

  • Key Drivers

    • Limited access to nutritious meals
    • Poor diet impacting glucose and blood pressure control
    • Mobility limitations restricting food access
    • Increased risk of complications
    • Social isolation

02. Approach

Community Supports focused on ensuring consistent access to appropriate nutrition while addressing underlying access barriers.

  • Interventions

    • Enrollment in medically tailored meal program
    • Nutrition counseling aligned with conditions
    • Home-delivered meals to eliminate access issues
    • Connection to local food and community resources
    • Ongoing monitoring and engagement

03. Outcome

Improved nutrition access resulted in measurable improvements in chronic disease management and overall wellbeing.

  • Outcomes

    • Improved A1C levels
    • Stabilized blood pressure
    • Reduced acute care utilization
    • Increased daily energy and function
    • Improved quality of life

Key shift: Addressing food insecurity enabled effective chronic disease control.

~70%+

Enhanced Care Management (ECM) – Care Coordination Impact

of DHCS quality measures tied to care coordination (MCAS) show improvement in access, timeliness, and continuity of care

Signal: ECM-driven coordination is directly improving member engagement and reducing fragmentation.

52%

Community Supports (CS) – Preventive & Whole-Person Care

of plans improved preventive care engagement (e.g., well-care visits) tied to upstream interventions and social supports

Signal: CS services (housing, nutrition, transitions) are contributing to better preventive care uptake and long-term outcomes.

90%

Behavioral Health (BH) – Follow-Up & Engagement

of plans meet benchmarks for follow-up after emergency department visits for substance use disorders (FUA/FUM measures)

Signal: Strong follow-up rates are improving stabilization and reducing repeat crisis utilization.

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Coordinated care improving community health and wellbeing

Advancing Healthier Communities

Our mission is to advance healthier communities by delivering coordinated care management, behavioral health services, and community-driven support systems that address the full spectrum of medical, behavioral, and social needs. Through collaboration with healthcare providers, community organizations, and trusted community health workers, we connect individuals to the resources, services, and support necessary to improve health outcomes, promote stability, and empower members to live healthier, more independent lives.

Aligning healthcare, services, and community partners together.

Removing Barriers to Care

Our purpose is to remove barriers to care by aligning healthcare providers, social service organizations, and trusted community partners to deliver coordinated, person-centered support. By integrating medical care, behavioral health services, and community-based resources, we address the social and environmental factors that influence health and well-being. Through collaboration, culturally responsive engagement, and community health worker outreach, we ensure individuals can access the services, guidance, and support they need to navigate complex systems, stabilize their lives, and achieve improved health outcomes.

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