Source: ASCENSION SETON submitted to NRP
THE ASCENSION FOODRX-SOCIAL SYSTEMS INITIATIVE (AFRX-SSI): MIXED METHODS DESIGN FOR POVERTY DISRUPTION AMONG OUR MOST VULNERABLE PREGNANT PERSONS AND BABIES
Sponsoring Institution
National Institute of Food and Agriculture
Project Status
ACTIVE
Funding Source
OTHER GRANTS
Reporting Frequency
Annual
Accession No.
1031415
Grant No.
2023-70413-41056
Cumulative Award Amt.
$483,612.00
Proposal No.
2023-06353
Multistate No.
(N/A)
Project Start Date
Sep 15, 2023
Project End Date
Sep 14, 2026
Grant Year
2023
Program Code
[PPR]- Produce Prescription
Recipient Organization
ASCENSION SETON
1345 PHILOMENA ST
AUSTIN,TX 787233210
Performing Department
(N/A)
Non Technical Summary
The Ascension FoodRx-Social Systems Initiative (AFRx-SSI): Mixed Methods Design for Poverty Disruption Among Our Most Vulnerable Pregnant Persons and Babies will focus on patients receiving maternal health services at an Ascension Medical Group (AMG) site, and who ultimately deliver at an Ascension Seton Hospital location in central Texas. In central Texas from 2020 through present day (May, 2023), nearly 1 in 5 (18.2%) of Medicaid and Self-pay persons screened positive for an SDoH related need. Within this group, more than half indicated food insecurity and transportation were primary barriers to improving their health. Prenatal healthcare offers a unique opportunity to influence long term health outcomes of pregnant persons and their babies, providing frequent touch points to offer education and low cost interventions. Compared with infants born to pregnant persons who received prenatal care, infants whose pregnant persons did not receive prenatal care are three times more likely to have a low birth weight and are five times more likely to die in infancy. Additionally, pregnant persons who do not receive prenatal care are three to four times more likely to die from pregnancy-related complications than those who do receive care.Pregnant Persons enrolling in AFRx - SSI will be offered a range of pre-built produce boxes to select from, and will include general FFV, condition-specific FFV identified by the provider, and culturally appropriate FFV over the course of the intervention period. AFRx will be filled utilizing the Athena EMR referral function, and delivered to the patient's home, at no cost to participants. Refills will be provided during attendance at prenatal visits or navigator engagement. In person education and nutrition counseling will be provided as part of the Navigator activities. Navigators will capture and track participants fulfilling an AFRx within the EHR (Athena) to establish incentive eligibility, assist participants in completing pre- and post- enrollment surveys as required for grant reporting and evaluation, and also track additional social barriers the participant experiences in accessing healthcare services. Relevant healthcare outcomes and metrics will be tracked over the course of the healthcare encounter to evaluate efficacy of the intervention.Ultimately, this project aims to achieve the following:Improve the dietary health of a cohort of pregnant participants at risk for developing SMM through increased consumption of fruits and vegetables;Reduce the impact of household food insecurity among participants;Increase the percentage of pregnancies reaching term and being born at ideal birth weight; andCompile qualitative and quantitative data to support scale and spread of PPR through AFRx-SSI model to other care settings within the Ascension network
Animal Health Component
40%
Research Effort Categories
Basic
40%
Applied
40%
Developmental
20%
Classification

Knowledge Area (KA)Subject of Investigation (SOI)Field of Science (FOS)Percent
7046099101080%
7046050310020%
Knowledge Area
704 - Nutrition and Hunger in the Population;

Subject Of Investigation
6099 - People and communities, general/other; 6050 - Communities, areas, and regions;

Field Of Science
1010 - Nutrition and metabolism; 3100 - Management;
Goals / Objectives
The goals of this project are to improve dietary health by reducing the impact of household food insecurity and diet-related chronic conditions and measurably improving the percentage of pregnancies reaching term and being born at ideal birth weight. Concurrently, we seek to create a value of investment for insurers to provide ongoing navigation and access to AFRx to reduce disparities in selected outcomes. Objectives include:Improve the dietary health of a cohort of pregnant participants at risk for developing SMM through increased consumption of fruits and vegetables;Reduce the impact of household food insecurity among participants;Increase the percentage of pregnancies reaching term and being born at ideal birth weight; andCompile qualitative and quantitative data to support scale and spread of PPR through AFRx-SSI model to other care settings within the Ascension network
Project Methods
Effort:Our area of innovation is the layered application of the Social Systems Initiative (SSI) framework, combiningz-code documentation and high touch navigation with nutritional intervention as a cost-effective strategy to reducing and/or preventing SMM among a cohort of pregnant persons. The project Team will recruit and retain a navigator social worker with lived experience with food insecurity and barriers to accessing prenatal care (Other Attachments: Navigator JD). DCHP, the Medicaid HMO Plan administrator for the selected clinical sites, and the Clinical Operations Team will identify participants from existing EHR data to refer to the navigator for participation in AFRx-SSI based on Medicaid status and attendance at prenatal visits. If needed, at least one additional identified risk factor associated with risk for SMM will be included to ensure enrollment meets, but does not exceed the targeted participation volume. Rolling enrollment will be utilized, and the referral and review process will continue monthly until we achieve a minimum cohort of 150 participants over the two-year intervention period. The navigator will meet with identified pregnant persons during established prenatal visits, or through home visit outreach to educate the participants on the program benefits, and initiate qualitative data collection via the Social Barrier Tracking tool, to capture ongoing barriers participants experience accessing healthcare and consumption of FFV.In person education and nutrition counseling will be provided as part of the Navigator activities. Navigators will capture and track participants fulfilling an AFRx within the EHR (Athena) to establish incentive eligibility, assist participants in completing pre- and post- enrollment surveys as required for grant reporting and evaluation, and also track additional social barriers the participant experiences in accessing healthcare services.Evaluation - Key ActivitiesGoalKey ActivitiesResponsible Role/OrgImprove the dietary health of a cohort of pregnant participants at risk for developing SMM through increased consumption of fruits and vegetables;Reduce the impact of household food insecurity among participants;Conduct pre-pilot survey during enrollment and post-pilot survey 6 months postpartumProvide nutritional education and SDoH resource connectivityFill AFRx for participant and track volume in EHRTrack eligibility and distribute stipends according to program detailsNavigator/AMG Clinical OperationsIncrease the percentage of pregnancies reaching term and being born at ideal birth weight;Retrospective review of EHR for selected metrics and enrolled participants (pregnant persons and babies)Analysts - DCHP and ADSICompile qualitative and quantitative data to support scale and spread of PPR through AFRx-SSI model to other care settings within the Ascension networkAggregate Social Barrier Tracking themes with Quantitative dataDevelop business case to demonstrate opportunity to scale and spreadAnalysts - DCHP and ADSICo-Leads - Community Impact

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

Outputs
Target Audience:We did not begin patient enrollment during this report period. We started enrollment on Sept 3, 2024. Changes/Problems: Nothing Reported What opportunities for training and professional development has the project provided? Provider education flyer: provided to clinic OB's to educate on which patients are eligible for the FoodRx program How have the results been disseminated to communities of interest? Nothing Reported What do you plan to do during the next reporting period to accomplish the goals?Our next reporting period will be very active. During this periodwill enroll 150 pregnant people into the FoodRx program and provide them with produce prescription boxes every 2 weeks during pregnancy and through 6 months postpartum.

Impacts
What was accomplished under these goals? During this reporting period we worked on setting up logistics for this grant project. We began patient enrollment September 3 2024, and therefore we did not collect enough patient data that would show progress toward any of the patient-related goals. Our progress during this reporting period can be measured in process implementations that allow for patient enrollment beginning on Sept 3, 2024. Examples of processes that have been implemented to set this program up for success include: Produce box prescription added to Athena (EHR) and prescription process verified. The prescription can be placed in Athena by the Maternal Health Navigator, through delegation by the providers, on any eligible diagnoses. The receipt of the prescription by pharmacy has been confirmed. Methods to screen for patient eligiblity have been identified and the Maternal Health Navigator is trained to schedulefor new OB appointments and navigation intake appointments as well as ongoing navigation appointments.This process is handled in close collaboration with the clinic front desk. Education to clinic providers on patient eligibility has been distributed. Process for ordering produce through vendor, inbound delivery and receipt at packaging site, packaging and outbound delivery tested to ensure quality Maternal Health Navigator hired and onboarded

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