Non Technical Summary
The prescription produce program (PPR) will incentivize the purchase of fruits and vegetables for low-income persons who receive medical assistance under a state plan. Medical providers will propose referrals for produce prescriptions to the Diabetes Prevention and Control (DP&C) department for patients who screen positive and have a documented diagnosis of food insecurity. Providers will propose a prescription to DP&C for eligibilty verification and review. DP&C will verify eligibility and, when appropriate, write prescriptions for produce that can be redeemed at participating local stores or may elect to receive curated produce boxes from a local farm.. Each prescription will allow for the purchase of $45-$90 of f/v per month depending upon household . Participants will receive 3 months of vouchers at a time that can be redeemed once per month. Additional refills (vouchers) will be distributed quarterly. In order to renew the prescription, patients will a follow up appointment with their provider for 6 months after their initial visit for a chronic care/preventative care appointment. The anticipated impact of this project is an increase in healthcare utilization for the purpose of preventative care rather than treatment of acute issues. Improvements in food security are anticipated as well and reported increases in consumption of fruits and vegetables.

Classification

Knowledge Area (KA)	Subject of Investigation (SOI)	Field of Science (FOS)	Percent
703	6010	1010	50%
704	6010	1010	50%

Knowledge Area
703 - Nutrition Education and Behavior; 704 - Nutrition and Hunger in the Population;

Subject Of Investigation
6010 - Individuals;

Field Of Science
1010 - Nutrition and metabolism;

Goals / Objectives
Recruit participants that screen positive for food insecurity and subsequently have a diagnosis of food insecurity in their electronic medical record, receive benefits under the Food and Nutrition Act of 2008 or medical assistance under a State plan, and are a member of a low-income household that suffers from, or is at risk of developing a diet-related health conditionGoal #1 Increase the number of eligible individuals that are accessing and consuming fruits and vegetables. We aim to enroll 400 participantsSub-goal #1 Increase fruit and vegetable consumption among family members of prescription produce participantsGoal #2 Increase individual and household food securityGoal #3 improve the health of individuals acessing and consuming the produce by encouraging participants to seek preventative health exams and decrease healthcare access for acute conditions

Project Methods
Methods: Medical providers and CHA's will receive education to screen patients for food security throughout the project and will be provided with educational materials to encourage enrollment for eligible participants. Providers will be encouraged to conduct preventative health exams to ensure surveillance of risks associated with diet-related health conditions. Providers will propose a prescription for review by DP& C staff. Patients will be screened for food insecurity utilizing the following 2 questions: Within the past 12 months(1) we worried whether our food would run out before we got money to buy more; (2) the food we bought just didn't last and we didn't have money to get more." Yes or no? Those that screen positive, meet eligibility criteria, and are interested in participating will complete a baseline survey assessing their current fruit and vegetable consumption habits and food security status. Afollow-up survey will be administered after6-months of participation. Chart reviews will be conducted to evaluate overall healthcare utilization based on acute care exams versus chronic care visits. This information will be included as core participant-level metrics and shared with the NTAE.Participants will be offered nutrition education every 3 months vianutrition tip cards, one-on-one dietary counseling, access to lifestyle coaches, and monthly region-wide news articles andrecipe videos viasocial media campaigns. Nutrition tips and education provided will be culturally relevant and include items readily available in village stores and incorporate subsistence foods. Participants will be notified about additional educational resources available via SNAP-ed programs, local food bank offerings, and on-line resources which provideeducation for individuals with overweight, obesity, hypertension, or a high risk of developing diabetes.Efforts:Advertising for program participation will encompass Facebook posts on the YKHC page,YouTube ads, word of mouth, flyers, and partner agencies. Fliers will be widely distributed across the community that describe the program, explain how to participate, andhow to redeem vouchers. To support program development, DP&C will employ a prevention specialist responsible for daily functions, including staff training, program advertising, eligibility verification, prescription distribution, participant list maintenance, follow-up medical appointment,data collection, and evaluation. The Program Director and other DP&C staff will assist as needed to fulfill program requirements. Upon receiving a proposed prescription from a provider, the prevention specialist will verify eligibility based on project and SNAP requirements before submitting prescriptions to BCSF for voucher distribution or direct-to-consumer produce boxes. BCSF will partner with YKHC to assist in voucher distribution, vendor communication, and coordination of produce box shipments. BCSF will encourage participants to maintain eligibility and meet follow-up assessment requirements.DP&C has established relationships with several vendors that supplyfruits and vegetables in the region. Each vendor has expressed interest in continuing to participate and promote the PPR. Existing MOUs with numerous village stores will be expanded, allowing produce prescriptions to be used at participating stores with a specified cash value ($45-$90 depending on household size), adhering to SNAP guidelines. If a participant lacks access to a participating store or so desires, Meyers Farm will deliver produce boxes. Participating vendor information will be collected and reported to the NTAE as firm-level data. The existing MOUs outline how vendors will process participant vouchers and what information needs to be documented to receive payment. All invoices will be evaluated for appropriateness of items purchased and on-going training will occur when needed to ensure vendors are adhering to program guidelines. Most village stores have appropriate software to generate electronic invoices for each transaction. Some of the smaller stores do not have software and will provide hand-written invoices that will include the same information as above. The stores that have been participating with our current PPR program are well versed in the required documentation and are efficient and organized with their internal processes to provide invoice information to receive reimbursement for items purchased through the PPR program. It has been identified that some of the smaller stores that do not have current MOUs with YKHC are hesitant to participate based on lack of technology available to generate and submit invoices. Because of the vastness of the region and the lack of infrastructure to access participating stores, it is imperative that a flexible model exist to be able to recruit as many participants as possible, thus allowing for individual purchasing of fresh, frozen, or canned items or delivery of a procured box.Evaluation:YKHC will create an MOU with the NTAE centers to developself-assessments that follow the guidelines developed by the NTAE centers to ensure an appropriate level of comparability of methods, outcomes and measures. Evaluations conducted by YKHC will include documentation of the process, challenges, and successes that accompany running the PPR. Additionally, evaluations will include anassessment that documents the program's effectiveness in increasing fruit and vegetable purchases among eligible participants of the PPR. The evaluation of effectiveness will reviewmultiple data sets collected in the project period including the number of prescriptions utilized, the number of educational sessions attended, healthcare utilization, and anecdotal data provided by participants.Data will be collected through surveys regarding the number of people living in the household andpercentage of shared meals that included fruits/vegetables. The ages of household members consuming fruits and vegetables will be recorded. Success will be measured by the number of prescriptions and refills used for purchasing fruits/vegetables. Partnering stores will collect this data by returning used prescription vouchers monthly with their reimbursement invoices. Each prescription form will have a patient identification number to trackusage without revealing PHI. Invoices received from stores will include an itemized list of all items purchased. Baseline data collected from participant assessments will be compared to data collected as part of the post-participant survey. Participants will complete a survey on their fruit/vegetable purchasing habits at baseline and after six months of participation. This information will be shared with the NTAE and entered via the Qualtrics. The Prevention Specialist will betasked with ensuring surveys and firm level data is provided as requested with oversight from the Project Director. YKHC will track the number of enrolled participants, the number of vouchers distributed, the number of vouchers redeemed, and the number of education sessions attended. This will be evaluated on a quarterly basis to ensure participation rates are in-line with outcome goals. Data will be analyzed and a continuous quality improvement process will be utilized to surveil for low enrollment number or low rates of redemption amongst participants; any identified gaps or potential causes will then be addressed to ensure enrollment and redemption meet project goals. YKHC will also review rates of healthcare utilization rates to evaluate for number of acute care visits versus chronic care visits. The assumption is that chronic care/preventative health visits will increase as a result of being able to participate in PPR.