Progress 09/01/22 to 08/31/23
Outputs
Target Audience:The Recipe4Health program targets members at Federally Qualified Health Centers in Alameda County. This population primarly includes Medicaid patients and those who are uninsured. The clinic populations tend to be racially and ethnically diverse with a high number of LatinX, African American, Native American and Asian Pacific Islander (API) populations. Recipe4Health then targets those who experience food insecurity and/or diet-sensitive chronic disease. Changes/Problems:Recipe4Health faced several challenges during the grant period. Recipe4Health officially transitioned to a new agency, the Health Care Services Agency, in September of 2022 and has also experienced significant transitions during this grant period, including staff transitions and the need to hire and train new staff. Lifelong Medical Center- Ashby Clinic experienced staffing shortages and could no longer staff a medical provider, leading to the eventual closing of the Group Medical Visit. R4H maintained access to the program for Ashby patients through the new virtual county-wide groups and individual coaching offerings. Ashby hopes to restart a GMV once their staffing shortage problem has improved. In addition, during the reporting period, Recipe4Health was actively experiencing it's first year as a Community Supports Provider under the state-wide California Advancing Innovations in Medi-Cal (CalAIM), a 5-year state Center for Medicare & Medicaid Services waiver. This change is a positive step towards bringing sustainability to food as medicine programs, but also brought new challenges. To function under CalAIM, R4H needed to build a new data infrastructure including developing systems to process referrals and ensuring they met health plan requirements for authorization of services, developing a system for making claims to the health plan and providing audits and reports on services provided to patients. Another challenge faced by R4H in this reporting period was the temporary and unanticipated pause placed on R4H's expansion efforts by Alameda Alliance for Health. The pause was put in place while the health plan developed an assessment tool and process for approval of expansion requests of community supports providers. Once the tool was developed, R4H worked to meet all the requirements of the health plan, including process changes and implementing new steps in the referral workflow. This pause pushed back expansion to additional clinic sites and Health Centers. In September 2023 the health plan lifted the pause on expansion and R4H is working to adjust timelines for expansion to additional locations. What opportunities for training and professional development has the project provided? To ensure smooth operations, Recipe4Health staff held the following trainings: Recipe4Health partnered with OSW and DDF to hold Kick-Off meetings for clinic staff (TVHC: 35 staff; LLMC WB: 56 staff) that provided an overview of the Food as Medicine initiatives as well as an experiential opportunity of the Behavioral Pharmacy. Additionally, Recipe4Health provided the Combined Workflow Training to TVHC (29 staff) and the Food Insecurity Screening Workflow training to TVHC (22 staff) and LLMC WB (27 staff). Clinical Nutrition training series were provided to prescribers; Clinical Nutrition #1 (TVHC: 36 staff, LLMC WB: 27staff ), Clinical Nutrition #2 (TVHC: 23 staff, LLMC WB: 25 staff), Clinical Nutrition #3 (TVHC: 29 staff). LLMC Ashby and NAHC experienced high staff turn-over and therefore needed refresher trainings with LLMC Ashby completing a total of 5 trainings and NAHC completing 3 trainings in the reporting period. GMV team trainings for NAHC, TVHC, and LifeLong were provided as needed. Recipe4Health staff have held further follow-up with staff, including 1:1 meetings with providers and participating in huddles with prescribers How have the results been disseminated to communities of interest? During the reporting period, presentations to stakeholders have included: RosasLG,ChenS,XiaoL, et al Addressing food insecurity and chronic conditions in community health centres: protocol of a quasi-experimental evaluation of Recipe4Health BMJ Open2023;13:e068585.doi:10.1136/bmjopen-2022-068585 Talking with Dr. Donna Podcast California Medically Supportive Food and Nutrition Knowledge Network Webinar Bridging Food as Medicine, Sourcing of Food (Organically and Regeneratively), and Equity: Force Multipliers for Health Roundtable with Health and Human Services Secretary Xavier Becerra and Congresswoman Barbara Lee Food as Medicine Global Webinar CleanMed Panel Hunger2Health Collaboratory Panel National Board for Health and Wellness Coaching Webinar Health and Human Services /Office of Assistant Secretary of Health and United States Department of Agriculture Site Visit Nourish Food for Health Symposium Keynote Kaiser Lifestyle Medicine Summit Panel Medically Supportive Food & Nutrition Lunch and Learn Food As Medicine in California Panel Purchaser Business Group on Health Food as Medicine Webinar What do you plan to do during the next reporting period to accomplish the goals? Recipe4Health received a one year extension to continue services for TVHC due to the pause in operations and will continue to serve TVHC patients with remaining funding. Recipe4Health will maintain services for patients at NAHC, TVHC and LLMC clinics who will not be covered by CalAIM, including food insecure patients (but no qualifying chronic disease) and patients whose health plans have not opted in to CalAIM. Maintaining services for this patient population is key in Recipe4Health's mission to address racial and health equity and to move healthcare upstream by addressing social determinants of health, such as food insecurity. For all partnering clinics, Recipe4Health staff will continue to convene meetings to ensure smooth operations and navigate issues. As needed, Recipe4Health will provide additional trainings for new prescribers and other clinic staff.
Impacts
What was accomplished under these goals?
Goal 1: i) Fruit and Vegetable Consumption Based on a 2-item fruit and vegetable intake screening, daily servings of fruits and vegetables (which was 3.9 servings at baseline) increased by more than 1 servings per day (0.89 adjusted; p<.0001) among GMV patients (n=218). For Food Farmacy patients (n=128) increased by half a serving per day (0.54 adjusted; p=0.04).Similarly, results from the DSQ10 (Daily servings intake of Fruits and Vegetables) for n=190 GMV patients, found an adjusted .38 increase (p=0.007) in servings from pre to post. Health Outcomes i) Hypertension Data for GMV patients (n=241) showed no statistically significant change in systolic blood pressure, but for diastolic blood pressure, there was a small adjusted 1.36 increase 6 month increase (p=0.04). ii) Obesity Before and after data (pre and post) of GMV patients (n=168) shows a small but statistically significant 0.45 adjusted decrease in BMI (p=0.02), after 12 months. Similarly, in Food Farmacy patients (n=401), a 0.2 adjusted decrease in BMI (p=0.05) is seen at the 12 months mark. Additionally, among Food Farmacy patients (n=432), a 1.5 pound adjusted decrease in weight (p=0.01) was seen at the 12 months mark. Among GMV patients, an average of 2.5 pound weight loss is seen at the 12-month mark (n=195). Though after statistical analysis to adjust for other factors, this is not statistically significant in this small sample. iii) Prediabetes and Diabetes Among patients only participating in the Food Farmacy (n=292), there has been a significant decrease in HbA1c (a measure that captures average glucose in the past 3 months) across all comers. Among patients overall, where the baseline HbA1c was 7.6%, there was a significant decrease of 0.34% (p<0.001) (adjusted 12-month decrease).When we limit analysis to Food Farmacy patients with diabetes (n=204), excluding patients with prediabetes and normal glucose levels to start, the mean baseline HbA1c was 8.5% and had a larger decrease (adjusted 12 months decrease of 0.39%, p=0.003). iv) Dyslipidemia After adjusting for baseline values, we are finding improvements in cholesterol across the board in our Food Farmacy patients. Specifically, in 86 patients, total cholesterol (200 mg/dl) had an adjusted (12 months) decrease of 19 mg/dl (p=0.01). In 77 patients, LDL cholesterol (122 mg/dl at baseline) had an adjusted (12 months) decrease of 14.5 mg/dl (p=0.02).In Food Farmacy patients with diabetes (n=49), total cholesterol (201.8 mg/dl at baseline) had an adjusted (12 months) decrease of 29.mg/dl (p=0.02). In 41 Food Farmacy patients, LDL cholesterol (117.5 at baseline) had an adjusted (12 months) decrease of 22 mg/dl (p=0.05). v) Illness GMV and Food Farmacy patients reported decreased illness and improved overall health. We use the standard 4-item set of Healthy Days core questions (CDC HRQOL- 4) to capture self-reported physical and mental health (range of 0-30). From baseline to program completion, GMV patients saw decreases in the number of unhealthy days across the board, including an adjusted 2.42 decrease (p<.001) in overall unhealthy days (n=194), an adjusted 1.35 decrease (p= 0.03) in physically unhealthy days (n=200), an adjusted 2.85 decrease (p<.0001) in mentally unhealthy days (n=197), and an adjusted 1.32 decrease (p=0.02) in activity limitation days (n=200). Smaller, but significant changes were also seen in Food Farmacy patients, with an adjusted 2.34 decrease of (p=0.01) in overall unhealthy days (n=128), an adjusted 2.27 decrease (p=0.002) in in mentally unhealthy days (n=128) from baseline to program completion. vi) Depression Patients participating in the Behavioral Pharmacy Group Medical Visits (GMVs) showed significant reductions in depression scores, moving from the higher to the lower end of the moderate depression range. Depression data represent a subsample of patients with elevated depression (PHQ-9≥10) at baseline (n=80). Using the Patient Health Questionnaire-9 (PHQ-9) depression scores improved from pre-test to post-program participation, showing reduction from 14.6 (moderate depression) to 10.9 (rated as moderate depression), an adjusted decrease of 3.99 (p<.001). Food Farmacy patients (n=45) also saw a reduction from 15.7 pre-test to 12.8 post-test and had an adjusted decrease of 2.92 (p<0.01). The PHQ-9 has a range of 0-27, with 5, 10, 15, and 20 as cut points for mild, moderate, moderately severe, and severe depression. vii) Anxiety Patients participating in the GMVs showed significant reduction in anxiety scores. Anxiety outcomes represent a subsample of patients (n=55) with elevated anxiety (GAD7≥10) at baseline. Anxiety improved from pretest to post-program participation, with a reduction on the Generalized Anxiety Disorder-7 (GAD-7) 30, with scores reduced from the 14.9 to 9.9, an adjusted 4.45 decrease (p<.001). Food Farmacy patients (n=43) also saw significant reductions in anxiety scores, with scores reduced from 14.7 to 10.8, an adjusted 3.91 decrease (p<.001). The GAD-7 has a range of 0-21 with 5, 10, and 15 as cut points for mild, moderate, and severe anxiety. Goal 2: Social Determinants of Health i) Patient Demographics Patients (n=2455) were 69.4% female and 30.5% male. The majority of patients (38.4%) of were 45-64 years old, a little more than a third (37%) were 18-44 years old, 13.8% were under age 18, and 10.8% were 65 years or older. The majority (44.3%) of patients identified as Hispanic, followed by 18.5% identifying as Non-Hispanic Black, 16.5% as Unknown/other, 11.7% as Non-Hispanic White, 3.3% as Asian/Pacific Islander, 3.2% as Mixed race and 2.6% as American Indian or Alaska Native. The primary language of most patients was English (51.4%), followed closely by Spanish (46%) and other language (2.6%). ii) Food Insecurity GMV (n=166) and Food Farmacy patients (n=128) completed pre and post surveys that included a question about household food insecurity. This question categorizes respondents into one of four categories: food security, marginal food security, low food security, and very low food security. Post survey results showed 44% of GMV patients and 28% of Food Farmacy patients improving food security status by at least one category from baseline. iii) CalFresh CalFresh is California's Supplemental Nutrition program which provides monthly benefits to low-income households that can be used to purchase most foods. R4H trains Medical Assistants and "Allied Health Prescribers" (behavioral health practitioners, nutritionists, nurses, CHWs, etc.) to screen for food insecurity and to refer patients who screen positive to both the R4H Food Farmacy and to CalFresh. Of unique patients screened with the hunger vital sign questionnaire during the reporting period (n=3,425), 34% were food insecure, and among these food insecure cases,11% were referred to CalFresh. iv) Social Isolation Patients participating in the GMV saw a decrease in loneliness. Based on the UCLA 3-item loneliness screener, the social isolation score among GMV patients (n=227) decreased from the 5.2 baseline score to 4.8 (questionnaire score ranges from 3-9). Goal 3: Healthcare Utilization Recipe4Health patients who received the Food Farmacy were 15% less likely to visit the emergency room compared to a control group of matched patients.
Publications
- Type:
Journal Articles
Status:
Published
Year Published:
2023
Citation:
Rosas LG, Chen S, Xiao L, et al Addressing food insecurity and chronic conditions in community health centres: protocol of a quasi-experimental evaluation of Recipe4Health BMJ Open 2023;13:e068585. doi: 10.1136/bmjopen-2022-068585
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Progress 09/01/21 to 08/31/22
Outputs
Target Audience:The Recipe4Health program targets members at Federally Qualified Health Centers in Alameda County. This population primarily includes Medicaid patients and those who are uninsured. The clinic populations tend to be racially and ethnically diverse with a high number of Latinx, African American, Native American, and Asian and Pacific Islander (API) populations. Recipe4Health then targets those who experience food insecurity and/or diet-sensitive chronic disease. Changes/Problems:Recipe4Health faced several challenges during the grant period. The COVID pandemic continued to cause challenges during the reporting period for healthcare clinics which continue to experience low patient visit rates and staff furloughs. With fewer patients having visits, enrollment in Recipe4Health was initially lower than expected. Further, the clinics faced many unique issues which impacted Recipe4Health. For example, many clinic staff were pulled into testing and vaccine rollout efforts, reducing their capacity to support Recipe4Health. Clinics also experienced staffing shortages from Shelter in Place due to staff or family getting sick and increased staff turnover. Recipe4Health has also experienced significant transitions during this grant period, including staff transitions and the need to hire and train new staff, separating from ALL IN and moving to a new home department under the Health Care Services Agency (HCSA). The transition to HCSA has provided challenges as staff must learn and adjust to new organizational structures but in the long-run will offer Recipe4Health a stable home-base with more support. In addition, during the reporting period, Recipe4Health was actively preparing to become a Community Supports Provider under the state-wide California Advancing Innovations in Medi-Cal (CalAIM), a 5-year state Center for Medicare & Medicaid Services waiver. These transitions have demanded intense staff resources, temporarily pulling staff from other areas of Recipe4Health and slowing expansion of Recipe4Health to focus on the CalAIM transition. The transition to CalAIM, while challenging, is a step towards food as medicine/produce prescription initiatives becoming more sustainable and integrated into healthcare. The steps taken now should support the program in later years and has the potential to be a part of transforming healthcare. What opportunities for training and professional development has the project provided?Workflow Trainings: To ensure smooth operations, Recipe4Health staff held the following trainings: Recipe4Health partnered with OSW and DDF to hold Kick-Off meetings for clinic staff, including Year 2 Kick-Off meetings (NAHC:78 staff) and (LLMC:39 staff) that provided an overview of the Food as Medicine initiatives as well as an experiential opportunity of the Behavioral Pharmacy. Additionally, Recipe4Health created and provided a new "Combined Workflow Training" for all 3 groups (NAHC: 37 staff; LLMC: 20 staff). Recipe4Health staff have held further follow-up with staff, including 1:1 meetings with providers and participating in huddles with prescribers GMV team trainings for NAHC (English and Spanish), and LifeLong and refresher trainings as needed Alameda County Recipe4Health developed a CalAIM Updates Training to share with staff on programmatic and workflow changes that will occur with Recipe4Health's transition to a Community Supports Provider under CalAIM. These trainings were provided to staff (NAHC: 27 staff, LLMC:24 staff) in June-August for in preparation for 9/1/2020 transition to CalAIM. How have the results been disseminated to communities of interest?To date, results are primarily preliminary and continuing to be updated. Recipe4Health holds regular meetings with clinic staff and operational partners (OSW and DDF) for quality improvement purposes, including improving referral quality and streamlining processes. Presentations to stakeholders have included: National Institutes of Health (NIH) Annual Conference UCSF Integrated Health Equity and Applied Research (IHEAR) Program Integrated Medicine for the Underserved (IM4US) Decolonizing Medicine Conference Touro University Integrative Medicine Symposium Alameda County Board of Supervisor Health Committee Hearings House Rules Committee Roundtable "Ending Hunger in America: Food as Medicine" Presentation and discussion with U.S. Secretary of Health Services Xavier Becerra, which inspired a request for the National Food as Medicine Pilot represented by Congresswoman Barbara Lee Michael Reid Dimock's Flipping the Table podcast Kansas Food is Medicine Keynote White House Conference on Hunger, Nutrition and Health- Listening Sessions What do you plan to do during the next reporting period to accomplish the goals?To further accomplish our overarching goals, Recipe4Health intends to strengthen our work with partnering clinics by transitioning to a community supports provider under CalAIM on September 1, 2022. Once established with clinics that are currently operating the program, Recipe4Health will re-engage with Tiburcio Vasquez Health Center (TVHC) and continue expansion efforts to new clinic locations within existing clinic partners and new health centers. Additionally, throughout this transition to CalAIM, Recipe4Health will maintain services for patients at partnering clinics who will not be covered by CalAIM, including food insecure patients (but no qualifying chronic disease) and patients whose health plans have not opted in to CalAIM. Maintaining services for this patient population is key in Recipe4Health's mission to address racial and health equity and to move healthcare upstream by addressing social determinants of health, such as food insecurity. Recipe4Health's evaluation team continues to expand upon its analysis and plans to utilize a propensity matching approach to develop a control group for the evaluation. For all partnering clinics, Recipe4Health staff will continue to convene meetings to ensure smooth operations and navigate issues. Recipe4Health will continue work with the appropriate clinic staff to develop care team data dashboards to identify barriers, challenges, and identify opportunities for program improvement and increased levels of quality referral into the program. As needed, Recipe4Health will provide additional trainings for new prescribers and other clinic staff. Finally, should the external context change regarding COVID-19, Recipe4Health will lead discussions about if and how to move all or parts of the program back into the clinic. If this occurs, staff will work with the clinics to take the best pieces of the virtual model and rebuild workflows and train staff as necessary.
Impacts
What was accomplished under these goals?
Key accomplishments for the Recipe4Health program during the progress report period (September 1, 2021- August 31, 2022), include: Continued the programat Tiburcio Vasquez Health Center (TVHC) from September 1, 2021- December 31, 2021. TVHC paused operations until the program could be transitioned to CalAIM in 2022 Launcheda second "Behavioral Pharmacy" for Spanish-speaking patients at Native American Health Center (NAHC) on September 1, 2021 Planned expansion to 1-2 additional clinic locations within LifeLong Medical Center (LLMC) for the2022-2023 year. Distributed 606 produce prescriptions andenrolled619 new patients in the Food Farmacy. Delivered9970 bags of food containing 159,520 servings of fresh produceto patients' homes Referred 532 patients to four Behavioral Pharmacy Groups (TVHC, LLMC, NAHC- Englsih and NAHC-Spanish) and enrolled 146 patients Preliminary data results from start of each clinic program through August 2022 are based on participants enrolled in the "Behavioral Pharmacy" group medical visit (GMV) at the TVHC, LLMC and NAHC clinics unless otherwise specified. Social Determinants of Health i) Patient Demographics Patients (n=1906) were 69.4% female and 30.5% male. The majority of patients (38.2%) of were 45-64 years old, a little more than a third (34.4%) were 18-44 years old, 17.6% were under age 18, and 9.8% were 65 years or older. The majority (59.5%) of patients identified as Hispanic, followed by 18.3% identifying as Non-Hispanic Black, 7% as Non-Hispanic White, 5.9% as Unknown/other, 3.9% as Asian/Pacific Islander, 2.8% as Mixed race and 2.5% as American Indian or Alaska Native. The primary language of most patients was English (49.6%), followed closely by Spanish (48.1%) and other language (2.3%). ii) Food Insecurity GMV (n=143) and Food Farmacy patients (n=78) completed pre and post surveys that included a question about household food insecurity. This question categorizes respondents into one of four categories: food security, marginal food security, low food security, and very low food security. Post survey results showed 46% of GMV patients and 31% of Food Farmacy patients improving food security status by at least one category from baseline. iii) CalFresh CalFresh is California's Supplemental Nutrition program which provides monthly benefits to low-income households that can be used to purchase most foods. R4H trains Medical Assistants and "Prescribers without MAs" (behavioral health practitioners, nutritionists, nurses, CHWs, etc.) to screen for food insecurity and to refer patients who screen positive to both the R4H Food Farmacy and to CalFresh. Of patients screened with the hunger vital sign questionnaire (n=4891), 22% were food insecure, and among these food insecure cases, 5% were referred to CalFresh. iv) Social Isolation Patients participating in the GMV saw a decrease in loneliness, despite still being in a pandemic often mandating social distancing. Based on the UCLA 3-item loneliness screener, the social isolation score among GMV patients (n=193) decreased from the 5.2 baseline score to 4.7 (screener ranges from 3-9). Healthcare Utilization Analysis on healthcare utilization data is currently underway to evaluate changes in relevant ED visits and hospitalizations (i.e. attempting to separate non-relevant visits such as those for Covid-19). While this analysis is not yet available, we anticipate having results by September 2023. Health Outcomes i) Hypertension Data for GMV patients (n=137) showed no statistically significant change in systolic and diastolic blood pressure. ii) Obesity Before and after data (pre and post) of GMV patients (n=90) shows a lower BMI of close to 1 point, after 12 months, and an average of 6-pound weight loss at the 12-month mark (n=106). Though after statistical analysis to adjust for other factors, this is not statistically significant in this small sample. iii) Prediabetes and Diabetes Among patients only participating in the Food Farmacy (n=253), there has been a significant decrease in HbA1c (a measure that captures average glucose in the past 3 months). Among patients overall, where the baseline HbA1c was 7.7%, there was a significant decrease of 0.27 (p=0.02) (adjusted 6-month decrease) and 0.32 (p=0.005) (adjusted 12-month decrease). When we limit analysis to Food Farmacy patients with diabetes (n=164), excluding patients with prediabetes and normal glucose levels to start, the mean baseline HbA1c was 8.5% and had a larger decrease (adjusted 12 months decrease of 0.37%, p=0.01). Among patients also participating in the GMV (n=101), we have not found significant changes in the data, presumably due to the smaller sample size. For patients with diabetes who participated in the GMV (n=17), there was a small but significant change in urine microalbumin of 1-2 mg/dl from baseline to 6 months (p=0.003) and 12 months (p< 0.001). iv) Dyslipidemia While not seeing this in the GMV due to the small sample (n=30), we are finding improvements in dyslipidemia in emerging data from our Food Farmacy patients (n=71). After adjusting for baseline values, we are finding improvements in cholesterol across the board. Specifically, total cholesterol (198 mg/dl) had an adjusted (12 months)decrease of 24 mg/dl (p=0.002). LDL cholesterol (122 mg/dl at baseline)had an adjusted (12 months)decrease of 18 mg/dl (p=0.01). Furthermore, serum triclycerides (162 mg/dl at baseline)had an adjusted (12 months) decrease of 28 mg/dl (p=0.01). In Food Farmacy patients with diabetes (n=39), total cholesterol(194 mg/dl at baseline) had an adjusted (12 months) decrease of 32 mg/dl (p=0.01). LDL cholesterol (115.4 at baseline)had an adjusted (12 months)decrease of 22 mg/dl (p=0.04).Finally, serum triglycerides (177mg/dl at baseline) had an adjusted (12 months) decrease of 47 mg/dl (p=0.02). v) Illness GMV patients reported decreased illness and improved overall health. We use the standard 4-item set of Healthy Days core questions (CDC HRQOL- 4)to capture self-reported physical and mental health (range of 0-30). From baseline to program completion, patients recorded on average 13.5 fewer unhealthy days between all 4 categories. Categories include overall unhealthy days (n=160), physically unhealthy days (n=166), mentally unhealthy days (n=162) and activity limitation days (n=165). vi) Depression Patients participating in the Behavioral Pharmacy Group Medical Visits (GMVs) showed a 4.1 point reduction, from the higher to the lower end of the moderate depression range. Depression data represent a subsample of patients with elevated depression (PHQ-9≥10) at baseline (n=48). Using the Patient Health Questionnaire-9 (PHQ-9) 29, depression scores improved from pre-test to post-program participation, showing a reduction from 14.7 (moderate depression) to 10.6 (rated as moderate depression). The PHQ-9 has a range of 0-27, with 5, 10, 15, and 20 as cut points for mild, moderate, moderately severe, and severe depression. vii) Anxiety Patients participating in the GMVs showed a 5.1 point reduction from moderate anxiety to mild anxiety scores. Anxiety outcomes represent a subsample of patients (n=34) with elevated anxiety (GAD7≥10) at baseline. Anxiety improved from pre-test to post-program participation, with a reduction on the Generalized Anxiety Disorder-7 (GAD-7) 30, with scores reduced from the 14.5 to 9.4. The GAD-7 has a range of 0-21 with 5, 10, and 15 as cut points for mild, moderate, and severe anxiety. Health-Promoting Behaviors i) Exercise/Physical Activity: Weekly minutes of moderate exercise (which was 68.2 minutes/week at baseline) increased to 110 minutes/week (50 adjusted; p<.0001) from pre to post among GMV patients (n=192). ii) Fruit and Vegetable Consumption Based on a 2-item fruit and vegetable intake screening, daily servings of fruits and vegetables (which was 4.0 servings at baseline) increased by more than 1 servings per day (0.95 adjusted; p<0.0001) among GMV patients (n=184).
Publications
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Progress 09/01/20 to 08/31/21
Outputs
Target Audience:The Food as Rx program targets members at Federally Qualified Health Centers in Alameda County. This population primarily includes Medicaid patients and those who are uninsured. The clinic populations tend to be racially and ethnically diverse with a high number of Latinx, African American, Native American, and Asian and Pacific Islander (API) populations. Food as Rx then targets those who experience food insecurity and/or diet-sensitive chronic disease. Changes/Problems:ALL IN faced several challenges during the grant period. The COVID pandemic continued to cause challenges during the reporting period. Healthcare clinics were struck by many challenges, including low patient visit rates and staff furloughs. With fewer patients having visits, enrollment in Food as Rx was initially lower than expected. Further, the clinics faced many unique issues which impacted Food as Rx. For example, many clinic staff were pulled into testing and vaccine rollout efforts, reducing their capacity to support Food as Rx. Internally, ALL IN experienced delays to contracts due to established County procurement practices and policies. This requires several layers of approval, as well as approval by the County Board of Supervisors for contracts over $25,000. New staff had to learn how to navigate the county systems which requires significant on-the-job learning and training. While staff were able to move through these challenges and learned lessons that will benefit the program in the future, it resulted in delayed contract start dates. One additional challenge was the length of time it has taken to get the evaluation up and running. ALL IN staff did not anticipate the complexity of a research evaluation and the requirements of working with academic partners. For example, even upon completion of data use agreements between partners, Stanford learned of mandatory data risk assessments that needed to be completed before data could be shared. However, we expect that the evaluation will yield large amounts of data demonstrating the success of Food as Rx and know that the time spent building the infrastructure will serve the program for many years. What opportunities for training and professional development has the project provided?Presentations to stakeholders have included: Project Open Hand and California Food Is Medicine Coalition Workshop: Integrating Sustainability and Equity in Nutrition and Health Programs Alameda Health Services Foundation San Bernardino County Anti-Hunger Task Force Webinar Redwood Community Health Coalition QI Chat Room Podcast (in partnership with TVHC staff) University California, San Francisco Grand Rounds American Public Health Association: Food as Medicine American Public Health Association: From Implementation to Impact: How Do We Connect Dots Across Nutrition Incentive Programs Center for Health Law and Policy Innovation: Mainstreaming Produce Prescriptions (https://dialogue4health.org/web-forums/detail/mainstreaming-produce-prescriptions-a-policy-strategy-report) Healthy Food as Preventative Medicine: California and Beyond (https://www.spur.org/events/2021-02-16/healthy-food-preventative-medicine-california-and-beyond) Medically-Supportive Food and Nutrition: California's Opportunity to Expand Access to Food Supports through Medi-Cal (https://www.spur.org/events/2021-04-26/medically-supportive-food-and-nutrition-californias-opportunity-expand-access) How have the results been disseminated to communities of interest?To date, results are primarily operational and internal. ALL IN holds regular meetings with clinic staff and operational partners (OSW and DDF) for quality improvement purposes, including improving referral quality and streamlining processes. In August 2021, The Gretchen Swanson Center for Nutrition featured a staff person from Open Source Wellness and the work done with ALL IN Alameda County. ALL IN Alameda County reports to a Steering Committee chaired by two elected officials and provides regular updates on the Food as Rx initiative. This provides an opportunity to ensure community groups and other county agencies can provide feedback and identify areas for alignment with Food as Rx. What do you plan to do during the next reporting period to accomplish the goals?To further accomplish our overarching goals, ALL IN intends to strengthen our work with Native American Health Center and begin planning for sustainability of work at Tiburcio Vasquez Health Center (TVHC) and LifeLong Medical Care (LLMC). For all three clinics, ALL IN staff will continue to convene meetings to ensure smooth operations and navigate issues. ALL IN will continue work with the appropriate clinic staff to develop care team data dashboards to identify barriers, challenges, and identify opportunities for program improvement and increased levels of quality referral into the program. As needed, ALL IN will provide additional trainings for new prescribers and other clinic staff. For TVHC and LLMC, ALL IN will work on sustainability planning to identify opportunities to expand the work to more group medical visits and/or additional clinic sites within the healthcare system. ALL IN will also work with the clinics on financial sustainability so that the clinics are no longer reliant on ALL IN (e.g., GusNIP) funding. Finally, should the external context change regarding COVID-19, ALL IN will lead discussions about if and how to move all or parts of the program back into the clinic. If this occurs, staff will work with the clinics to take the best pieces of the virtual model and rebuild workflows and train staff as necessary.
Impacts
What was accomplished under these goals?
During the progress report period (9/1/20 - 8/31/21), ALL IN built on lessons learned to expand the program to additional sites and expand the reach to more vulnerable populations. ALL IN continued the Food as Rx clinically-integrated model at Tiburcio Vasquez Health Center (TVHC) clinics throughout Alameda County and the Native American Health Center (NAHC) clinic in Fruitvale (Oakland, CA). Food as Rx launched at LifeLong Medical Care (LLMC) in the Ashby neighborhood of Berkeley, CA (February 2021). ALL IN accomplishments include: Developed relationships with clinic staff to ensure smooth program implementation. Given that this program is integrated into clinic workflows and the electronic health record (i.e., EPIC) Food as Rx requires strong buy-in of and time commitment by all clinic staff. Supported the Food as Rx model at TVHC, including working with clinic leadership to develop sustainability models that will allow for program continuation. ALL IN worked with clinic staff to expand the program from 1 site (San Leandro) to allow adult medicine providers at 4 clinic sites to refer patients into the program. ALL IN trained providers and medical assistants at the 4 sites to become prescribers for Food as Rx. Amplified the scope and sustainability of Food as Rx at NAHC. This involved planning to expand from 1 "Behavioral Pharmacy" group medical visit to 2 groups. The second one (launching in 9/21) will be for Spanish-speaking patients, expanding our ability to reach that population. Worked with LLMC staff to develop workflows, identify necessary EPIC electronic health record changes, and navigate clinic operational needs. The EPIC integration supports ALL IN to meet the program goal of documenting racial/ethnic disparities in food insecurity and subsequent impact on health outcomes. Supported "Behavioral Pharmacy" group medical visit operations by training providers, nutritionists, and medical assistants at NAHC and TVHC. ALL IN staff held evidence-based, Food as Medicine trainings to shift the practice of food prescribers to use produce prescriptions to treat, prevent, and reverse chronic disease in a 15-minute primary care visit and increase referrals to the Food Farmacy. ALL IN staff partnered with a physician chef to hold 8 hours of training for clinic prescribers (e.g., doctors, nurse practitioners, nutritionists, behaviorists). Twenty-two prescribers attended trainings. Topics included, but were not limited to: eating patterns (e.g., Mediterranean, DASH), condition-specific food interventions (e.g., hypertension, depression), organic vs. regenerative vs. GMO foods, whole grains, reading food labels, fruit and vegetable dosage, and practical tools for use in a primary care setting. ALL IN administered pre- and post-surveys to assess training effectiveness and identify opportunities for improvement. Survey results showed improvements in prescriber understanding in using food to treat and prevent chronic conditions. ?Preliminary Data Results Preliminary results are based on participants enrolled in the combined "Behavioral Pharmacy" group medical visit (GMV) and food farmacy and indicate improvements in health outcomes, mental health, health promoting behaviors, and food/nutrition security. The following data were collected during the pandemic when physical and mental health were worsening nationwide. As required, de-identified data has been shared with GusNIP's evaluation team NTAE. References available upon request. The proportion of participants with food insecurity (n=88; p<0.001) decreased from 61% to 34%, a 27 point reduction. This was significant given the United States population experienced a doubling in food insecurity and tripling among households with children. Patients reported decreased illness and improved overall health, showing a reduction of 13 points (n=50; p<0.001) on the 4-item Healthy Days core questions (CDC HRQOL- 4), used to capture self-reported physical and mental health (range of 0-90). Patients showed a change from moderate to mild depression based on Patient Health Questionnaire-9 (PHQ-9) scores. Depression data represent a subsample of patients with elevated depression at baseline (n=22). Depression improved from pre- to post-program participation, showing a reduction of 35% with scores reduced from 13.8 to 8.9 (p=0.01). Patients showed a change from moderate to mild anxiety based on Generalized Anxiety Disorder-7 (GAD-7) scores. Anxiety outcomes represent a subsample of patients with elevated depression at baseline (n=19). Anxiety improved from pre- to post-program participation, with a reduction of 38%, with scores reduced from 12.7 to 7.8 (p=0.01). Patients saw a decrease in loneliness, despite dramatically increasing isolation during the pandemic. Based on the UCLA 3-item loneliness screener, social isolation (n=22) decreased 12.5% (p<0.01) among patients. Weekly minutes of exercise increased among patients from 71.5 to 134.8 minutes/week (n=87; p<0.001) during a pandemic year associated with decreases in exercise. Based on a 2-item fruit and vegetable intake screening, daily fruit and vegetable intake increased by 1.5 servings/day among patients (n=88) from 4.4 to 5.9 servings/day (p<0.001). Accomplishments related to food insecurity: ALL IN worked with LLMC to integrate a 2-question Hunger Vital Sign (HVS) screening into the in-person and telemedicine workflows for all patients (i.e., adults and children, regardless of visit reason). ALL IN developed materials and ensured language translation to make Spanish and Arabic screening available. ALL IN trained 21 staff on food insecurity and how to administer the HVS. ALL IN worked with LLMC's eligibility department to ensure the new EPIC pathway would support their operations. The workflow includes adding the results of the HVS screening into EPIC for all patients and creating referrals to CalFresh and the Food as Rx program. It is expected this will lead to higher CalFresh referrals as well as create a smooth pathway for referral to Food as Rx. ALL IN continued to work towards a full research evaluation, including qualitative and quantitative components in partnership with Stanford University and UC, San Francisco (UCSF). Evaluation accomplishments include: Identified research expertise (Dr. Ariana Thompson-Lastad, UCSF) to support qualitative research and improve clinic operations. Through this support, researchers completed 27 interviews with patients, clinic staff, and DDF and OSW staff. Rather than waiting until the completion of all surveys, the feedback was compiled into two quality improvement "lightning reports" (9/20 and 4/21) which were shared back with the evaluation and operations teams. ALL IN used the reports to make operations and systems level changes to Food as Rx. Supported Community Health Center Network (CHCN) and Stanford University in completing data use agreements and data risk assessments. Received approval from the Stanford University Institutional Review Board. Finalized a set of patient survey questions. Questions are being asked of all Behavior Pharmacy patients and Stanford began surveying Food Farmacy-only patients during summer 2021. Partnered with OSW and Stanford analyze preliminary data from the GMV, which showed improvements in patient outcomes. More information available above. Worked with CHCN and clinic staff to start building a systemwide Care Team Dashboard to identify patients who could be supported through Food as Rx and identify opportunities to improve the program. Used and improved an operations dashboard for the Food Farmacy (referral numbers, number of new patients, number of bags delivered) and the Behavioral Pharmacy (referral numbers, enrollment numbers, number of provider visits) for continuous quality improvement. ALL IN leveraged GusNIP funding to secure funding from the Alameda Alliance for Health (i.e., public managed care health plan) to support Food as Rx.
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Progress 09/01/19 to 08/31/20
Outputs
Target Audience:Food as Medicine targets members at Federally Qualified Health Centers in Alameda County. This population primarily includes Medicaid patients and those who are uninsured. The clinic populations tend to be racially and ethnically diverse with a high number of Latinx, African American, Native American, and Asian and Pacific Islander (API) populations. Food as Medicine then targets those who experience food insecurity and/or diet-sensitive chronic disease. Changes/Problems:ALL IN faced several challenges during the grant period which led to changes in timeline and program operations. COVID-19 created setbacks in the timeline for work at the first clinic, Native American Health Center. Staff anticipated starting planning with Native American Health Center in April 2020 and launching in July 2020; planning and launch were pushed back two months to June 2020 and September 2020 respectively. While this delay was unfortunate and unavoidable, ALL IN staff were pleased that once planning began things moved smoothly. In addition, the plan was to hold the Food Farmacy and Behavioral Pharmacy Group Medical Visit in-person at the clinic, which were impossible to do due to safety concerns and state/county regulations. As a result, the program shifted from an on-site food farmacy to a doorstep delivery and moved the group medical visit to a video call. The Deputy Sheriffs' Activities League, Dig Deep Farm developed a new enrollment process, identified vans, and retrained staff to deliver food directly to patients weekly. This has increased our redemption rate, significantly supporting more individuals in accessing high-quality, locally grown produce. Open Source Wellness moved the nutrition and behavioral education component of the program, which is a group medical visit from an in-clinic program to a phone/video-based program. Health coaches were trained to support participants in accessing a HIPAA-protected Zoom so that they can fully participate. What opportunities for training and professional development has the project provided? Dr. Steven Chen presented for the Community Action Partnership "Food as Medicine: Partnering to Improve Food Security and Health Outcomes Among Vulnerable Populations." This webinar included key operational partners including Open Source Wellness, the Deputy Sherriffs' Activities League, and Alameda Alliance for Health. (2/5/20) Dr. Chen presented on "Local Partnerships Boost Access to Fruits and Vegetables" to California State Women, Infants, and Children (WIC) program (5/27/20) Dr. Chen presented on "Applying Multi-Level Approaches to Address Racism and Advance Integrative Health Equity" at the IM4US conference (8/29/20) ALL IN had two abstracts accepted for 2020 American Public Health Association Annual Meeting. Dr. Chen and Dr. Emma Steinberg, a physician chef, presented four 2-hour trainings for clinic prescribers (including but not limited to doctors, nurse practitioners, nutritionists, behaviorists) on Food as Medicine educational material. (6/10/20, 7/14/20, 7/23/20, 8/25/20) How have the results been disseminated to communities of interest?To date, results are primarily operational and internal. ALL IN holds regular meetings with clinic staff and operational partners (OSW and Dig Deep Farms) for quality improvement purposes, including improving referral quality and streamlining processes. ALL IN Alameda County reports to a Steering Committee chaired by two elected officials and provides regular updates on the Food as Medicine initiative. This provides an opportunity to ensure community groups and other county agencies can provide feedback and identify areas for alignment with Food as Medicine. What do you plan to do during the next reporting period to accomplish the goals?To further accomplish our overarching goals, ALL IN intends to strengthen our work with Native American Health Center and begin planning and implementation of the Food as Medicine model at a second clinic. For Native American Health Center, ALL IN staff will continue to convene meetings to ensure smooth operations and navigate issues. In addition, staff will work with the appropriate clinic staff to develop care team data dashboards to identify barriers, challenges, and identify opportunities for program improvement and increased levels of quality referral into the program. If needed, ALL IN will provide additional Food as Medicine trainings for new prescribers. For the second clinic, ALL IN staff will begin the process of planning and implementation, including workplan development, facilitating meetings, co-creating workflows, ensuring leadership support, and engaging in other necessary activities. Finally, should the external context change regarding COVID-19, ALL IN will lead discussions about if and how to move all or parts of the program back into the clinic. If this occurs, staff will work with the clinics to take the best pieces of the virtual model and rebuild workflows and train staff as necessary.
Impacts
What was accomplished under these goals?
Over the progress report period (September 1, 2019 - August 31, 2020), ALL IN successfully built on the lessons learned at a pilot site (not funded through GusNIP) to develop a robust infrastructure for Food as Medicine. This infrastructure will allow not only for the expansion of the Food as Medicine clinically-integrated model (i.e., Food as Medicine training + Food Farmacy + Behavioral Pharmacy) into the two Federally Qualified Health Centers (FQHCs) funded through GusNIP, but will also support plans to expand to other FQHCs throughout Alameda County over the next several years. The model will support the collection and evaluation of data on dietary health, individual and household food insecurity, and healthcare utilization and associated costs. During the progress report period, ALL IN established the Food as Medicine clinically-integrated model at the first of two GusNIP-funded clinics: Native American Health Center (NAHC) in the Fruitvale neighborhood of Oakland, California. Key accomplishments include: ALL IN staff developed relationships with leadership, managers, and clinic staff to ensure smooth operations and program implementation. Given that this program is fully integrated into clinic workflows and the electronic health record (i.e., EPIC) Food as Medicine requires strong buy-in of and time commitment by clinic staff at all levels. During bi-weekly operations meetings facilitated by ALL IN staff and at additional ad hoc meetings, ALL IN staff worked with NAHC staff to develop workflows, identify necessary EPIC electronic health record changes, and navigate clinic operational needs. The strong integration with the EPIC electronic health record supports ALL IN's ability to meet the program goal of documenting any racial/ethnic disparities in food insecurity and subsequent impact on health outcomes. ALL IN developed contracts with the Deputy Sherriffs' Activities League (Dig Deep Farms) to provide the produce for the Food Farmacy and with Open Source Wellness for nutrition education services. Staff worked with clinic staff and Dig Deep Farms to establish and modify the existing Food Farmacy model (which had been previously used at a pilot site) to be appropriate for a COVID-19 environment. This involved developing new workflows and training staff for a doorstep delivery model, rather than a farm stand on-site in the clinic as initially planned. Staff worked with clinic staff and Open Source Wellness (OSW) to establish a Behavioral Pharmacy for the clinic. This included working with clinic staff and OSW to move from a clinic-based model to a virtual visit using a HIPAA-compliant Zoom platform. ALL IN worked with staff to develop workflows, create referral pathways, and train staff as appropriate. Further, ALL IN staff trained the NAHC provider, nutritionist, and medical assistant who are part of the Behavioral Pharmacy Group Medical Visit. Food as Medicine Trainings: ALL IN staff held a series of evidence-based, state-of-the-art Food as Medicine trainings to shift the mindset and practice of prescribers such that they can effectively promote dietary health through food and clinical nutrition in a 15-minute primary care visit and increase referrals to the Food Farmacy, which increases produce consumption. ALL IN staff partnered with Dr. Emma Steinberg, a physician chef, to hold eight hours of training for clinic prescribers (including but not limited to doctors, nurse practitioners, nutritionists, behaviorists). Forty prescribers attended the trainings. Topics included, but were not limited to: evidence-based training on eating patterns (e.g., Mediterranean, Whole Food Plant Based, Ketogenic, DASH, etc.), food interventions specific for particular conditions (e.g., hypertension, chronic kidney disease, depression, etc.), organic vs. regenerative food vs. GMO foods, whole grains, how to read food labels, and practical tools for use in a primary care setting. ALL IN administered pre- and post-surveys to assess training effectiveness and identify opportunities for improvement. The survey results showed improvements in prescriber understanding in using food to treat and prevent chronic conditions as well as improvement in confidence doing so with their patients. ALL IN had a number of accomplishments specifically related to reduction of household and individual food insecurity. Prior to their work with ALL IN, Native American Health Center referred patients to their membership department for CalFresh (i.e., California's SNAP program) enrollment through warm handoffs (e.g., a Medical Assistant walking a patient over to the membership department), which were not always trackable. Through building Food as Medicine in the clinic, staff created a new referral pathway integrated into the electronic health record. This allows membership department staff to follow-up with referred patients and increase enrollment support. Staff can develop reports to monitor the status and follow-up of referrals. In addition, creating this system allows for quality improvement by identifying the clinic staff with higher/lower levels of referral to CalFresh. ALL IN worked with clinic staff to integrate a 2-question Hunger Vital Sign screening into both the in-person and telemedicine workflows for all patients (i.e., adults and children, regardless of visit reason). This included developing materials and ensuring appropriate language translation. In partnership with Dr. June Tester (UC San Francisco Benioff Children's Hospitals), ALL IN trained 40 Medical Assistants and prescribers on food insecurity and how to administer the Hunger Vital Sign screening. The workflow includes adding the results of the Hunger Vital Sign screening into EPIC for all patients and creating referrals to CalFresh as appropriate. It is expected that this will lead to higher CalFresh referrals as well as creates a smooth pathway for referral to the Food as Medicine program. During the grant period, ALL IN took important steps towards setting up the infrastructure to collect data and evaluate the overarching project goals. This includes: Building and contracting with an expert evaluation and research team comprised of Stanford University (Stanford) and the University of California, San Francisco (UCSF). Creating a robust data architecture and identifying the data elements that need to be collected from the operational partners, including the data elements required by the GusNIP program. Creating a data sharing ecosystem between the operational, data, and evaluation partners. Partners include Alameda Alliance for Health, Alameda County Health Services Informatics, Community Health Center Network (CHCN) and involved clinics, Dig Deep Farms, and Open Source Wellness. ALL IN identified CHCN as a data hub and developed the data use agreements and other partnership agreements necessary to share data legally and appropriately. Several Business Associate Agreements (BAAs) were successfully completed including between CHCN and Stanford University and between CHCN and Alameda Alliance. Supporting Stanford in securing approval from the Stanford Institutional Review Board (IRB). Identifying additional research expertise (Dr. Ariana Thompson-Lastad, UC San Francisco) to support qualitative research and improve clinic operations. During the grant period ALL IN was able to leverage the GusNIP funding to secure additional funding from the Alameda Alliance for Health (i.e., county public health plan) to support pieces of the Food as Medicine work. ALL IN was also able to secure funding from the Stupski Foundation to support the evaluation in partnership with Stanford and UCSF. The success of the work done during the grant period will reap benefits for the GusNIP-funded work in the long-term.
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