Progress 09/01/23 to 08/31/24

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 experienced significant transitions during this grant period, including staff transitions and the need to hire and train new staff, changes brought on by the health plan and unexpected issues with our food provider. During the reporting period, Recipe4Health had four staff transitions that led to staff shortages and required significant program resources to recruit, hire and train new staff. Additionally, during the reporting period, Recipe4Health was in its second 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. Recipe4Health navigated several changes brought on by Alameda Alliance for Health (AAH), including, reductions in the number of health coaching sessions patients could receive and a new authorization process, among others. Furthermore, R4H has been working with county data teams to identify and improve processes for determining AAH eligibility to ensure we capture as many CalAIM dollars as possible. Another challenge faced by R4H in this reporting period was the unanticipated loss of the fiscal home for R4H's food vendor and partner, Dig Deep Farms (DDF). This forced R4H to pause all expansion efforts and focus on ensuring that the program would have a food vendor secured by the time of the planned separation. Recipe4Health supported DDF in finding a new fiscal home with the Alameda County Community Food Bank (FB) as of July 1st, 2024. The FB is supporting food delivery to all patients who were receiving food from DDF at the time of the transition. Additionally, Recipe4Health secured Farm Fresh To You (FFTY) as it's new food vendor that started providing services to all newly referred patients in August, 2024. FFTY has been in operation since 1976 and has been providing doorstep delivery of local organic food boxes to clients statewide. We successfully prevented pausing program operations, but these unexpected transitions have required team resources and further pushed back Recipe4Health expansion timelines. R4H plans to restart expansion in 2025. While these challenges have delayed R4H's ability to meet the grant's expansion goals and objectives, Recipe4Health has met and exceeded all other grant goals related to number of CalAIM patients served, number of patients who received health coaching in Spanish through community groups and individual coaching. Additionally, Recipe4Health has continued to meet the overarching GusNIP award goals of 1) improvement of dietary health through increased consumption of fruit and vegetables 2) reduction of individual and household food insecurity, and 3) reduction in healthcare use and associated costs, as evidenced by our evaluation findings that are presented in our 2019 and 2021 GusNIP award reports. What opportunities for training and professional development has the project provided?Staff held an evidence-based, state-of-the-art "booster" training on "food as medicine" to shift the mindset and practice of prescribers so they can effectively use food and clinical nutrition in a 15-minute primary care visit and increase referrals to the Food Farmacy and Behavioral Pharmacy, which increases consumption of fresh produce. The following training were held during the reporting period: -NAHC: two one- hour sessions of training with 47 and 30 staff trained Taught by Recipe4Health's Chief Medical Officer with pedagogical approaches informed by culinary medicine experts, topics included but were not limited to: a framework to understand the impact of insulin resistance and chronic inflammation on various conditions connected to cardiometabolic health (e.g., pre/diabetes, hypertension, dyslipidemia, overweight/obesity, depression, anxiety, etc.), a framework to treat cardiometabolic problems using a practical 6 step approach, organic vs. regenerative food, fruit and vegetable dosage and health outcomes, and other practical tools for use in a primary care setting. Recipe4Health staff administered pre- and post-surveys to assess training effectiveness and identify opportunities for improvement. The surveys showed participation in the Clinical Nutrition Trainings resulted in prescribers feeling more confident in addressing food insecurity, social isolation, and using food as medicine to treat, prevent and reverse chronic illness in their patients. Training participants ranked the trainings positively: 82% ranked the training 5 out of 5, 18% ranked it 4 out of 5 and 100% said they would recommend the R4H trainings to colleagues. How have the results been disseminated to communities of interest?Recipe4Health holds regular meetings with clinic staff and operational partners (OSW and DDF) for quality improvement purposes, including improving referral quality and streamlining processes. During the reporting period, presentations to stakeholders have included: IM4US Decolonizing and Recentering Climate Health HRSA Policy and Program Development Meeting NIFA Community Nutrition Project Director's Meeting 2023- New Orleans Alameda County Health Care Services Agency Board of Supervisors Meeting National Association of Community Health Centers Presentation Congressional Presentation for Representative Barbara Lee: Leveraging Medicaid for Equitably Sourced Regenerative and Organic Food as Medicine Cornerstone Presentation HHS Food as Medicine Summit Public Health Alliance HRSA Bureau of Primary Care and Office of Program and Policy Development Presentation Alameda County Health Commission Presentation California Wellness Foundation GusNIP PPR Community of Practice Food for Health Collaborative SF 7thAnnual AHIP Conference What do you plan to do during the next reporting period to accomplish the goals?Recipe4Health aims to continue to provide food and health coaching services to vulnerable food insecure patients and patients who are not part of a CalAIM participating health plan. Recipe4Health also aims to complete the training and launch of LLMC West Berkeley in mid 2025. In addition, R4H plans to start training Axis Health Center in late 2025. Recipe4Health will work with clinic leadership to ensure staff who missed the initial trainings or any new staff watch the training videos. Recipe4Health's ability to expand and to maintain services for all patients not currently covered by CalAIM could be impacted by future health plan changes that impact the Recipe4Health budget.

Impacts
What was accomplished under these goals? Goal 1: Maintain access to R4H Program for patients who experience food insecurity and/or who are not members of participating health plans under CalAIM. Recipe4Health transitioned to becoming a Community Supports provider under the CalAIM initiative (CMS 1115/1915b waiver with ILOS) on September 1, 2022. Under CalAIM, Recipe4Health can receive reimbursement for any patients who are Alameda Alliance for Health members who have a qualifying chronic condition, however, patients who screen positive for food insecurity but who do not have a qualifying chronic condition are not eligible under CalAIM. Recipe4Health remains committed to working upstream to address the social determinants of health, such as food insecurity and social isolation. Therefore, R4H is continuing to provide coverage to patients who are food insecure but have no qualifying chronic conditions under CalAIM, are pre-diabetic but have no other qualifying chronic conditions, and for Medi-Cal eligible patients who qualify for the program but are not Alameda Alliance for Health members. From September 1st, 2023 - August 30th, 2024, Recipe4Health served 3107 patients who were not eligible for CalAIM and/or who are food insecure. Of the3107 who were not eligible for CalAIM, 2600 (84%) were patients who were not members of Alameda Alliance for Health and 875 (28%) were food insecure patients with no qualifying chronic condition. Of the food insecure patients, 443 (51%) were Alameda Alliance for Health patients. Of the 2600 non-AAH patients, 226 (9%) received at least one health coaching session. Goal 2: Expansion to additional clinic locations with existing R4H Health Center partners In the first year of the grant (Sept 2022 - Aug 2023), Recipe4Health expanded to four new clinic site locations at Tiburcio Vasquez Health Center (Hayward, Union City, Firehouse, Hesperian) and one new Bay Area Community Health (BACH) clinic site location (Irvington). Five of the six trainings were also completed at Lifelong Health Center (West Berkeley) with an average of 92.5% of relevant staff completing trainings. During this grant period, a second BACH location launched (Main Street Village) on February 1st, 2024. Main Street Village clinic was trained in the first grant year, with 75% of Medical Prescribers, 86% of Allied Health Prescribers, and 71% of Medical Assistants completing at least one of the Recipe4Health core trainings. Their launch was delayed due to a fire at the clinic site in 2023. Unfortunately, all additional expansion was put on hold in late 2023 when R4H learned that our food vendor, Dig Deep Farms, would be separating from its fiscal home on June 30th, 2024. The program needed to shift its resources to securing a food vendor to support with the transition. Recipe4Health has multiple clinic sites, including Lifelong Health Center (West Berkeley), Newark Wellness, Lifelong Health Center (East Oakland) that are ready to launch as soon as the program has capacity to take on additional clinics. Goal 3: Launch R4H program with new Health Center partners Recipe4Health did not launch any new Health Center partners in this grant year, however, there are several health centers (Axis Community Health, West Oakland Health Center, Asian Health Services, and UCSF-Benioff Children's Hematology and Oncology) who have agreed to begin R4H training as soon as R4H has capacity to take on additional health centers. R4H had to pause all expansion in late 2023 after learning that it's food vendor, Dig Deep Farms, would be separating from its fiscal home on June 30th, 2024. The majority of program resources were shifted to supporting DDF in finding a new fiscal home and securing a secondary food vendor to support with the transition. These unexpected transitions prevented further expansion. Goal 4: Offer two additional health coaching services to all referred patients under Recipe4Health: Starting in September of 2022, Reciep4Health expanded the menu of health coaching options available to patients. The new options included 1) virtual group options (Countywide groups) in English and Spanish that would serve patients from all partnering health centers and health plans across Alameda County and 2) individual coaching sessions in English and Spanish. These new options have increased access to health coaching for patients whose schedules did not allow them to enroll in the Group Medical Visit at their home clinic. During the reporting period, a total of 140 unique patients were enrolled and attended at least one session of the Spanish Countywide group. This group has been an important offering to better serve our Spanish speaking patients. Similarly, 98 unique patients enrolled in and attended at least one session of the English county-wide group. Additionally, a total of 324 patients received at least one individual coaching session. Of those patients 157 received the sessions in English 147 patients received sessions in Spanish. Additionally, patients received individual health coaching sessions in Hindi (6), Punjabi (3) Tamil (1), Farsi (1), Arabic (1), and Tagalog (1). Individual coaching continues to be a great option for patients who are unable to commit to a group. Finally, our coaching vendor, Open Source Wellness (OSW) decided to offer a new community group site option that provided a shorter session length of time. Two of these groups launched in October 2023 (one in English and one in Spanish) and due to their popularity, a second Spanish group was launched in January of 2024. The two new Spanish community groups served a total of 75 patients in the reporting period and the English group served a total of 8 patients.

Publications

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 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. 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. While in the middle of launching with R4H, BACH MSV experienced a fire that closed the clinic and resulted in staff being moved to different locations. This impacted the training numbers and R4H is working with leadership to train staff who missed the initial trainings. 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 prevented R4H from meeting the 2022 year one objectives of expanding to another health center which had been planned for the summer of 2023. It also pushed back expansion to additional clinic sites within BACH and LLMC. In September 2023 the health plan lifted the pause on expansion and R4H is working to adjust timelines for expansion to additional clinic sites. 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 that provided an overview of the Food as Medicine initiatives as well as an experiential opportunity of the - Behavioral Pharmacy Lifelong Medical Center (LLMC) Ashby: 16 staff, Bay Area Community Health (BACH) Irvington (IRV) and Main Street Village (MSV): 37 staff, Tiburcio Vasquez Health Center (TVHC): 35 staff and Lifelong Medical Center (LLMC) West Berkeley (WB): 56 staff. Recipe4Health trained Medical Assistants and Allied Health Prescribers on food insecurity and how to administer the Hunger Vital Sign screening BACH IRV and MSV:19 staff, TVHC: 22 staff and LLMC WB: 27 staff. Recipe4Health provided separate workflow trainings for Medical Prescribers, Allied Health Prescribers, and Medical Assistants on the R4H program components and EPIC workflow (BACH IRV and MSV: 22 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, and refresher trainings, as needed. Clinical Nutrition Trainings (Formerly Food as Medicine Trainings): Recipe4Health staff held a series of evidence-based, state-of-the-art trainings on "food as medicine" to shift the mindset and practice of prescribers so they can effectively use food and clinical nutrition in a 15-minute primary care visit and increase referrals to the Food Farmacy and Behavioral Pharmacy, which increases consumption of fresh produce. The following trainings were held during the reporting period: -BACH IRV & MSV: three one- hour sessions of training and an average of 18 staff trained -TVHC: three one-hour sessions of training and an average of 21 staff trained -LLMC WB: two one-hour sessions of training and an average of 26 staff trained Topics included but were not limited to: a framework to understand the impact of insulin resistance and chronic inflammation on various conditions connected to cardiometabolic health (e.g., pre/diabetes, hypertension, dyslipidemia, overweight/obesity, depression, anxiety, etc.), a framework to treat cardiometabolic problems using a practical 6 step approach, organic vs. regenerative food, fruit and vegetable dosage and health outcomes, and other practical tools for use in a primary care setting. Recipe4Health staff administered pre- and post-surveys to assess training effectiveness and identify opportunities for improvement. The surveys showed participation in the Clinical Nutrition Trainings resulted in prescribers feeling more confident in addressing food insecurity, social isolation, and using food as medicine to treat, prevent and reverse chronic illness in their patients. Training participants ranked the trainings positively (4.7 out of 5) and 97% said they would recommend the R4H trainings to colleagues. How have the results been disseminated to communities of interest? Recipe4Health holds regular meetings with clinic staff and operational partners (OSW and DDF) for quality improvement purposes, including improving referral quality and streamlining processes. During the reporting period, presentations to stakeholders have included: RosasLG, 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 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 will continue to provide food and health coaching services to vulnerable food insecure patients and patients who are not part of a CalAIM participating health plan. Recipe4Health will complete the training and launch of LLMC West Berkeley in early 2024. In addition, R4H plans to start training Axis Health Center and West Oakland Health Center by June of 2024. Recipe4Health will work with clinic leadership to ensure staff who missed the initial trainings or any new staff watch the training videos.

Impacts
What was accomplished under these goals? Goal 1: Maintain access to R4H Program for patients who experience food insecurity and/or who are not members of participating health plans under CalAIM. Recipe4Health transitioned to becoming a Community Supports provider under the CalAIM initiative (CMS 1115/1915b waiver with ILOS) on September 1, 2022. Under CalAIM, Recipe4Health can receive reimbursement for any patients who are Alameda Alliance for Health members who have a qualifying chronic condition, however, patients who screen positive for food insecurity but who do not have a qualifying chronic condition are not eligible under CalAIM. Recipe4Health remains committed to prevention and addressing the social determinants of health, such as food insecurity. Therefore, R4H is continuing to provide coverage to patients who are food insecure but have no qualifying chronic conditions under CalAIM, are pre-diabetic but have no other qualifying chronic conditions, and for Medi-Cal eligible patients who qualify for the program but are not Alameda Alliance for Health members. From September 1st, 2022-August 2023, Recipe4Health served 817 patients who were not eligible for CalAIM and/or who are food insecure. Of the 817 patients, 563 (69%) received at least one health coaching session. Of the 817 who were not eligible for CalAIM, 537 (66%) were patients who were not members of Alameda Alliance for Health and 280 (34%) were food insecure patients with no qualifying chronic condition. Of the food insecure patients, (156) 56% were Alameda Alliance for Health patients. Goal 2: Expansion to additional clinic locations with existing R4H Health Center partners One new Lifelong Medical Center (LLMC) clinic site, West Berkeley, has started but has not completed all core trainings, completing 3 of the 4 core trainings so far. Among the relevant LLMC West Berkeley staff, 89% completed at least one of the R4H core trainings. 91% of Medical Prescribers and 96% of Allied Health Prescribers attended at least one core R4H training. Additionally, 86% of Medical Assistants attended the Food Insecurity Screening training, a core training. Any staff who misses a core training will be required to watch a training video before participating in the program. LLMC West Berkeley plans to resume training and launch in early 2024. During the grant period, Bay Area Community Health (BACH) Irvington and Main Street Village (MSV) Clinic completed Recipe4Health core training. Unfortunately, a fire at the MSV site prevented them from launching and resulted in lower-than-expected training completion, as all MSV staff were transferred to different BACH clinic site locations. However, BACH Irvington was able to launch on July 14th, 2023. During the reporting period, 75% of Medical Prescribers, 86% of Allied Health Prescribers, and 71% of Medical Assistants completed at least one of the Recipe4Health core trainings. Recipe4Health will continue to work with clinic leadership to ensure all relevant staff complete required trainings. A second LLMC site and a third BACH site has also been identified to participate in Recipe4Health but was unable to start due to the Alameda Alliance for Health pause on Recipe4Health expansion. The expansion pause has been lifted and R4H is working with clinic partners to determine new launch dates for the additional clinic sites. While R4H was not able to add the second LLMC site and the third BACH site as planned, when the Tiburcio Vasquez Health Center re-launched in April 2023, after a 13 month pause, it re-started at all 5 clinic locations (previously it had been at only the San Leandro location). This re-launch effectively started 4 new clinic locations (Hayward, Union City, Firehouse, Hesperian) with an existing health center (Tiburcio Vasquez Health Center. Goal 3: Launch R4H program with new Health Center partners Recipe4Health did not launch any new Health Center partners in this grant year, however, additional health centers (Axis and West Oakland Health Center) have agreed to begin R4H training by June 2024. The Alameda Alliance for Health paused all expansion efforts in the Spring of 2023 while they created a set of criteria needed for CalAIM Community Supports Providers to expand. While the expansion was lifted in September of 2023, this pushed back all plans to expand with new Health Center partners. Goal 4: Offer two additional health coaching services to all referred patients under Recipe4Health: Starting in September of 2022, Reciep4Health expanded the menu of health coaching options available to patients. The new options included 1) virtual group options (Countywide groups) in English and Spanish that would serve patients from all partnering health centers and health plans across Alameda County and 2) individual coaching sessions in English and Spanish. These new options have increased access to health coaching for patients whose schedules did not allow them to enroll in the Group Medical Visit at their home clinic. During the reporting period, a total of 98 unique patients were enrolled and attended at least one session of the Spanish Countywide group. This group has been an important offering to better serve our Spanish speaking patients. Similarly, 55 unique patients enrolled in and attended at least one session of the English county-wide group. Furthermore, a total of 435 patients received at least one individual coaching session in English and 345 patients received at least one individual coaching session in Spanish. The individual coaching has been a great option for patients who are unable to commit to a group. Additional accomplishments include: launching a Care-Team Tableau Dashboard that CHCN clinic partners can use to track their food insecurity screenings, and referrals to Recipe4Health. The dashboard allows the user to filter by date, clinic site, department, and by provider or staff name.

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