FOOD IS MEDICINE: FIELD STUDIES

Produce Rx

Can changing diets change lives?

Michel Nischan
Founder, Wholesome Wave

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PEOPLE LIVING IN LOW INCOME COMMUNITIES have food access issues that can lead to a number of chronic diseases that are devastating. Fresh produce has been proven to produce better health outcomes for those who effectively increase their produce consumption. Instead of waiting until they require treatment, doctors can prescribe healthy food instead of medicine with the resources that result in affordable access to fresh food, and the knowledge to use it. 

 

Here’s how it works: A patient is diagnosed as at-risk, and then qualifies for an intervention that includes the diagnosis from a prescriber, counseling from a nutritionist, basic nutrition and cooking education, and the financial incentive to purchase the produce. The “patient” participates in the programming, purchases and consumes more produce, then visits the clinic to check-in, adjust their healthy weight goals, and get a refill.

Modeling a Produce Rx Program in Washington, DC’s Ward Eight

Lauren Biel
Executive Director, DC Greens

With the recent crisis in Flint, Michigan, it became clear that as a nation, we expect our cities to guarantee clean water to all people. When that doesn’t happen, we are rightfully indignant, yet it wasn’t always that way. It was only by the turn of the century, when the connection was made between cholera and clean water, that people started to view access to clean water as a public health issue.  

 

We believe that we’re in that “cholera moment” now with food; the connections have been made between the “unclean” food that gets piped into communities of color, and the diet-related chronic illnesses that are plaguing these communities at astonishing rates. 

 

Ward 8 has the highest rates of food-related chronic disease in the Washington, DC area, and only one grocery store for 85,000 people. In a community that battles alarming rates of violence, illiteracy, unemployment, and poverty, DC Greens, Giant Foods, AmeriHealth Caritas DC and DC Health have partnered to create the DC Produce Rx Program to positively impact the health outcomes of Ward 8 residents. 

 

The program equips doctors with the tools to write prescriptions for fresh produce for low-income patients experiencing one of three chronic conditions—diabetes, prediabetes or hypertension—then combines food intervention with nutrition education to give ward residents confidence in making healthier food choices for themselves and their families. 

photography by Douglas Gayeton - click to enlarge

The Produce Rx program launched in early 2019 with 500 AmeriHealth Caritas DC patients from 3 partner clinics; they can visit the Giant pharmacy in Ward 8, redeem prescriptions for a $20 weekly allotment of fruits and vegetables, and meet with a Giant nutritionist to discuss their specific dietary needs. This iteration of the Produce Rx program is one of the few large-scale ventures bridging health needs with a grocery store in the United States.

This innovative initiative links food retailers, health care providers and Medicaid providers to create better access to fresh fruits and vegetables as well as nutrition and wellness opportunities for Medicaid patients experiencing or at risk for diet-related chronic diseases. While a number of other cities across the country are also administering similar programs, what makes DC’s program unique is their relationship to the largest Medicaid provider, AmeriHealth Caritas DC, and the access they’ve been granted to not only patient medical records but also claims data. This unprecedented access will provide the District with an opportunity to fully understand the ROI (e.g. ambulatory utilization, acute utilization, total cost of care) on a program such as this, with the goal being to show that it’s both good policy and good business to integrate Produce Rx Programs fully into healthcare systems.

DC Greens

The Health Equity Activists

For food as medicine to become standard practice, a need exists for organizations willing to foster collaboration between partners that yearn to connect, yet lack the capacity to make it happen. Government agencies can certainly play a role, but on value of community-based organizations is their ability to incubate creative ideas that can eventually scale. In the early stages of any program, it’s necessary to be nimble, responsive and creative. Nonprofits are able to adjust faster, in order to perfect a program.

 

DC Greens, with financial support from DC Health and AmeriHealth Caritas, has put these principles into practice with the DC Produce Rx Program. DC Greens, in knowing that any meaningful systemic shift/solution requires weaving together previously unconnected players, focuses their work on the spaces between different sectors. In this case, they’ve brought together DC government, Medicaid payers, clinical partners, grocers, evaluators, and patients to create a system that can be sustainable for the long-run.

information artwork by Douglas Gayeton - click to enlarge

“Today we’re seeing the connection between ‘unclean’ food piped into communities of color, and the diet-related chronic illnesses that plague these communities,” notes Lauren. “In DC’s Ward 8, for example, four of the top five leading causes of death result from diet-related chronic illnesses.” Programs like Produce Rx may has the power to create environmental shifts in communities where there has typically been low physical access to healthy foods.

People often ask what our exact role is in the program, and the answer is: making it happen. We are living and working in a city where there is a 17-year life expectancy difference between one area of the city (Ward 8, a high poverty, largely African American neighborhood) and Ward 3 (affluent, mostly white neighborhood across town). Four of the top five leading causes of death in Ward 8 diet-related chronic illnesses.  The diabetes rates in Ward 8 are 5 times higher than in Ward 3. We know that people in both communities want healthy food, but in Ward 8 they simply don’t have the means to buy it. 

We need to stop viewing healthy food as a luxury item. For many people, food is a basic medical necessity.

Building the pipe structure that connects clinical care with healthy food access requires DC Greens to juggle a variety of roles, from approaching partners and raising funds, to figuring out workflows and a proving return on investment, all to prove out a model that show where doctors prescribe fruits and vegetables to food insecure patients as a matter of course.  


DC Greens also believes that a program like Produce Rx can help healthcare providers support local economies, with the added benefit of building new markets that can remove the risk for grocers with thin profit margins, and encourage them to carry more fruit and vegetables. 

AmeriHealth Caritas

The Health Plan (with a plan)

AmeriHealth Caritas DC is the managed care organization (MCO) for patients enrolled in the DC Produce Rx Program. Their interest is to see increased visits to a patient’s primary care practitioner (PCP), improved health biomarkers, and a reduction in ER admissions.

information artwork by Douglas Gayeton - click to enlarge

ACDC first identified at risk patients, then offered them the opportunity to enroll in a Produce RX program that provides $20 a week vouchers for fresh produce at a local supermarket, where they can receive support from pharmacists and nutritionists trained to help integrate fruits and vegetables into participants’ diets. The goal is to increase visits with Primary Care Physicians, improve health biomarkers, reduce Emergency Room admissions, and provide the path

to better health outcomes.

Socially Determined

Analyzing the data

Given the increased relevance of social determinants, it’s become fashionable to say that your zip code says more about your health outcome than a genetic test, which may explain the pivotal role that a DC-based data-analytics firm plays in the DC Produce Rx program.

The "Significant Seven" social determinants of health that negatively impact
resident's in DC's Ward 8. [Courtesy of Socially Determined, Inc.]

Socially Determined takes that analogy a step further by using highly refined tools that can look at social determinants of health not on a community level or even by zip code, but literally block by block, house by house, to help healthcare providers assess risk. They combine community-level contextual data from their national repository of social determinants of health (SDOH) data with risk scores captured from individual-level clinical, claims, screening, and programmatic data. This allows them to help clients like Amerihealth Caritas identify SDOH risks at the domain-level (e.g., food insecurity, crime, and housing instability) for the communities and populations the healthcare provider serves.

 

Harnessing the power of their tools will provide a groundbreaking new approach for evaluating the impact of the Produce Rx intervention on claims level outcomes. Measuring the specific quality and financial ROI implications of the program, and performing a comparative ROI analysis of various integration models of Produce Rx, will hopefully be key drivers to convince other health insurance companies of the viability of this initiative. 

information artwork by Douglas Gayeton - click to enlarge

Addressing food insecurity requires taking a comprehensive view of all factors that impact a community or an individual’s ability to procure and prepare healthy food. SDOH risks can negatively impact health care utilization, costs, and outcomes for health plans, health systems in risk-based contracts, government agencies (CMS and state Medicaid programs), and self-funded employers. Using evidence-based interventions like Produce Rx to address these risks offers the potential to reduce a patient’s use of health plan services, achieve better health outcomes and reduce costs. 

Socially Determined began their work on the program by integrating three years of encounter-based EMR data into their analytic platform. This enabled them to analyze utilization patterns, chronic disease burdens, and other relevant clinical factors in their analysis. For their Produce Rx evaluation, they are focused on a more limited set of biometric data, which includes height, weight, BMI, A1c, and blood pressure for program participants for each clinical encounter during the intervention.

Socially Determined gathered data from a variety of sources to assess the ROI and positive patient outcomes
that will show the benefits of the Produce Rx program. [Courtesy of Socially Determined, Inc.]

In every community and population Socially Determined has analyzed to date, food insecurity remains one of the most consistently impactful domains in terms of its correlation to elevated social risk, increased utilization and cost. 

 

At the close of this pilot program, Socially Determined will deliver a full evaluation report to the program partners that quantifies the impact of the intervention clinically, financially, and experientially. Their analysis of the claims data during this program may also provide key findings that help explain the role a Produce Prescription model can play as an evidence-based intervention that addresses food access and affordability, both of which are key drivers of food insecurity risk.  Their strategic recommendations may also suggest additional communities or populations that could benefit from the program and/or potential refinements to the program design that would maximize impact and ROI. 

Community of Hope

We sometimes think that we haven’t been cared for in a medical sense unless we walk away with a prescription. The Produce Rx program gives us something tangible to offer other than 'eat your vegetables' and will hopefully prevent some patients from going on medications in the first place.​​

Megan Moore, Community of Hope

Community of Hope is one of three Federally Qualified Health Centers offering Produce Rx to AmeriHealth Patients in Ward 8. Their care coordinators enroll patients in the program and call prescriptions into the Giant pharmacy.

information artwork by Douglas Gayeton - click to enlarge

THE REFERRAL

The patient’s electronic medical record (EMR) notes her enrollment in the Produce Rx program and whatever counseling she has been provided regarding diet and nutrition. Her produce prescription will be faxed to a nearby pharmacy to show she is receiving Produce Rx, and prompts the provider to send a refill when the patient comes in for a follow-up exam.

 

When a patient is examined at Community of Hope, these are the obvious indicators that a patient would benefit from a Produce Rx program: 1) obesity-related illness; 2) on medications for obesity-related illness, but would rather not be on meds or have so many medical appointments; 3) known financial/food insecurity; 3) interest in changing their lifestyle; 4) interest in eating more fruits & veggies.

Community of Hope believes that the best way to improve health outcomes is to meet people where they are, listen to what’s getting in the way of their health (taking care of everyone else, distrust of healthcare system, trauma, lack of resources, etc.), and build trust by meeting those needs with compassion and high quality services and referrals. 

 

Produce Rx is an important new tool for addressing the barriers to good health, which include low health literacy, difficulty navigating the healthcare system, lack of transportation, and food insecurity. 

Giant Supermarkets

Pharmacists fill prescriptions for fruits and vegetables to help patients battle chronic disease.

After an Ameri-Health Caritas member is prescreened by a medical clinic worker for type 2 diabetes, pre-diabetes, or hypertension, and is also found to be food insecure, they become eligible to participate in the Produce Rx program. They are referred to the Giant pharmacy in DC’s Ward 8, where they consult with a pharmacist, obtain medications prescribed by their physician and receive a 20 dollar weekly voucher for free produce. Anchoring the Produce Rx program in the supermarket’s pharmacy helps participants shift how they see the role food plays in their personal health by showing them that “food” is a medicine, just like any other pill.  

By promoting programs like Produce Rx, pharmacists can help the healthcare profession recognize the importance of targeting both prevention and treatment.

In areas with patients on fixed incomes, the Produce Rx program allows patients to better allocate their resources, and make smarter food choices, which even means experimenting with produce, which has a decreased shelf-life when compared to non-perishables. “We’ve positioned ourselves as a healthcare destination within the store for all our customers,” says Giant Pharmacist Samir Balile.

“Pharmacy is a changing field,” Samir explains. “First, pharmacists are the most accessible healthcare provider. There’s no copay, short wait times, free professional advice, and we’re open 7 days a week! Second, we turn patient contacts into opportunities to make important clinical interventions. Pharmacist can identify gaps in patient care, provide immunizations, educate patients and emphasize the importance of medication adherence, as well as other potential adherence deterrents patients may be experiencing with their medications regimens. These are tasks that pharmacist complete daily that minimize healthcare costs such as hospitalizations, acute illness and more medications to mitigate undesired side-effects.

Can he explain how medication compliance works, and why Produce Rx is a valuable tool to support this?

“Pharmacies are now assessed by PDC (proportion of days covered),” Samir continues. “It’s a metric developed by insurance companies that dictates reimbursements based on patients’ adherence to their medication regimen (blood pressure, diabetes medications, cholesterol meds). From a pharmacy perspective, programs that incentivize individuals with free produce, both increase adherence and allow pharmacists to address any medication-related issues patients may be experiencing. From a retailer perspective, this program also increases foot traffic into the store and can drive further produce sales. It’s a win-win.”
The pharmacist then provides a warm hand-off to Giant’s in-store nutritionist, Jillian, who offers store-tours and free one-on-one counseling. Everything Jillian teaches helps to increase food literacy, from what to look for on a product label to manage weight, cholesterol, blood pressure, diabetes or overall wellness, to understanding the different roles of macro and micro nutrients. When people become confident in their daily decisions about food, they see changes in their health outcomes.

Giant’s nutritionists can be found in stores across Maryland, DC, and Virginia. While Jillian will meet any customer who makes an appointment, she often receives referrals from Giant pharmacists, local clinicians, and other community members. What questions is she asked most? How to read a product’s nutrition facts and how to determine the correct portion sizes, saturated fat, sugar or calories in the foods they should be eating.

Project Outcomes

Produce Rx is currently available at three health care centers across DC.  While it’s too early in the program to see changes in health outcomes, data on program usage is available. 72% of participants are actively using the program, meaning that they have visited the pharmacy to fill their prescription at least once since enrollment. On average, 86% of vouchers that are distributed to participants on a monthly basis are used by participants to purchase fruits and vegetables.  

In the long term, Produce Rx is expected to improve health-related outcomes relating to body-mass index, blood pressure, and blood glucose levels among individuals with pre-diabetes or diabetes. As patients visit their primary care physician more often to pick up their produce prescriptions, they have more frequent health check-ins and develop better relationships with their providers. As a result, Produce Rx is expected to decrease total health care expenditures and emergency care utilization costs among participating Medicaid patients. These cross-cutting findings have the potential to embed a ‘food as medicine’ approach across the local healthcare system by illustrating the role of food in shaping the social determinants of health. Produce Rx redefines fresh, healthy food as a critical component of clinical care, and offers a promising solution for sustainably improving patient health at a time when Medicaid providers, clinics, and hospital systems are searching for ways to lower rates of chronic disease and manage their costs

Coda

There are many ways to assess whether a program “works.” As pre-diabetic and diabetic patients change their relationship with food and get access to healthier diets, they will stabilize their conditions and engage more fully with their healthcare system. 

 

With the DC Produce Rx Program, doctors have noted that they “finally have a way to help patients follow their medical advice.” Patients say that their diets have changed, and that they are modeling new behaviors for their children. At Giant, pharmacists say that are seeing patients more frequently, and their team is able to follow up with patients on their overall medication compliance. And with the unprecedented access to claims data gathered through the partnership between AmeriHealth Caritas and Socially Determined, cost savings on ER diversion, medication compliance, prevention of disease progression and much more can now being analyzed. Hopefully, capturing data from food is medicine initiatives like the DC Produce Rx program will lead to increased investment from the healthcare system in providing access to healthy food as a key component of prevention.