Progress 09/15/23 to 09/14/24

Outputs
Target Audience: Project Open Hand (POH) provides medically tailored meals and groceries to people living with diet-modifiable chronic conditions, most of whom are food insecure and members of marginalized communities. Our Wellness Program serves almost 4,000 clients annually who are living with serious illnesses in San Francisco, Alameda, and Contra Costa Counties. The POH Produce Prescription Program (POH PPP) targets individuals who utilize our medically supportive grocery service (able and desire to prepare food on one's own), are food insecure, eligible for or on Medi-Cal, and are living with a diet-modifiable chronic condition, such as: HIV/AIDS, Type I/II diabetes with an HbA1c of 8 or higher, Hepatitis C, end stage renal disease, or heart disease - congestive heart failure (CHF), coronary artery disease (CAD) and/or chronic obstructive pulmonary disease (COPD). POH targets this audience because the risk of and challenges of living with a limited income and food insecurity are heightened when one is also managing a chronic condition. The rates of these diseases are at greater levels among certain population groups due to social determinants of health such as poverty, unequal access to health care, stigma, and racism. Thus, the program targets those in groups that have historically experienced interpersonal, systemic, and/or institutional racism, ageism and discrimination based on sexual orientation and gender identity. The POH PPP was available to all grocery clients through USDA and POH funding. During this reporting period, 3,322 grocery clients had access to fresh fruit, vegetables and herbs through the USDA funded POH PPP in San Francisco (63%), Alameda (31%) and Contra Costa (6%) counties. Fifty-five percent of clients picked-up groceries at either POH grocery centers or one of three mobile sites in San Francisco at some point during the year; fifty-three percent of clients accessed delivery services at some point during the year. The population accessing the POH PPP is diverse: 32% are Latino/Hispanic, 26% European descent, 26% Black/African American, 14% API, and 3% Native American. Fifty-nine percent identify as male, 37% female, and 4% non-binary or transgender. Seventy-one percent of these clients are 50 years of age or older. At least 30% are LGBTQIA+. Fifty-five percent of participants are unemployed, and 72% live below the federal poverty level (FPL), with 91% at or below 200% FPL. As part of program goals and evaluation, the POH team aimed to enroll approximately 200 patients for more in-depth evaluation via EHR and health care cost data through a partnership with the UCSF Food Pharmacy Alliance. POH enrolled clients from the following six clinics in San Francisco: the Division of General Internal Medicine, 360 Wellness Center (Men's HIV), Women's HIV Program, Family Medicine at Lakeshore, Primary Care at China Basin, Women's Primary Care. Initially, UCSF partners conducted outreach solely to existing Food Pharmacy patients, but this expanded to all patients in these clinics who met eligibility criteria in December 2023. Ultimately, POH enrolled eighty-six participants; 48 participants (56%) completed at least 12 weeks of POH PPP programming, 18 (21%) completed between four and eleven weeks, and 20 (23%) completed less than four weeks. The demographics of this cohort are representative of the population exposed to the intervention broadly. However, those who disengaged prior to completing 12 weeks of programming included a higher proportion of African American/Black participants (39%), more male (71%), younger (55% at 50 years of age or older), and a lower proportion living below FPL (58%). Reasons for disengagement were captured for 29% of those who completed less than 12 weeks of programming. Key themes included difficulty accessing services due to time or transportation issues, lack of need for food resources, and illness or death. Changes/Problems: The team experienced several challenges in reaching our program goals. Recruitment and enrollment - The first challenge is related to the enrollment of a cohort of an estimated 200 new clients from six UCSF clinics for evaluation. While provider education efforts were on track leading up to program launch in May 2023, very few referrals were made between May and early mid-December 2023. Several contributing issues identified during this reporting period include: (1) Referral tools and workflows - Kinks in the APeX EHR referral added burden to the referring providers, and confusion on the POH and UCSF teams about referral format and content resulted in delays in referral submission and processing; (2) Limitations in identifying a patient pool for recruitment due to -- (a) limited eligible diagnoses prior to expansion from CalAim Community Supports programming (https://www.dhcs.ca.gov/CalAIM/Documents/DHCS-Medi-Cal-Community-Supports-Supplemental-Fact-Sheet.pdf) initiated in January 2024, (b) reduction in the number of patients naive to POH services or who had not experienced POH services within six months, given that POH is a longstanding provider of FIM services for HIV care in San Francisco, and (c) restricting scope to those patients already engaged with the UCSF Food Pharmacy program; (3) Staffing capacity - The UCSF Food Pharmacy Alliance team lacked a project manager to support outreach and enrollment until December 2023, and providers and clinic managers at several participating clinics experience competing priorities and limited capacity. The POH Client Services team also lacked staffing capacity to provide hands-on outreach and support for UCSF providers. Additionally, beginning in January 2024, shifts in funding streams and related criteria for POH services added complexity to the understanding of referral mechanisms for UCSF providers, and communication about these adjustments needed improvement. Specifically, demand for POH services through a contract covering those with diabetes and heart disease via the Department of Disability and Aging Services exceeded its cap, and at the same time, CalAIM Community Supports launched in support of a wider range of diagnoses but with the requirement that a patient have Medi-Cal coverage through San Francisco Health Plan or Anthem. Eligibility requirements and referral processes required more provider education. Several steps were taken to overcome these challenges. First, the POH team created a short-form digital referral for use while EHR referrals were being adjusted. Second, the UCSF team expanded their targeting beyond existing Food Pharmacy patients to anyone with eligible diagnoses to increase the possible patient pool. Third, to reduce the burden on clinicians, the UCSF team started sending lists of eligible patients to POH in December 2023 for screening and enrollment (versus in-clinic referrals as the sole referral mechanism). Related, the UCSF team hired a new project manager, and the UCSF physician partner (Dr. Moreno-John) conducted outreach to each of the participating clinics to bring referrals to POH up to their list of priority initiatives. The POH PPP PD and the POH Vice President of Programs meet with Dr. Moreno-John once per month, and Dr. Moreno-John attended technical assistance calls with POH and the GusNIP NTAE advisor, as needed. EHR referrals - The original proposal for this project included the intent to integrate UCSF patient data and referrals via UCSF's Epic EHR system, APeX. As noted in the "Other Products" section, the POH team, UCSF clinicians and UCSF IT team successfully created a provider-facing referral in APeX. However, the referral is not fully integrated because of technical constraints in linking APeX to the current POH proprietary database, and the ability to transmit a referral between APeX and POH's database is unlikely during the project period. Currently, POH operates a proprietary database and has experienced significant delays in developing and onboarding a new, enhanced client management database via Eccovia (ClientTrack). Moreover, the launch of CalAIM Community Supports programming for Medi-Cal beneficiaries added a required referral pathway not considered during development of the initial EHR referral design. POH and UCSF teams are committed to the continued pursuit of streamlined referral systems andthis work continues beyond the life of this grant. Adherence to minimum service period - While eighty-six UCSF patients were enrolled in POH programming, only 48 (56%) completed the minimum of 12 weeks of nutrition service. Eighteen (21%) completed four to 11 weeks and 21 (23%) completed less than four weeks of service. Of those who did not complete 12 weeks of service, only 28% completed post-program calls with the POH Client Services team. Within that group, anecdotal themes related to disengagement/lack of adherence include lack of need, access issues such as transportation, as well as illness, hospitalization or death. Of note, a greater proportion of those who did not complete 12 weeks of service were new/resurfacing patients from HIV clinics (37%) versus those who did complete at least 12 weeks of service (19%) who were referred from general internal medicine clinics. In general, this case study has pushed the POH team to investigate root causes for low adherence to services to identify the best mechanism for optimizing engagement. While there is work to be done to identify the core needs of the diverse populations served - culturally relevant menus, accessibility, other community resources to address comorbidities that cause barriers to managing nutritional health - POH is taking steps to provide baseline support for clients and learn more about disengagement. Specifically, the team has included adherence calls/navigation in strategic plans for the upcoming year - already engaging in a pilot with the UCSF Cardiac Rehabilitation clinic. The team is also discussing offboarding calls to assess satisfaction and reasons for disengagement to help guide quality improvement plans. Issues with survey completion - The nature of the POH PPP as an added benefit to an existing medically tailored grocery program creates complications with the interpretation of survey results. Specifically, while the completion rate for surveys for those who completed at least 12 weeks of service was good (85%), several respondents were completing POH PPP post-program surveys while still engaged with POH core grocery services. Additionally, all results regarding food security, confidence, and consumption, may be subject to the conflating of participation in medically tailored grocery programming and participation in the added benefit of the POH PPP. These factors were not considered when the initial proposal and evaluation plan was crafted. Working with the GusNIP NTAE over the next several months will help characterize the outcomes for inclusion in national data summaries. Future evaluation plans will account for the relationship between existing interventions and their enhancements. Finally, while the team benefitted from success in phone outreach for post-program surveys, future approaches will consider response bias when determining who is making these calls and/or opting for other methods of survey completion.Additionally, staff will be trained in best practices when administering surveys. What opportunities for training and professional development has the project provided? Three methods of training and professional development took place during this reporting period. The first is technical assistance for various aspects of program implementation from external entities. Specifically, the team has learned from working with the GusNIP Training, Technical Assistance, Evaluation, and Information Center and the related Produce Prescription (PPR) Community of Practice. Direct support from the Reporting and Evaluation Program Advisor during monthly and ad hoc one-on-ones helped the team in strategizing recruitment and overcoming barriers to working with healthcare partners. Additionally, the POH team has limited experience with local produce procurement and has benefitted from the regular guidance of Heather Nieto-Friga/Supply Change, LLC and her team to train on forecasting and building relationships with local farms within POH's operational structure. The team at Health Care Without Harm's Healthy Food in Health Care program provided support directly to the PD in developing survey and interview tools to assess value and feedback from farm partners, and in tracking community health and wealth metrics. The second method is internal mentorship. This project has provided a platform for more experienced staff to work with newer staff to develop skills in their respective fields. For example, the Director of Operations and the PD launched the development of policies and procedures for local produce procurement and built initial relationships with area distributors. Then, they trained the Manager of Food Operations in these processes -- from ordering and building new items to tracking and inventory management. The Manager has gradually adjusted protocols and taken full ownership of the operational aspects of the POH PPP. Similarly, the PD worked with the grant Registered Dietitian (RD) to develop knowledge around the process for produce selection and dissemination of educational material. The PD also worked with the RD to revitalize the POH Sustainability working group. The RD transitioned out of POH when she was accepted to a MPH program with a focus on sustainable food systems, the motivation for which was spurred, in part, by her involvement with this work. When another team RD stepped into the role, that RD was trained in the same processes and has taken the lead on creating a calendar of produce items for purchase and is creating new approaches to educating clients and engaging them with the program. Finally, PD participation in conferences -- specifically, the USDA/NIFA Project Director's Conference and CleanMed 2024 -- provided professional development opportunities through didactic presentations related to grant management, and use of sustainability data management tools, as well as case study examples in implementation and evaluation of programs with common goals. How have the results been disseminated to communities of interest? The POH PPP is still in the process of evaluating individual-level outcomes related to participation in the program. In this reporting period, POH has reported internally and externally on the process evaluation of the POH PPP, sharing stories of specific participant experiences with the POH PPP, and the outcomes related to investment in local food systems. Specific activities/publications include: Project Open Hand blog posts - POH publishes monthly blog posts that detail priority initiatives, celebrations and nutrition education for over 22,000 subscribers to the POH email list. These subscribers are largely supporters, donors and volunteers. Posts related to the POH PPP captured POH's presentation of the program to national partners, efforts to tailor produce selection to client preferences, and the importance of investment in local produce/farms to ensure FIM organizations are able to complement what is donated from local food banks. "Project Open Hand Team Presents at National Food Is Medicine Coalition Symposium" (November 2023, https://www.openhand.org/blog/project-open-hand-team-presents-national-food-medicine-coalition-symposium) "Seasonal Produce, An Exciting Addition to Our Grocery Centers" (April 2024, https://www.openhand.org/blog/seasonal-produce-exciting-addition-our-grocery-centers) "Rose's Story" (November 2024, https://www.openhand.org/blog/roses-story-2024) MealTimes newsletters (January 2024) - MealTimes is a quarterly print newsletter produced by POH. The newsletter is mailed four times a year to donors and supporters. Clients, volunteers and friends can pick up a copy at grocery centers in San Francisco and Oakland or read the e-versions on the POH website. The printed newsletter has a reach of approximately 12K readers, with representation as a linked PDF in monthly e-newsletters that are sent to over 21K subscribers. Issue 131 in January 2024 ( https://www.openhand.org/sites/openhand.org/files/news-pdfs/01-2024_MealTimes131_11x17%20v6.pdf) focused on the GusNIP produce prescription grant, the importance of providing produce that aligns with client preferences and support local agriculture. The cover story documented the experience of one of our long-time clients living with HIV who incorporates fresh produce into his daily meals and highlights the importance of being able to rely on access via the POH PPP to a selection of foods one may not otherwise be able to acquire. FIMC National Symposium (September 18-20, 2023) - The Food is Medicine Coalition's national symposium convenes over 400 thought leaders, specialists, and agency staff who serve medically tailored food and nutrition services to discuss best practices in advocacy, research, and programming for coalition members. In September 2023, the PD presented alongside fellow FIMC member organizations and grantees Ceres Community Project and Open Hand Atlanta to describe the myriad ways to integrate produce prescription programming into Food is Medicine interventions. Participants learned about the operational infrastructure required to engage in procurement of local, regeneratively raised products and how to establish meaningful targets for community investment in food. CleanMed 2024 (May 6-8, 2024; Salt Lake City, UT) - Hosted by Practice Greenhealth (https://practicegreenhealth.org/topics/food ) and Health Care Without Harm (https://noharm.org/food), CleanMed (https://cleanmed.org/cleanmed-history/) is an annual, international health care sustainability conference that provides opportunities to gain knowledge, tools and connections to help organizations of various types meet their targets in environmental sustainability. During this reporting period, the PD presented in a two-part panel - Community Responsive Food Investments (https://cleanmed.app.swapcard.com/event/cleanmed-2024/planning/UGxhbm5pbmdfMTgxNjI3NQ==)- designed to highlight examples of community and health care sector partnerships that enable reconciliation and bolster resilience, sustainability and health. POH focused on sharing the key commitments organizations must make when engaging in the first steps of responsible procurement and the case study of an organization in its first two years of building infrastructure to develop and meet sustainable, client-centered procurement targets. Stanford Food Summit (November 1, 2024) - Hosted by the Stanford University Nutrition Studies Research Group through their Plant-Based Diet Initiative (https://web.stanford.edu/group/nutrition/cgi-bin/pbdi/wordpress/), The Stanford Food Summit is a one-day gathering that highlights the latest innovations and research on plant-based solutions to major public health and environmental challenges. The PD joined a panel to discuss how Food is Medicine (FIM) initiatives can support both human and planetary health, with an emphasis on increased consumption of plant foods and the work accomplished through GusNIP grants to support resilience in local foodways that contribute to community health and wealth. Participants gained familiarity with the range of FIM interventions and the current state of evidence and policy related to FIM, as well as knowledge about the opportunity and challenges in operationalizing sustainable procurement efforts in organizations providing FIM. The PD made connections with other FIM providers and with researchers interested in collaborating to study FIM interventions. What do you plan to do during the next reporting period to accomplish the goals?In order to meet the primary goal of this project - to increase access to and intake of high-quality, California grown culturally appropriate fruit and vegetables among low-income individuals living with diet-modifiable chronic conditions, POH will continue to identify funding streams (i.e., renegotiating health plan reimbursement for meals and groceries, philanthropic commitments) to support long-term operational sustainability of values-based produce purchasing. Collaboration with area farms and food hubs will continue and include the development of a community food council to inform the produce selection in grocery and meal offerings. Additionally, standards for the quality, quantity and variety of produce available in the existing medically tailored grocery program will be finalized to ensure consistent provision of FV that will drive consumption. Regarding, outcome evaluation, the following will be accomplished: Data extraction ofutilization and healthcare cost data from UCSF systems will be complete by February 2025. Summary statistics for all biometric, utilization and cost metrics will be complete by July2025.

Impacts
What was accomplished under these goals? Accomplishments this year, by objective, include the following: Obj 1. Established partnerships with local organic farmers and Health Care Without Harm (HCWH). Partnerships with local farms via regional distributor or direct farm purchases resulted in procurement of over $205K of California-grown produce, with over 70% of this sourced within 150 miles of our grocery centers. Over 85% percent of these FV were organically grown, and 80% came from BIPOC-led farms. Additionally, the infrastructure built in the first eight months of the POH PPP allowed direct farm purchasing for a subset of products. In April 2024, POH scheduled farm visits in Hollister, CA to learn more aboutpivoting to a new purchasing model for grocery produce. Direct farm purchasing began in May 2024. The team has benefitted from more direct communication, reliable delivery and quality product, while the farmers cite benefits of precommitments and access to a new market. Obj 3. By May 2023, develop tracking and distribution workflows to support novel produce distribution. The first grant year involved new development of policies and procedures for produce purchasing through a regional distributor. Two enhancements have taken place in this reporting period. First, the purchasing procedures have been revised to include direct farm purchasing. Second, the POH team built on policies and procedures by beginning development of comprehensive produce procurement standards for the agency, aligning with Health Care Without Harm Anchors in Action. Additionally, the team is establishing a data infrastructure through Key Green Solutions - a sustainability management software -- to assess baseline and progress towards targets in procurement. Obj 6. By September 2023, implement POH PPP. During this reporting period, over 3,300 grocery clients had access toFVthrough the USDA funds across San Francisco (63%), Alameda (31%) and Contra Costa (6%) counties. Fifty-five percent of clients picked-up groceries at either POH grocery centers or one of three mobile sites in San Francisco at some point during the year; fifty-three percent of clients accessed delivery services at some point during the year. The population accessing the POH PPP is diverse: 32% are Latino/Hispanic, 26% European descent, 26% Black/African American, 14% API, and 3% Native American. Fifty-nine percent are male, 37% female, and 4% non-binary or transgender. Seventy-one percent of these clients are 50 years of age or older. At least 30% are LGBTQIA+. Fifty-five percent of participants are unemployed, and 72% live below the federal poverty level. Obj 7. By February 2024, enroll 200 participants from UCSF clinics through the EHR referral system outlined above. By February 2024, POH and the six UCSF partner clinics had enrolled fifty-four patients in the POH PPP. At the close of Year 2, the team enrolled a total of eighty-six participants. While enrollment did not reach the estimated target, several process-related accomplishments allowed pivoting to achieve optimal enrollment given several unforeseen constraints. By October 2023, the team realized the need to expand the scope of outreach for UCSF patients beyond those currently engaged with the UCSF Food Pharmacy. The UCSF clinics also started providing lists of eligible patients to POH, and POH staff conducted outreach as an extension of their health care. This resulted in a significant increase in enrollment between December 2023 and June 2024 -- 85% were enrolled once this adjustment was made. This approach also relieved the burden on clinic staff and reduced the number of contacts required to enroll patients. Obj 8. Assess the accessibility and appropriateness of the POH PPP intervention via surveys that capture client satisfaction, changes in self-reported access to healthy foods, efficacy in utilizing produce, and intake of FV. Of the eighty-six UCSF patients enrolled in the POH PPP, 48 completed at least 12 weeks of service required to be included in survey analysis. Overall, forty-one (85%) of those participants who completed at least 12 weeks of service completed post-program surveys, contributing to assessment of satisfaction and baseline-to-post comparisons. Satisfaction - Eighty percent of respondents cited a positive experience with the POH PPP and the remaining 20% cited a neutral experience. Food security - Forty-six percent of respondents reported some improvement in food security status (ex, very low food security to marginal food security) through responses to the six-item short form food security survey, from baseline to post-program. Thirty-four percent maintained the same level of food security. Overall, when described by categories of "food secure" and "food insecure," 23% moved from food insecurity to food security, and 11% maintained food security status. Knowledge and confidence in consuming FV - Eighty-one percent of respondents cite that participation in POH services increased their knowledge of nutrition in addressing their diagnosis. Eighty-eight percent of respondents agree that POH services have increased confidence in the ability to eat FV on a budget. Consumption of FV - Ninety-two percent of respondents cite that participation in POH services increased the variety of FV they consume. Regarding consumption as captured through the 10-item DSQ, 68% of respondents increased their vegetable consumption, with a maximum increase of 1.3 cups per day and an average increase of 0.3 cup. Sixty-four percent of respondents increased their fruit consumption, with a maximum increase of 1.75 cups and an average of 0.9 cup. Obj 9. Assess the effectiveness of the POH PPP intervention in improving the health of individuals by collecting data related to biometrics, self-report of general health and health care utilization. Thirty-six (42%) of those UCSF patients enrolled in the POH PPP responded to both baseline and post-program questions about general health. Among respondents, 75% cited improvements or maintenance of general health. The team acknowledges that there may be characteristics unique to those who completed the program and the post-program survey versus those who did not. As of report submission, the UCSF team has extracted diagnosis, biometric data, PHQ9 and GAD7 responses and submitted these data to the NTAE team to contribute to initiative-wide analysis. In the next reporting period, full analysis of baseline and intervention values will be summarized for biometrics as well as healthcare utilization and cost data.

Publications

Progress 09/15/22 to 09/14/23

Outputs
Target Audience: Project Open Hand (POH) provides medically tailored meals and groceries to people living with diet-modifiable chronic conditions, most of whom are food insecure and members of marginalized communities. Our Wellness Program serves almost 4,000 clients annually who are living with serious illnesses in San Francisco, Alameda, and Contra Costa Counties. The POH Produce Prescription Program (POH PPP) targets individuals who utilize our medically supportive grocery service (able and desire to prepare food on one's own), are food insecure, eligible for or on Medi-Cal, and are living with one of the following conditions: HIV/AIDS, Type I/II diabetes with an HbA1c of 8 or higher, Hepatitis C, end stage renal disease, or heart disease - congestive heart failure (CHF), coronary artery disease (CAD) and/or chronic obstructive pulmonary disease (COPD). POH targets this audience because the risk of and challenges of living with a limited income and food insecurity are heightened when one is also managing a chronic condition. The rates of these diseases are at greater levels among certain population groups due to health disparities such as poverty, unequal access to health care, stigma, and racism. Thus, the program also targets those who represent groups who have historically experienced interpersonal, systemic, and/or institutional racism, ageism and discrimination based on sexual orientation and gender identity. Since program launch, 1,722 grocery clients have accessed fresh fruit, vegetables and herbs through the POH PPP between our San Francisco (72%) and Oakland (28%) locations. Sixty-five percent have picked-up groceries at either POH grocery centers or one of three mobile sites in San Francisco (16%). The population accessing the POH PPP is diverse: 34% are Latino/Hispanic, 27% European descent, 24% Black/African American, 8% API, and 4% Native American. Sixty-seven percent of these clients are 50 years of age or older. At least 36% are LGBTQIA+. Fifty-six percent of POH PPP clients are unemployed, and 70% live below the federal poverty level, with 86% at or below 200% FPL. The POH PPP is available to all grocery clients through USDA and POH funding, and as part of program goals and evaluation, the POH team is enrolling 200 new patients through a partnership with six UCSF clinics that are members of an existing UCSF Food Pharmacy Alliance that launched in 2019: the Division of General Internal Medicine, 360 Wellness Center (Men's HIV), Women's HIV Program, Family Medicine at Lakeshore, Primary Care at China Basin, Women's Primary Care. Initially, UCSF partners conducted outreach to existing Food Pharmacy patients only. This cohort will complete baseline and post-surveys, and the team will analyze biometric and healthcare utilization data for this group. Upon request from POH, UCSF has expanded the patient list to include any patients in their clinics meeting the eligibility criteria noted above. Thus far, the clients enrolled from these clinics reflect the demographics and experience of the broader POH client population. Low-income, food insecure residents in the Bay Area benefit from the POH Produce Prescription Program (POH PPP) by increasing their intake of high-quality, fresh fruits and vegetables. In addition to providing high-quality produce to support health and increase nutrition security, our diverse populations have a say in the types of produce that meet cultural food preferences and increase access to varieties that may be more challenging to procure affordably in the community. Changes/Problems: Two major issues have caused challenges in reaching our program goals. 1. Recruitment and enrollment delays and process issues - The first challenge is related to the cohort of 200 new clients to be referred from UCSF clinics for more intensive evaluation of health indicators, utilization and cost measures. While the IRB and provider education efforts were on track leading up to program launch in May 2023, very few referrals were made between May and early August 2023. Several contributing issues identified include: (1) kinks in the APeX EHR referral that added burden to the referring providers, (2) perceptions of limitations in the patient pool due to eligible diagnoses as a requirement for enrollment, (3) as a longstanding provider in San Francisco referrals for clients naive to POH services versus existing or resurfacing clients was limited, (4) absence of a project manager on the UCSF Food Pharmacy Alliance team until December 2023, (5) competing priorities and limited capacity amongst providers and clinic managers at several participating clinics. As of report submission, 20 clients (10% of target) have been enrolled from UCSF clinics, with only three of the six clinics participating thus far. Several steps have been taken to mitigate the risk of these challenges. First, the POH team created a short-form digital referral for use while EHR referrals were being adjusted. Second, the POH team requested that the UCSF clinicians expand their targeting beyond existing Food Pharmacy patients to anyone with eligible diagnoses to increase the possible patient pool. To reduce the burden on clinicians, the POH team is now receiving lists of potentially eligible patients to screen and enroll (versus in-clinic referrals as the sole referral mechanism). The POH Client Services team is also attending Food Pharmacy pick-up events to promote the POH PPP directly to patients. Additionally, the UCSF team has hired a new project manager, and the UCSF physician partner (Dr. Moreno-John) has conducted outreach to each of the participating clinics to bring referrals to POH up to their list of priority initiatives. The POH PPP Protocol Director and the POH Vice President of Programs meet with Dr. Moreno-John once per month, and Dr. Moreno-John will be attending monthly technical assistance calls with POH and the GusNIP NTAE advisor. Finally, the Protocol Director sends monthly emails to all UCSF clinic contacts to provide updates on the program, enrollment numbers and tips for successful referral. 2. EHR referrals - The original proposal for this project included the intent to integrate UCSF patient data and referrals via UCSF's Epic EHR system, APeX, which would essentially reduce burden for providers, POH and create a paperless system of client tracking for this program. As noted in the "Other Products" section, the POH team, UCSF clinicians and UCSF IT team successfully created a provider-facing referral in APeX. This referral took much longer to create than expected, with the final usable version available five months after the program's launch. In addition, the referral is not fully integrated because of technical constraints in linking APeX to the current POH proprietary database, and the ability to transmit a referral between APeX and POH's database is unlikely during the project period. Currently, POH operates a proprietary database and has experienced significant delays in developing and onboarding a new, enhanced client management database via Eccovia (ClientTrack). Moreover, the IT support required and institutional buy-in for full integration of the referral was previously thought to be more than this grant budget and scope would support. However, in the last week, the POH team has scheduled preliminary discussions with the UCSF team about an effort at UCSF to secure a contract with Find Help (Aunt Bertha), a technology platform that helps both patients and providers search for community resources to address social determinants of health. One relevant feature of Find Help is the ability to send referrals to community organizations directly via the platform, and POH will likely be onboarded as a pilot organization using the POH PPP as a first launch. This endeavor would be supported by Find Help - their staff have successfully worked with many CBOs across California. What opportunities for training and professional development has the project provided?Two methods of training and professional development took place during this reporting period. The first is technical assistancefor various aspects of program implementation from external entities. Specifically, the team has learned from working with the GusNIP Training, Technical Assistance, Evaluation, and Information Center and the related Produce Prescription (PPR) Community of Practice. Direct support from the Reporting and Evaluation Program Advisor during monthly and ad hoc one-on-one meetings provided training for the POH team in the planning and documentation related to implementing a PPR program. The Program Advisor and several others on the technical assistance team supported the team in strategizing recruitment and overcoming barriers to working with healthcare partners. The Community of Practice - regular Zoom gatherings for PPR grantees and TA team members -- has provided valuable training in areas such as building participant advisory opportunities, troubleshooting work within healthcare, and more. Additionally, the POH team has limited experience with local produce procurement and has benefitted from the regular guidance of Heather Nieto-Friga/Supply Change, LLC and her team to train on forecasting and building relationships with local farms within POH operational structure. The second method is internal mentorship. This project has provided a platform for more experienced staff to work with newer staff to develop skills in their respective fields. For example, the Director of Operations and the Protocol Director launched the development of policies and procedures for local produce procurement and built initial relationships with area distributors. Then, they trained the Manager of Food Operations in these processes -- from ordering and building new items to tracking and inventory management. The Manager has gradually adjusted protocols and taken full ownership of the operational aspects of the POH PPP. Similarly, the Protocol Director has worked with the grant Registered Dietitian (RD) to develop knowledge around the process for produce selection and dissemination of educational material. Now, the RD has taken the lead on creating a calendar of produce items for purchase and is creating new approaches to educating clients and engaging them with the program. How have the results been disseminated to communities of interest?The POH PPP is still in the early phases of implementation with data limited to participation trends, anecdotal qualitative feedback from clients regarding produce selections, and procurement figures. That said, several publications have been or are in the process of being shared with the community. In June 2023, one month after program launch, the Gretchen Swanson Center for Nutrition published an article, "Pride Month: Removing barriers to food access for the LGBTQIA+ communities", highlighting POH and the POH PPP as an example of combatting disparities through access to nutritious food. Currently, POH is publishing a blog post on its website that details the POH PPP goals and will feature the POH PPP in the upcoming issue of MealTimes, a quarterly mailed publication for donors and community members that is also posted online. POH has been asked to present on a panel at the CleanMed 2024 conference in May 2024, an international gathering for environmental sustainability in healthcare organized by Health Care Without Harm and Practice Greenhealth. POH will share the experience of a CBP in developing values-based food procurement through the POH PPP to support the growth of a climate-smart food system that fosters community resilience. At the time of this conference, POH will have one year of participation and procurement data, as well as the first round of six-month post-survey data to share with the community. What do you plan to do during the next reporting period to accomplish the goals? In order to meet the primary goal of this project - to increase access to and intake of high-quality, California grown culturally appropriate fruit and vegetables among low-income individuals living with diet-modifiable chronic conditions, POH will continue to refine the established processes for enrollment, produce procurement, distribution and education for the benefit of POH PPP clients. Specific areas of focus include: Adjustments to the recruitment for the UCSF cohort (evaluated cohort of 200) to help meet targets. The POH Client Services team and the Protocol Director will conduct direct outreach to lists of patients with eligible diagnoses provided by UCSF clinic staff. POH staff will report enrollments back to the UCSF team for care coordination and for evaluation purposes. Modifying produce rotations to support long-term operational sustainability while still prioritizing client preferences. Build relationships with a new produce distributor, Daylight Foods, which took over the POH account when the initial distributor, Bay Cities Produce, suddenly closed operations. This will include work with Supply Chain, LLC and advocacy for onboarding of local, BIPOC farms. Enhance nutrition education to include strategies to engage clients through food demonstrations, YouTube food preparation videos on the POH Nutrition Kitchen channel, and ongoing farmers market tours with a potential tour to a partner farm. Outcome evaluation POH will begin to collect post-program surveys in February 2024 for the first enrolled UCSF clients. Post-program survey data collection will continue through August 2024. Data extraction from APeX (UCSF EHR) and analysis of biometric, utilization and healthcare cost data will begin in Summer 2024. Farm surveys and interviewswill commence in April 2024, one year into program launch. Data will inform ongoing work with local farms. POH leadership will reconvene the internal Impact Committee comprised of POH staff and board members to develop strategies for sustaining the level of local produce procurement beyond the life of this grant. Regarding the secondary goal strengthening referrals for food is medicine interventions, POH will: Explore acting as a pilot for fully integrated referral via a UCSF contract with Findhelp.org (Aunt Bertha). Planning meetings commence in December 2023, and Continue to conduct quality improvement efforts on the existing referral and work flow with UCSF clinics.

Impacts
What was accomplished under these goals? The POH PPP aims to improve nutrition security, dietary quality and health outcomes for the diverse population of low-income individuals in the Bay Area living with chronic conditions by providing high quality, culturally preferred produce as part of the POH medically tailored nutrition intervention. The POH PPP supports individuals who are food insecure, eligible for or on Medi-Cal, and are living with HIV/AIDs, Type I/II diabetes, Hepatitis C, end stage renal disease, or heart disease. The program also targets those who represent groups who have historically experienced interpersonal and/or institutional racism, ageism and discrimination based on sexual orientation and gender identity. Through this project, POH can play a role in challenging systemic inequalities that impact the communities we serve.Moreover, POH recognizes that equitable access and improved intake relies on sourcing foods that are high-quality, familiar and preferred. This project provides produce selections that are responsive to the cultural context and desires of the community while contributing to economic opportunities for local farms. Finally, the POH PPP addresses barriers to accessing food is medicine programs by building tools that facilitate streamlined referrals from healthcare providers to CBOs. The primary goal of this project is to increase access to and intake of high-quality, California grown culturally appropriate fruit and vegetables among low-income individuals living with diet-modifiable chronic conditions. During the first grant year, POH laid the groundwork to provide this access and to begin to evaluate changes in intake as related to participation in the POH PPP. Many of the outcomes related to knowledge, behavior and health will be summarized in the next reporting period. Accomplishments this year, by objective, include the following: 1. Established partnerships with local organic farmers and Health Care Without Harm (HCWH). In January 2023, POH held a convening with representatives from HCWHand Heather Nieto-Friga, an experienced value chain strategist with strong roots in Bay Area agriculture. Collectively, the team built processes through POH's existing produce distributor that allowed onboarding for new BIPOC-led farms and sourcing of local, majority organic produce. In the first six months of the program's launch, Project Open Hand has purchased $113K worth of California-grown produce, with 65% of this sourced within 150 miles of our grocery centers. Sixty-five percent of these fruits, vegetables and herbs are organically grown, and 80% comes from BIPOC-led farms.POH also developed a portfolio of community investment indicators to measure the progress towards goals in responsible sourcing and a survey for local farmers to help understand the impact of this project on economic stability and opportunities for future growth. 2. By May 2023, identify quantity of produce for distribution to each of 1,500 clients during program period. In March 2023, the team established a budget of $4.40 per week per client for produce based on trends in client and service usage data and GusNIP funding duration. Within this budget and a survey of food cost, the team prioritized two items at any given time to ensure the portion size was sufficient for culinary use and number of servings. For example, a pound of strawberries and a head of garlic, or 5-ounces of baby spinach and three Asian pears. Produce selections are generally rotated every two weeks. 3. By May 2023, develop tracking and distribution workflows to support novel produce distribution. In April 2023, the Operations team began to develop policies and procedures for the management of local produce procurement. Roles were assigned for each step of the process - forecasting and product selection, ordering and invoicing, receiving, storage and distribution. The workflows include use of food service software, Computrition, to track produce items. The policies and procedures have been revised throughout the first six months of launch. For example, the team recognized challenges with unstable product due to weather and other supply issues. They developed a contingency plan workflow to share with the produce distributor to enable quick pivots in product sourcing that still meet the criteria for this project. This work has increased the preparedness for POH and local distributors to sustain this approach to procurement. 4. By May 2023, develop educational materials, including paper-based, video and in-person support that introduce new produce selections and support preparation/use of produce in the home. In January 2023, the team conducted a survey to assess client produce preferences. Over 200 surveys were completed by phone (56%), email/QR code (39%), and paper (5%). Results were analyzed to formulate preference lists for fruit, vegetables and herbs. The team utilized these data and produce seasonality to develop a calendar of selections for the first several months of the POH PPP. This calendar informed the development of educational brochures that offer details about nutritional content, a storage guide, steps for basic preparation and a recipe. Brochures are available in English, Spanish and traditional Chinese, and they are distributed by email or available at pick-up up points in San Francisco and Oakland. To date, sixteen rotations of these produce brochures have been distributed to support client use of fresh fruit and vegetables. Clients have contacted POH to express their appreciation for these supportive materials. 5. By September 2023, implement POH PPP, offering additional produce to food insecure clients living with diet-modifiable chronic conditions. The POH PPP was launched on May 1, 2023. To date, over 1,700 clients have accessed weekly packages of over 25 different varieties of produce not previously available at POH between our San Francisco and Oakland locations. The population accessing the POH PPP is diverse: 34% are Latino/Hispanic, 27% European descent, 24% Black/African American, 8% API, and 4% Native American. Sixty-seven percent of clients are 50 years of age or older. At least 36% are LGBTQIA+. Fifty-six percent cite being unemployed, and 70% live below the federal poverty level, with 86% at or below 200% FPL. 6. Assess the accessibility and appropriateness of the POH PPP food and education intervention via surveys that capture client satisfaction, changes in self-reported access to healthy foods, efficacy in utilizing produce, and intake of fruit and vegetables. The team developed baseline and post-program surveys in collaboration with the GusNIP NTAE Center. To date, twenty UCSF patients have enrolled in the POH PPP and completed baseline surveys. The next reporting period will include evaluation of participant survey data. ? The secondary goal of the POH PPP is to strengthen linkages between healthcare and CBOs providing food as medicine by streamlining referral processes. During this reporting period, POH worked with UCSF clinicians and IT department to develop a referral embedded within a social determinants of health module in the UCSF electronic health record system, APeX (Advanced Patient-Centered Excellence; version of EPIC). Clinicians and POH staff benefit from an integrated referral - reduced burden in submission and potentially increased referral volume related to ease and salience. The team experienced challenges in building the EHR-based referral, but the referral has been functional since May 2023 and underwent enhancements in late Summer 2023, which has resulted in increased usage during Fall 2023. Additionally, the team expanded clinic participation from an initial three to six UCSF Food Pharmacy Alliance clinics to increase reach and help meet enrollment target of 200 by February 2024. This is particularly helpful, as many referred patients are existing or resurfacing clients with POH. To date, 20 new patients have successfully enrolled in the POH PPP.

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