Addressing Food Insecurity as Part of the Clinical Workflow: CRISP and Meals on Wheels

Food Insecurity in Maryland

Before the COVID-19 pandemic, more than 600,000 Marylanders were served by the Supplemental Nutrition Assistance Program (SNAP), according to the Maryland Department of Human Services. This number included seniors, children, people with disabilities, low-income families, and unemployed workers. COVID-19 subsequently caused hundreds of thousands of Marylanders lost jobs and income. Montgomery County has seen a 322%  increase in average monthly applications since March 2020.

Prior to the pandemic, The Maryland Food Bank estimated that 1 in 6 Marylanders struggled with food insecurity. Recently reported figures through The Maryland Food Bank’s Hunger Map project an additional 980,000 Marylanders are now food insecure, 339,000 of which are children.

In response to this unprecedented level of need, MCMS collaborated with Netrin Health, Meals on Wheels of Central Maryland, and the Maryland Primary Care Program to host a webinar on addressing food insecurity in clinical settings. It is available on-demand.

How Meals on Wheels Can Help

The Chesapeake Regional Information System for our Patients (CRISP) has a referral feature to Meals on Wheels that both primary care and specialists can use to simplify clinical workflows and improve patient utilization of this important service.

Meals on Wheels can help patients eliminate food insecurity, decrease social isolation, and aim to reduce their all-cause acute care utilization through the provision of home delivered meals, personal contact  and related services.  One year of comprehensive service through Meals on Wheels costs less than 1 day in the hospital.

Meals on Wheels Services include:

  • Home Delivered Meals
  • Grocery Assistance Program (GAP)
  • Housing Upgrades to Benefit Seniors (HUBS)
  • Together In Care
  • Crisis Intervention
  • Information & Referral
  • Isolation Reduction – Companion visits
  • In Home Assessment & Service Planning
  • Case Management & Service Linkage
  • Data Collection & Real-time Response

Two local chapters of Meals on Wheels serve Montgomery County. Meals on Wheels of Central Maryland covers the eastern corner of the county, including Silver Spring.  Meals on Wheels Rockville covers the remainder of the county. Both report that they continue to meet volume needs during the pandemic, with more than 1.5 million meals delivered since March 2020.

Meals on Wheels Intake Overview

Meals on Wheels receives referrals from physicians through CRISPdirect mail, Monday through Friday.  Clients are contacted within 24 hours of receipt to verify their information, determine service area, and applicable services.  The service start is scheduled, if eligible, as soon as 24 hours later.  If the client is ineligible, Meals on Wheels uses its extensive referral network to appropriately connect the individual to another service.  The status is then reported back to CRISP, so physicians can see that a placement was made.

Referring Through CRISP

The referral functionality through CRISP, which is open to all physicians and their practices, is configured upon request.  To request this added functionality, contact Kerron Richards at or by calling 410.450.4856.

CRISP has provided screen shots of the referral workflow, so practices may preview it. Please note that both front- and back-end workflows are available to select from, depending on what your practice prefers.

Further Reading & Resources

MCMS On-Demand Webinar: Success Stories: Hear from Meals on Wheels representative Stacy Payton how they work with practices on patient referrals, and success stories from other local practices. To contact local Meals on Wheels chapters visit:

SNAP Information Sheet for Patients: A useful tool to share with patients about SNAP eligibility, and how they can apply for the program.

Montgomery County Food Council: Resource Map: A comprehensive map of all food assistance programs in Montgomery County.

Manna Food Center: Our local food bank, Manna, continues to distribute food every day to neighbors in need at drive-thru satellite sites across the county. Home delivery is also available.

No Kid Hungry Maryland: Help advocate for expanded aid to address hunger at the federal and state level.

Maryland Food Bank: Maryland’s largest food bank, which also reports extensively on uptake and need across the state.