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December 2018, Volume XXXII, No 9

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Meals for Healing

Second Harvest Heartland’s FOODRx program tackles food insecurity and chronic illness, paving the way for better outcomes and lower costs

Ralph and Lisa, a married couple in St. Cloud, Minnesota, have a range of challenging health diagnoses between them, including type 1 diabetes, type 2 diabetes, and congestive heart failure. They also struggle with food insecurity, with Lisa’s health conditions making it difficult for her to work. At a recent trip to their doctor’s office, they were offered a unique opportunity to enroll in a new program, FOODRx, that would provide them with a monthly box of shelf-stable, wholesome food at no cost—food specifically chosen to support their health conditions.

They gave us healthier foods, like beans and milk, that we incorporated into our diet,” says Ralph. Lisa’s blood sugar levels showed improvement after they started receiving the boxes, and Ralph lost weight. When the program ended after 12 months, the family continued to enjoy their new favorite healthy foods. “I buy a lot more healthy food now than before the FOODRx boxes,” says Ralph. “I know how to enjoy it more.”

It’s no secret that nutrition plays a vital role in wellbeing. Health care professionals and hunger-relief organizations alike have looked across the divide at one another and seen the value of one another’s work.

But what about that divide? A physician may give a chronically ill patient detailed nutrition advice, but if that person doesn’t have consistent access to healthy food due to financial or logistical barriers, there’s not much either the patient or physician can do. Even if that patient makes her way to a local food shelf, she may be wary of choosing unfamiliar items or produce that she doesn’t know how to prepare or is worried she won’t like. The question is how both guidance and affordable access can be woven together, with nutritional support undergirding medical interventions in a way that promotes better health outcomes and reduces medical costs.

The Minnesota pilot program FOODRx, spearheaded by regional hunger-relief organization, Second Harvest Heartland, aims to bridge the historical divide between health care and nutrition support for food-insecure people with chronic illnesses. It aims to reach diverse populations with an intervention that can both manage and improve disease states—as well as improve outcomes and cost effectiveness for health care leaders and providers.

“FoodRx pilots showed improved health outcomes, lower costs, and fewer hospital visits.”

The High Cost of Hunger and Disease

Research has firmly established strong links between hunger and chronic disease. A 2017 report from the U.S. Department of Agriculture concluded that food insecurity is tied to 10 out of 10 major chronic illnesses (only 3 of 10 could be strongly associated with low income), with even relatively mild hunger raising rates of hypertension and diabetes by 20 and 59 percent, respectively. These chronic diseases have the greatest impact on quality of life, life expectancy, and societal costs in the form of medical expense and emergency room visits.

Another study at the University of Minnesota estimated that food insecurity in the state leads to $800 million to $1 billion in annual health care costs. A 2013 study conducted by the Boston Consulting Group also found strong connections between hunger and chronic conditions such as diabetes and heart disease and, even more provocatively, estimated that providing food through health care channels could lead to providing 30 to 45 million needed meals per year in the state. FOODRx sprang from this insight—that the doctor’s office could be a means of reaching hungry individuals who might otherwise not access food shelves or state supplemental nutrition benefits.

“If we can effectively integrate our work into the health care system, we can reach people we don’t usually reach,” says Jason Reed, Second Harvest’s Director of Strategy and New Ventures. “And our data showed that hungry people were accessing the health care system more often than the general population.”

FOODRx has strategically addressed the hunger-chronic disease linkage with a focus on creating a workable model that could be employed throughout the state. Its foundational idea is creating better outcomes and return on investment for health care systems, along with a financial model based on scale and sustainability. This business model is crucial—rather than create a philanthropy-based model FOODRx has focused on funding from health care systems, insurance providers, and other partners that stand to gain positive financial benefits for value-based cost lowering and positive health outcomes.

“FOODRx enabled us to test this value-based care model and see whether patients improved their health,” Reed adds. “Pilots showed improved health outcomes, lower costs, and fewer hospital visits.”

FOODRx pilots have focused on acute and chronic hunger among low-income patients in the Minnesota health care system. Qualifying individuals receive roughly 25 meals in a 30-pound box of food every month for six to 12 months. A staff dietitian at Second Harvest develops and designs the food boxes, which are tailored for chronic conditions such as diabetes and heart disease. The contents of the boxes, which contain recipes and nutrition information, can also be tailored for specific cultural populations such as Somalis, Latinos, and traditional American (these are options, not proscriptions—in one case, for instance, a younger Somali individual preferred the traditional American food option). Giving patients agency in choosing the boxes they prefer increases the likelihood that they will consume the contents.

“We were able to meet with patients at least quarterly, to talk about what was in their box, and which foods were good for their chronic disease states,” says dietician Paula Redemske, who worked with a pilot at the CentraCare Family Health Center in St. Cloud. “I saw people we’d had trouble getting into the clinic come and sit through education sessions and be successful because we were providing the food for them.”

“Addressing hunger as a health problem within the health care system makes a lot of sense.”

Targeting Conditions and Supplementing Nutrition

The FOODRx pilot program at CentraCare focused on patients with diabetes and cardiovascular disease, and also featured a partnership with a local grocery store for ten-dollar monthly vouchers good for fresh fruits and vegetables. Redemske adds that she saw visible relief for patients in their financial lives; while FOODRx isn’t intended to meet an individual’s entire food needs for the month, it has a tangible benefit both in supplying solid nutrition and creating some potential breathing room in tight household budgets.

In urban communities such as that served by North Memorial Health, food insecurity is exacerbated by limited access to healthy food options for individuals lacking independent transportation. Many patients with chronic conditions in these “food deserts” rely on small independent stores that they can reach on foot, which are often lacking in fresh, healthy food options.

“Food insecurities impact our patients across all cultural lines,” says Orenthal Avery, a clinic manager at University of Minnesota Physicians Broadway Family Medicine Clinic. “It’s still early in our pilot, but at a minimum this is a good educational tool for establishing healthy eating habits for our patients in regard to their chronic conditions. It also takes some stress and pressure off families. They look forward to food distribution dates, because it makes their food supply stretch.”

On the clinic level, FOODRx programs also yielded surprises. Manny Ravelo, a Second Harvest Project Coordinator who set up systems for screening needs in a St. Cloud pilot, soon learned that the status of an individual’s food insecurity was often unrelated to their dress or appearance. One well-dressed elderly couple only revealed their food insecurity while filling out a questionnaire; like many clinic patients, they were unaware of options for supplementing their food through assistance programs.

“I learned the importance of not assuming based on appearance,” says Ravelo, whose program screened patients for additional resources needs such as food, housing, and employment. “You never know what somebody might be going through.”

One recurring concern at the clinic level for FOODRx trials has been helping participating patients to physically transport their monthly 30-pound food boxes. Individuals with chronic health conditions and no vehicle face obvious obstacles getting their food from the health care setting into their home. One solution has been matching volunteers with FOODRx participants.

“Some of our individuals on Medicaid also have issues with their transportation,” says Michael Koch, a project manager at Minneapolis’s North Memorial Health who has been overseeing enrollment into the FOODRx program “Just recently we’ve been able to arrange delivery for some of these patients, mostly through partnering with medical teams and paramedics.”

It speaks volumes that these food deliveries are being done on a volunteer basis—front-line medical and transportation staff see such an obvious value for their patients’ health in FOODRx deliveries that they’re willing to donate their own time. These professionals see an opportunity to provide nutritional support for those with chronic conditions, as well as a way to help them stabilize their lives: it’s this kind of integrated approach to hunger and medicine that makes as much sense on the clinical level as it does in higher-level research.

“Ideally, we’d like to see individuals graduate from the FOODRx program and find stability in other, different aspects of their lives,” adds Koch. “If we can start building up stable legs for them, it’ll help them with their overall health and their overall lives.”

This is the higher goal: relieving food insecurity with balanced nutrition, supporting healthy function to improve chronic conditions, and empowering individuals to lead more proactive lives. The potential is to benefit the individual, families, and the health of the greater community while reducing considerable stresses and costs in the health care system.

“Probably the biggest thing is that those not participating wish it was more widespread,” adds Avery. “It’s also raising awareness of other resources for food insecurity, and now we’re always conscious of that with our patients. And with the chronic disease focus, we’re not just providing food—we’re letting people know that what’s in the box has a purpose.”

In terms of education, FOODRx enables crucial nutritional information to be delivered in a clinical setting to people with chronic conditions. Both dieticians and patients report that pairing education with actual food enables a breakthrough in viewing nutrition.

“One person with diabetes using the food shelf here ended up with improved lab tests after he worked with a dietician to pick out food,” says Hennepin Healthcare pediatrician Diana Cutts, MD. “He said, If you care enough to actually give me the food instead of just talking about the food, I should pay attention and use it.’”

The Long-Range Picture

Cutts’ office window looks out on a busy downtown Minneapolis street. She’s worked at the front lines of the intersection between public policy and children’s health care for decades, recently celebrating the 20th year of Children’s HealthWatch, which was launched to track the effects of 1998 cuts in national welfare spending. She’s been involved in extensive research-focused work on questions related to food insecurity and childhood development.

“It isn’t just about food, it’s about health and clearly drawing that intersection,” Cutts says. “Those of us who work in healthcare have to ask what is our opportunity and obligation to use the infrastructure of health organizations to do our part. It benefits our patients to address food insecurity.”

Hennepin Healthcare’s facility features an onsite food center for patients and those being discharged from care, as well as a summer meals program for kids and referrals to food outreach counselors. Cutts is involved in a FOODRx research program among the facility’s diabetic patients, and is focused on delivering more and more data to health care decision makers and practitioners to make the case for the improved health outcomes and economic benefits of systematically bringing nutritional solutions to the health care setting.

“There’s a financial payoff, aside from the philosophy that people should simply have access to healthy food,” Cutts adds. “Addressing hunger as a health problem within the health care system makes a lot of sense. The economic rationale is an important piece of the puzzle.”

A Model That Works

To date, Second Harvest Heartland has six FOODRx contracts, each based on different services. As with the studies with CentraCare and Hennepin Healthcare, the focus has been on the chronic illnesses such as diabetes and heart disease that drive up the cost of health care, putting a strain on the resources of hospitals and clinics, health care groups, and government.

“We’re drilling into where the cost is for providers,” says Second Harvest’s Reed. “Medicaid has encouraged states to pursue the value-based care model, with certain outcomes for care and lowering costs.”

The 10 diseases studied in the Department of Agriculture’s 2017 report—hypertension, coronary heart disease, hepatitis, stroke, cancer, asthma, diabetes, arthritis, chronic obstructive pulmonary disease, and chronic kidney disease—are a who’s who of those conditions that most seriously impact health, mortality, and quality of life. They’re also the source of billions of dollars in spending for the health care system on office appointments, ER visits, expensive procedures, and costly treatments.

No one argues that food is the cure for chronic disease. But when research links hunger to all 10 of the most common chronic diseases, professionals across the health care spectrum take note.

“In my work, we often pose the question: How would things be different today if we’d done a certain thing 20 years ago?” says Cutts. “If we had allocated certain funds to address this problem 20, or even 30, years ago, how would the system be better off? How would our workforce look different?”

How could our society and workforce look 20 or 30 years from now, if we put the full force of our human ingenuity into braiding hunger relief and health care?

“There’s a recognition today that health is based on social determinants rather than just genetics or access to health care,” Cutts adds. “They’re so powerful. And of all these determinants, food insecurity is the lowest-hanging fruit. We have the infrastructure, and we have the resources. It’s a new landscape.”

If you have patients who would benefit from the FOODRx program, please contact Alexandra De Kesel Lofthus at alofthus@2harvest.org or 651.282.0887 to learn more about bringing the program to your clinic.

Mo Perry and Quinton Skinner, are co-principals of Logosphere Storysmiths, a boutique content agency that creates vivid narratives for impactful companies, organizations, and leaders.   

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Mo Perry and Quinton Skinner, are co-principals of Logosphere Storysmiths, a boutique content agency that creates vivid narratives for impactful companies, organizations, and leaders.